Etudes spécifiques pays-régions sur le Nutri-Score

International

- International evidence for the effectiveness of the front-of-package nutrition label called Nutri-Score
Valentina A. Andreeva, Manon Egnell, Mathilde Touvier, Pilar Galan, Chantal Julia, Serge Hercberg
Cent Eur J Public Health 2021, 29(1):76-79

Abstract
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.]

- Objective Understanding of Front-of-Package Nutrition Labels : An International Comparative Experimental Study across 12 Countries
Nutrients 10, no 10 (2018) : 1542.
Egnell M, Talati Z, Hercberg S, Pettigrew S, Julia C.

Abstract
Front-of-Package labels (FoPLs) are efficient tools for increasing consumers’ awareness of foods’ nutritional quality and encouraging healthier choices. A label’s design is likely to influence its effectiveness ; however, few studies have compared the ability of different FoPLs to facilitate a consumer understanding of foods’ nutritional quality, especially across sociocultural contexts. This study aimed to assess consumers’ ability to understand five FoPLs [Health Star Rating system (HSR), Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes (RIs), and Warning symbol] in 12 different countries. In 2018, approximately 1000 participants per country were recruited and asked to rank three sets of label-free products (one set of three pizzas, one set of three cakes, and one set of three breakfast cereals) according to their nutritional quality, via an online survey. Participants were subsequently randomised to one of five FoPL conditions and were again asked to rank the same sets of products, this time with a FoPL displayed on pack. Changes in a participants’ ability to correctly rank products across the two tasks were assessed by FoPL using ordinal logistic regression. In all 12 countries and for all three food categories, the Nutri-Score performed best, followed by the MTL, HSR, Warning symbol, and RIs.
KEYWORDS :
comprehension ; international comparison ; nutritional labelling

PMID : 30340388
PMCID : PMC6213801
DOI : 10.3390/nu10101542

- Food Choice Under Five Front-of-Package Nutrition Label Conditions : An Experimental Study Across 12 Countries
Am J Public Health. 2019 ;109(12):1770 5
Talati Z, Egnell M, Hercberg S, Julia C, Pettigrew S.

Abstract
Objectives. To determine which front-of-package label (out of 5 formats) is most effective at guiding consumers toward healthier food choices.Methods. Respondents from Argentina, Australia, Bulgaria, Canada, Denmark, France, Germany, Mexico, Singapore, Spain, the United Kingdom, and the United States took part in the Front-of-Pack International Comparative Experiment between April and July 2018. Respondents were shown foods of varying nutritional quality (with no label on package) and selected which they would be most likely to purchase. The same choice sets were then shown again with 1 of 5 randomly allocated labels on package (Health Star Rating (HSR), Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes, or Warning Label). We calculated an improvement score (from 11 100 valid responses) to identify the extent to which the labels produced healthier choices.Results. The most effective labels were the Nutri-Score and the MTL (mean improvement score = 0.09 ; 95% confidence interval [CI] = 0.07, 0.11), then the Warning Label (0.06 ; 95% CI = 0.04, 0.08), the HSR (0.05 ; 95% CI = 0.03, 0.07), and lastly the Reference Intakes (0.04 ; 95% CI = 0.02, 0.04).Conclusions. Well-designed, salient, and intuitive front-of-package labels can be effective on a global scale. Their impact is not bound to the country from which they originate.

- Consumers’ Perceptions of Five Front-of-Package Nutrition Labels : An Experimental Study Across 12 Countrie
Nutrients. 2019 Aug 16 ;11(8)
Talati Z, Egnell M, Hercberg S, Julia C, Pettigrew S

Abstract
Consumers’ perceptions of five front-of-pack nutrition label formats (health star rating (HSR), multiple traffic lights (MTL), Nutri-Score, reference intakes (RI) and warning label) were assessed across 12 countries (Argentina, Australia, Bulgaria, Canada, Denmark, France, Germany, Mexico, Singapore, Spain, the UK and the USA). Perceptions assessed included liking, trust, comprehensibility, salience and desire for the label to be mandatory. A sample of 12,015 respondents completed an online survey in which they rated one of the five (randomly allocated) front-of-pack labels (FoPLs) along the perception dimensions described above. Respondents viewing the MTL provided the most favourable ratings. Perceptions of the other FoPLs were mixed or neutral. No meaningful or consistent patterns were observed in the interactions between country and FoPL type, indicating that culture was not a strong predictor of general perceptions. The overall ranking of the FoPLs differed somewhat from previous research assessing their objective performance in terms of enhancing understanding of product healthiness, in which the Nutri-Score was the clear front-runner. Respondents showed a strong preference for mandatory labelling, regardless of label condition, which is consistent with past research showing that the application of labels across all products leads to healthier choices.

PII : E1934
DOI : 10.3390/nu11081934

Europe

- A cross-country experimental study on consumers’ subjective understanding and liking on front-of-pack nutrition labels

Abstract
Different Front-of-Pack (FOP) nutritional labels have been implemented in order to increase consumers’ awareness of food nutritional quality and encourage healthier choices. However, few studies have analysed the effects of FOPLs on consumers’ subjective understanding and liking across different socio-cultural contexts. This study tests the effect that the new enriched informative label NutrInform Battery and the summary label Nutri-Score have on subjective comprehension and liking across 2776 respondents of seven European countries (France, Germany, Greece, Italy, Portugal, Romania and Spain). Main effects regarding socio-demographic differences are also explored according to extant literature and highlighting significant effects of education and income. This study therefore extends the current research on subjective understanding and liking with a cross-country analysis. Findings suggest that NutrInform Battery can help consumers in understanding information in a relevant way, obtaining the highest performance across countries and showing limited impact of socio-cultural differences.

- Assessing the Effectiveness of Front of Pack Labels : Findings from an Online Randomised-Controlled Experiment in a Representative British Sample
Nutrients 2021
Jessica Packer, Simon J. Russell, Deborah Ridout, Steven Hope, Anne Conolly, Curtis Jessop, Oliver J. Robinson, Sandro T. Stoffel, Russell M. Viner, Helen Croker

Abstract
Front of pack food labels (FOPLs) provide accessible nutritional information to guide consumer choice. Using an online experiment with a large representative British sample, we aimed to examine whether FOPLs improve participants’ ability to identify the healthiness of foods and drinks. The primary aim was to compare ability to rank between FOPL groups and a no label control. Adults (≥18 years), recruited from the NatCen panel, were randomised to one of five experimental groups (Multiple Traffic Light, MTL ; Nutri-Score, N-S ; Warning Label, WL ; Positive Choice tick, PC ; no label control). Stratification variables were year of recruitment to panel, sex, age, government office region, and household income. Packaging images were created for three versions, varying in healthiness, of six food and drink products (pizza, drinks, cakes, crisps, yoghurts, breakfast cereals). Participants were asked to rank the three product images in order of healthiness. Ranking was completed on a single occasion and comprised a baseline measure (with no FOPL), and a follow-up measure including the FOPL as per each participant’s experimental group. The primary outcome was the ability to accurately rank product healthiness (all products ranked correctly vs. any incorrect). In 2020, 4504 participants had complete data and were included in the analysis. The probability of correct ranking at follow-up, and improving between baseline and follow-up, was significantly greater across all products for the N-S, MTL and WL groups, compared to control. This was seen for only some of the products for the PC group. The largest effects were seen for N-S, followed by MTL. These analyses were adjusted for stratification variables, ethnicity, education, household composition, food shopping responsibility, and current FOPL use. Exploratory analyses showed a tendency for participants with higher compared to lower education to rank products more accurately. Conclusions : All FOPLs were effective at improving participants’ ability to correctly rank products according to healthiness in this large representative British sample, with the largest effects seen for N-S, followed by MTL.

- Objective understanding of the Nutri-score front-of-pack label by European consumers and its effect on food choices : an online experimental study
International Journal of Behavioral Nutrition and Physical Activity (2020)
Egnell M, Talati Z, Galan P, Andreeva VA, Vandevijvere S, Gombaud M, et al.

Abstract
Background :The effectiveness of Front-of-Pack nutrition Labels (FoPLs) may be influenced by national context. In light of the ongoing efforts to harmonize FoPLs across Europe, this study aimed to compare the effectiveness of five FoPLs (Health Star Rating system, Multiple Traffic Lights, Nutri-Score, Reference Intakes, Warning symbols) on consumer understanding and food choice in 12 European countries.
Methods : In 2018–2019, for three food categories, approximately 1000 participants per country were asked to select which food they would prefer to purchase between three products with distinct nutritional quality profiles, and then to rank the products by nutritional quality. Participants (N = 12,391 in total) completed these tasks first with no FoPL and then, after randomization to one of the five FoPLs, with a FoPL on the food packages. Associations between FoPLs and change in (i) nutritional quality of food choices and (ii) ability to correctly rank the products by nutritional quality were assessed with logistic regression models adjusted for sociodemographic and lifestyle characteristics of participants, conducted overall and by country.
Keywords :Front-of-pack nutrition label, Objective understanding, Food choices, European consumers

- Rapport Technique de l’Equipe de Recherche en Epidémiologie Nutritionnelle - Ability of the front-of-pack nutrition label Nutri-Score to discriminate nutritional quality of food products in 13 European countries and consistency with nutritional recommendations
Université Paris 13, EREN, Centre de Recherche en Epidémiologie et Statistiques, Inserm (U1153), Inra(U1125), Cnam, COMUE Sorbonne Paris Cité, Département de Santé Publique, Hôpital Avicenne (AP-HP)
Szabo de Edelenyi F, Egnell M, Galan P, Hercberg S, Julia C


- Performance of the Front-of-Pack Nutrition Label Nutri-Score to Discriminate the Nutritional Quality of Foods Products : A Comparative Study across 8 European Countries
Nutrients 2020, 12(5), 1303
Dréano-Trécant L, Egnell M, Hercberg S, Galan P, Soudon J, Fialon M, et al.

Abstract
In Europe, discussions are currently ongoing to harmonize front-of-pack nutritional labelling, while some countries have adopted or are considering implementing the Nutri-Score. However, its adaptability to multiple nutritional contexts in Europe requires further investigation. This study aimed to evaluate the applicability of the Nutri-Score in various European countries, regarding its ability to discriminate the nutritional quality of foods and its consistency with national dietary recommendations. The European Food Information Resource (EUROFIR) nutritional composition databases from eight European countries (Finland, France, Norway, Poland, Portugal, Slovakia, Sweden, and Switzerland) were used. The distribution of foods across the Nutri-Score classes within food groups was assessed, as well as the discriminating performance of the label, and the adequacy of nutritional recommendations. The Nutri-Score demonstrated high discriminating ability for all food groups, with similar trends in the eight countries, and consistency with nutritional recommendations. For instance, fruit and vegetable products were mainly classified in the two healthiest Nutri-Score categories, while sugar and animal fat products were mainly classified in the two less healthy categories of the Nutri-Score. Our results support the fact that the Nutri-Score would be a relevant tool to discriminate the nutritional quality of products within and across relevant food groups in different European countries, with consistency with nutritional recommendations.
KEYWORDS :
front-of-pack nutritional labelling ; European countries ; discriminating performance ; nutritional recommendations

- Association between nutritional profiles of foods underlying Nutri-Score front-of-pack labels and mortality : EPIC cohort study in 10 European countries
BMJ - août 2020
Deschasaux M, Huybrechts I, Julia C, Hercberg S, Egnell M, Srour B, et al.

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.jective 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.
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.

- 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.
PLoS medicine 15, no 9 (2018) : e1002651.
Deschasaux M, Huybrechts I, Murphy N, Julia C, Hercberg S, Srour B, et al.

Abstract
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.

PMID : 30226842
PMCID : PMC6143197
DOI : 10.1371/journal.pmed.1002651

Allemagne

- Comparison of front-of-pack labels to help German consumers understand the nutritional quality of food products. Colour-coded labels outperform all other systems
Ernhahrung Umschau 66(5) : 76-84
Egnell M, talati Z, Pettigrew S, Galan P, Hercberg S, Julia C (2019).

Abstract
Front-of-Package labels (FoPLs) provide simplified nutritional information to consumers to help them make healthier food choices. Investigating consu-mers’ understanding of this information is of major importance. This study compared consumers’ objective understanding of five FoPLs (Health Star Rating System [HSR], Multiple Traffic Lights [MTL], Nutri-Score, Reference Intakes [RIs], warning symbol). In 2018, 1,000 German participants were en-rolled in an online survey and asked to rank three sets of products according to their nutritional quality, first in the absence of any labelling, and then with an FoPL displayed on-pack (randomized). Change in ability to correctly rank products was assessed using ordinal logistic regression. For all food catego-ries, the Nutri-Score performed best, followed by the MTL, warning Symbol, HSR and RIs. The Nutri-Score emerged as the most effective FoPL in conveying information on the nutritional quality of foods for German consumers.

- Ability of the Nutri-Score front-of-pack nutrition label to discriminate the nutritional quality of foods in the German food market and consistency with nutritional recommendations
Archives of Public Helth
Szabo de Edelenyi F, Egnell M, Galan P, Druesne-Pecollo N, Hercberg S, Julia C (2019).

Abstract
Background :There is currently a societal debate in Germany concerning the interest to introduce a comprehensive and simplified nutritional information label on foods. Consumer associations and some manufacturers are supporting the Nutri-Score, a summary, graded, colours-coded front-of-pack label (FoPL) adopted by public health authorities in France, Belgium and Spain. The Nutri-Score is using a Nutrient Profiling System (NPS) to define five different categories of nutritional quality (from ‘Dark green’ associated with the letter A to ‘dark orange’ with an E). The ability of the Nutri-Score to discriminate nutritional quality of foods was demonstrated in the French context. The objectives of this study were to verify its ability to discriminate the nutritional quality of foods and beverages currently present on the market in Germany and its consistency with German Food-Based Dietary Guidelines (FBDG).
Method : Nutritional composition of 8587 usual foods available on the German market collected from the web-based collaborative project Open Food Facts, were retrieved. Data were collected from 2012 to 2019, with regular updates each time a product is scanned again by a contributor. Distribution of products across the five Nutri-Score categories according to consumer-based food groups was assessed. The ability of the FoPL to discriminate the nutritional quality of foods and beverages was estimated by the number of available colours of the Nutri-Score in each food group and sub-groups.
Result : Overall, the classification of foods according to the Nutri-Score was consistent with German FBDG : foods which consumption is recommended were more favourably classified (e.g. 79.7% of products composed mainly of fruits and vegetables were classified as A or B) than foods which consumption should be limited (e.g. 93.4% of sugary snacks were classified as D or E).
Moreover, we observed that the nutrient profiling system underpinning the Nutri-Score was able to display the variability in nutritional quality of foods within the same food groups, with good discriminating performance (at least three colours represented with the Nutri-Score).
Conclusions : The Nutri-Score label displays a high ability in discriminating nutritional quality of foods across food groups and within a food group in the German market. This element is a key step in the validation process of a front-of-pack label, so that the Nutri-Score is an efficient tool which could help German consumers to make healthier choices.
Keywords : NButri-Score, Nutrient profiling system, Nutritional quality, Front-of-pack labelling, Food-based dietary guidelines.

DOI 10.1186/s13690-019-0357-x

Belgique

- The impact of the Nutri-Score nutrition label on perceived healthiness and purchase intentions
Appetite (2021) - Joyce De Temmerman, Eva Heeremans, Hendrik Slabbinck, Iris Vermeir

Abstract
Making healthier food choices easier at the time of purchase is a challenge for public policy makers. The Nutri-Score can be an effective tool for guiding and steering consumers toward more informed, healthier purchasing decisions. This research investigates the impact of the presence of the Nutri-Score and its five categories on consumers’ perceived healthiness perceptions and purchase intentions. Consumers in the EU took part in two online experiments, in which they rated products from different categories, with or without Nutri-Scores, in terms of their perceived healthiness and purchase intentions. The presence of the Nutri-Score enabled respondents to assess the healthiness of products better ; furthermore, it offers the potential to boost sales of healthy products, without affecting sales of unhealthy products. Perceived healthiness mediates the relationship between Nutri-Score categories and purchase intentions, and focusing on the healthiness of products can give producers a competitive advantage, regardless of whether it is a manufacturer brand or a private label. These findings offer actionable insights for public policy makers and manufacturers ; they also suggest the need to embrace the Nutri-Score as the standard front-of-pack label to help fight the increasing obesity pandemic.
Keyword :Nutri-score ; Front-of-pack label ; Healthy consumer behavior ; Perceived healthiness ; Purchase intentions

Bulgarie

- Bulgarian consumers’ objective understanding of front-of-package nutrition labels : a comparative, randomized study
Archives of Public Health - 2020
Andreeva VA, Egnell M, Handjieva-Darlenska T, Talati Z, Touvier M, Galan P, et al.

Abstract
Background : Bulgaria continues to lag behind other EU Member States with respect to chronic disease morbidity
and mortality prevention.
Methods : In line with efforts targeting the improvement of dietary practices, this comparative study assessed
objective understanding of five different front-of-package labels (FOPL) (Reference Intakes, Multiple Traffic Lights,
Warning label, Nutri-Score, and Health Star Rating) in a sample of 1010 Bulgarian adults. Objective understanding
was assessed by comparing the results of two nutritional quality ranking tasks (with and without FOPL) in an online
randomized experiment featuring three food categories (pizza, cakes, breakfast cereals). Multivariable ordinal logistic
regression models within and across food categories were fit.
Results : Compared with the Reference Intakes group, participants randomized to Nutri-Score exhibited the largest
improvement in product ranking ability across food categories (OR = 2.33 ; 95% CI : 1.55–3.51), followed by those
randomized to Health Star Rating (OR = 1.99 ; 95% CI : 1.32–3.00). Nutri-Score also performed best within two (pizza
and breakfast cereals) of the three food categories. The Multiple Traffic Lights and Warning label groups did not
display any significant improvement in objective understanding either within or across food categories compared
with the Reference Intakes group.
Conclusion : Nutri-Score, which is a summary, interpretive, polychromatic FOPL, emerged as the most effective
model in the Bulgarian context, with the potential to help consumers better understand the nutritional quality of
food. The findings are of particular interest to public health policymakers in the region and across Europe, as the
debate about an EU-wide FOPL model continues to gather momentum.
Trial registration : Registration number ACTRN12618001221246. Trial registered at the Australian New Zealand
Clinical Trials Registry.
Keywords : Front-of-package food label, Nutrition labeling, Diet, Eastern Europe, Public health

Colombie

- The Effect of Randomly Providing Nutri-Score Information on Actual Purchases in Colombia
Nutrients. 26 févr 2019 ;11(3) - Mora-García CA, Tobar LF, Young JC.

Abstract
Recently, front-of-package (FOP) food labeling systems have captured the attention of researchers and policy makers. Several Latin American governments are currently considering employing different FOP labeling systems. However, there is much need for more research-based evidence in these countries. In this paper, we study whether food-purchasing decisions and the nutritional qualities of those purchases are influenced by randomly informing some customers and not others about an FOP label known as Nutri-Score. We also separate the information effect from the effect of being aware of the system. We combined a randomized field intervention in a university cafeteria in Bogotá, Colombia with data from an after-purchase survey and receipts. We found that randomly providing information on Nutri-Score increased total expenditure by $0.18. Additional spending on healthier items was 21% or $0.26 higher, with no change for less healthy items. Expenditure estimates were higher among customers who were aware of the system’s existence. Customers in the study were also 10% more likely to buy a healthier item than control customers were, and the concentration of protein in their purchases was greater. Information on the Nutri-Score system increased the store’s sales. This potential financial incentive may facilitate the implementation of Nutri-Score.

Espagne

- Breakfast Food Advertising and Prevention of Obesity : Analysis of the Nutritional Value of the Products and Discursive Strategies Used in the Breakfast Ads from 2015 to 2019

Abstract
Breakfast is widely considered the most important meal of the day. Despite this, the consumption of ready to eat industrial products with low nutritional value is increasing. This study correlated longitudinally the nutritional value of breakfast products with advertising discursive strategies. The research design applied quantitative analysis to compile all media advertising data from 2015 to 2019, qualitative analysis of the content, and a study of the adverts’ discourse. Moreover, a Nutri-score analysis was used to determine the products’ nutritional value. Results indicated that breakfast products advertised in Spain presented a low or very low nutritional value. In addition, they showed that the lower the nutritional value of the product, the greater the proportion of positive emotions or moods that emerge from the discourse used in the advertisement. To establish effective policies for the prevention of obesity, greater involvement of the government, and better self-regulation mechanisms for the food industry, communication agencies, and advertisers are needed. In this sense, the hedonistic language used in advertisements for unhealthy food must treated as a priority. This measure would have the aim not only of protecting minors from ads for unhealthy food that are broadcast during breakfast time but would also generate healthy eating patterns within the family.

- Assessment of price and nutritional quality of gluten-free products versus their analogues with gluten through the algorithm of the nutri-score front-of-package labeling system

Abstract
Evidence has shown that the nutritional quality of gluten-free products (GFPs) is lower than that of non-GFPs. Our main objective was to compare the nutritional quality through nutritional profiles of foods underlying the Nutri-Score front-of-pack and the price of GFPs with respect to non-GFPs, and to evaluate whether there is a correlation between both parameters. Nutritional information of all products was obtained from the CELIACBASE database and the price through Spanish supermarkets websites. Global quality using the Nutri-Score algorithm and the price were compared between both types of products. GFPs do not always have poorer quality than their counterparts. A better quality of gluten-free pasta was correlated with the higher price but also a worse quality of gluten-free muesli was correlated with the higher price. The price of GFPs compared to non-GFPs was higher up to 391.5%. However, for ham and cheese pizza, ham pizza, Marie biscuits, and baby biscuits, the difference was not statistically significant. Generally, the price of GFPs did not correlate with better nutritional quality. Nutri-Score would ease the nutritional quality identification, empowering consumers and could also influence manufacturers to improve the nutritional quality of GFPs. Nowadays, given that many GFPs have poor nutritional quality, they should be included only occasionally in a balanced gluten-free diet.

- 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)
The American Journal of Clinical Nutrition, 1er mars 2021

Abstract
BackgroundThe 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.
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.

- 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
La revue Clinical Nutrition(juillet 2020). - Clara Gómez-Donoso, Miguel Ángel Martínez-González, Aurora Pérez-Cornago, Carmen Sayón-Orea, J. Alfredo Martínez, Maira Bes-Rastrollo

Abstract
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 grams 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.
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.
Keywords :Nutrient profiling system ; Front-of-pack nutrition label ; Non-communicable diseases ; Mortality ; Cohort study

- El logotipo nutricional NutriScore en los envases de los alimentos puede ser una herramienta útil para los consumidores españoles.
Rev Esp Nutr Comunitaria 23, no 2 (2017). - Galan P, Gonzalez R, Julia C, Hercberg S, Varela-Moreiras G, Aranceta-Bartrina J, Pérez-Rodrigo C et Serra-Majem L.

Abstract
Spain as other industrialized countries face a major public health challenge in the form of the increasing burden of chronic diseases, fuelled by the rising prevalence of obesity. Nutritional risk factors have been recognized as some of the main drivers of obesity and chronic diseases in the Western world. They are key levers to public health policies as they represent modifiable determinants of health that could be addressed through primary prevention interventions. In this context, France recently announced the implementation of a novel Front-of-Pack (FOP) nutrition labelling at national level to help consumers making healthier choice at the point of purchase and to incent manufacturers to improve the nutritional quality of foods they produce. The selected system, the NutriScore, five couloured label has been the object of scientific research for validation purposes. The objective of the present narrative review is to examine the existing literature on the development, validation and testing of the NutriScore. Elements of the validity of the nutrient profiling system underlying the label as well as the format of the label were investigated. Scientific evidence suggests that the nutrient profiling system underlying the Nutriscore FOP label can adequately characterize the nutritional quality of foods and may be associated at individual level with chronic diseases onset. Finally, the format of the NutriScore (and its former version, the 5-Colour Nutrition Label, 5-CNL) appears as a well-perceived and understood label. The NutriScore was associated with a higher nutritional quality of purchases in experimental and large scale trials. Altogether, these elements tend to corroborate the NutriScore as an efficient tool in public health nutrition for Spain.
Key words : Nutriscore ; Front-of-pack labelling ; nutritional quality of foods ; information ; prevention.

- Comprension de differentes etiquetados frontales en población española : Resultados deun estudio comparativo
Endocrinología, Diabetes y Nutrición - Galan P, Egnell M, Salas-Salvadó J, Babio N, Pettigrew S, Hercberg S, Julia C.

Abstract
Background and objectives :Increased prevalence of obesity and its comorbidities has shown the need to implement social policies to help curb this trend. Nutritional risk factors are recognized as key drivers of obesity and other chronic diseases in Spain and in other Western countries. Front-of-package labels (FoPLs) are efficient tools to help consumers make healthier choices. To be useful in purchasing situations, consumers need to understand the information provided by FoPLs. The study objective was to assess objective understanding by consumers of five types of FoPLs, i.e. Health Star Rating system (HSR), Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes (RIs), and Warning symbol in Spain.
Methods : In 2018, 1,000 Spanish participants were recruited and requested to rank three sets of label-free products (one set of three pizzas, one set of three cakes, and one set of three breakfast cereals) according to their nutritional quality in an on-line survey. Participants were then randomized to one of the five types of FoPLs, and were requested to rank the same sets of products again, this time with a given FoPL displayed on the package. Changes in ability to correctly rank products according to FoPLs were compared between both tasks using ordinal logistic regression.
Results :For all three food categories, Nutri-Score performed significantly better, followed by MTL, the Warning symbol, HSR and RIs.
Conclusions :Nutri-Score emerged as the most efficient FoPL in conveying information on the nutritional quality of foods among Spanish consumers.
Key words : Food labeling ; Spanish consumer behavior ; Nutrition policy.

DOI : 10.1016/j.endinu.2019.03.013

- El logotipo nutricional NutriScore en los envases de los alimentos puede ser una herramienta útil para los consumidores españoles.
Rev Esp Nutr Comunitaria 23, no 2 (2017).
Galan P, Gonzalez R, Julia C, Hercberg S, Varela-Moreiras G, Aranceta-Bartrina J, Pérez-Rodrigo C et Serra-Majem L.

Abstract
Spain as other industrialized countries face a major public health challenge in the form of the increasing burden of chronic diseases, fuelled by the rising prevalence of obesity. Nutritional risk factors have been recognized as some of the main drivers of obesity and chronic diseases in the Western world. They are key levers to public health policies as they represent modifiable determinants of health that could be addressed through primary prevention interventions. In this context, France recently announced the implementation of a novel Front-of-Pack (FOP) nutrition labelling at national level to help consumers making healthier choice at the point of purchase and to incent manufacturers to improve the nutritional quality of foods they produce. The selected system, the NutriScore, five couloured label has been the object of scientific research for validation purposes. The objective of the present narrative review is to examine the existing literature on the development, validation and testing of the NutriScore. Elements of the validity of the nutrient profiling system underlying the label as well as the format of the label were investigated. Scientific evidence suggests that the nutrient profiling system underlying the Nutriscore FOP label can adequately characterize the nutritional quality of foods and may be associated at individual level with chronic diseases onset. Finally, the format of the NutriScore (and its former version, the 5-Colour Nutrition Label, 5-CNL) appears as a well-perceived and understood label. The NutriScore was associated with a higher nutritional quality of purchases in experimental and large scale trials. Altogether, these elements tend to corroborate the NutriScore as an efficient tool in public health nutrition for Spain.
Key words : Nutriscore ; Front-of-pack labelling ; nutritional quality of foods ; information ; prevention.

- Nutri-Score : el logotipo frontal de información nutricional útil para la salud pública de España que se apoya sobre basas científicas
Nutrición Hospitalaria 2019 ; 36 (5):1213-1222
Galan P, Babio N, Salas Salvadó J

Abstract
The Spanish Ministry of Health, in November 2018, notified the officially adoption of the front-of-pack nutrition label Nutri-Score which will allow consumers to easily judge the nutritional quality of food at the time of purchase and to encourage industrialists to improve the nutritional composition of food. This article synthesizes the scientific work pertaining to the validation of the nutritional profile that underlies the computation of Nutri-Score and works that demonstrate its effectiveness and superiority in comparison to other existing logos or proposed by food companies. Likewise, it highlights its development in Spain and within the European Union and responds to the fake-news raised by its detractors. It also introduces the European Citizens’ Initiative to make it compulsory in Europe.

Grèce

- Dietary Intake Assessment of Pre-Packed Graviera Cheese in Greece and Nutritional Characterization Using the Nutri-Score Front of Pack Label Scheme

Abstract
Gravieras are ’gruyere’ type hard cheeses with a variety of different products and the second highest consumption in Greece. In this study, we present a dietary intake assessment and a nutritional characterization of pre-packed graviera products sold in the Greek market using Nutri-Score Front of Pack Label (FoPL). The nutrient contents of 92 pre-packed graviera products were combined with daily individual consumption data extracted from the Hellenic National Nutrition Health Survey (n = 93), attempting to evaluate the contribution of graviera’s consumption to the Greek diet. The analysis of nutrients’ intake as a Reference Intake (RI) percentage ranked saturated fat first on the nutrients’ intake list, with RI percentage ranging from 36.1 to 109.2% for the 95th percentile of consumption. The respective % RI for energy, total fat, carbohydrates, sugars, proteins and salt ranged from 12.7-20.7%, 21.6-50.4%, 0-3.1%, 0-6.1%, 37-57.1% and 6.3-42%. Nutri-Score classified 1% of the products to C-light orange class, 62% to D-orange and 37% to E-dark orange, while no products were classified to A-dark green or B-green classes. The comparison between the Nutri-Score classification and the nutrients’ intake assessment, also separately conducted within the classes, showed a higher salt intake after the consumption of products classified as D-orange and E-dark orange.

Italie

- Effects on consumers’ subjective understanding of a new front-of-pack nutritional label : a study on Italian consumers
International Journal of Food Sciences and Nutrition

Abstract
Front-of-pack nutritional label (FOPL) systems have been developed worldwide to amplify and simplify nutritional information and induce healthier choices. This study explores consumers’ internal reactions – in terms of subjective understanding and liking – to a new FOPL : the NutrInform Battery. The investigation aims to assess the clear comprehension by consumers of the information provided by the NutrInform Battery FOPL scheme, based on a sample of 200 Italian respondents, in a real-life setting, with products representative of the most widely consumed food categories, using a between-subject design. Participants were randomly assigned to one of the two conditions : products marked with NutrInform Battery or Nutri-Score labels. The results provided evidence of the effectiveness of NutrInform Battery in being perceived by consumers as an informative FOPL scheme. Specifically, consumers found NutrInform Battery more informative and helpful than Nutri-Score in terms of their understanding of the product composition.

- Effectiveness of Different Front-of-Pack Nutrition Labels among Italian Consumers : Results from an Online Randomized Controlled Trial
Nutrients (2020)
Fialon M, Egnell M, Talati Z, Galan P, Dréano-Trécant L, Touvier M, et al.

Astract
In Italy, discussions are currently ongoing to implement a front-of-pack nutrition label (FoPL) while a growing number of European countries are adopting the Nutri-Score. The effectiveness of the Nutri-Score among Italian consumers requires further investigation. This study compared five FoPLs among Italian participants (Health Star Rating system, multiple traffic lights, Nutri-Score, reference intakes, warning symbol) in terms of food choices and understanding of the labels by consumers. In 2019, 1032 Italian consumers completed an online survey in which they were asked to select one product they would likely purchase from a set of three foods with different nutrient profiles and then classify the products within the set according to their nutritional quality, first with no label and then with one of the five FoPLs on the pack. While no significant difference across labels was observed for food choices, the Nutri-Score demonstrated the highest overall performance in helping consumers to correctly rank the products according to their nutritional quality compared to the reference intakes (OR = 2.18 (1.50–3.17), p-value < 0.0001). Our results provide new insights on the effectiveness of the Nutri-Score, which would be a relevant tool to inform Italian consumers on the nutritional quality of food products.
Keywords : nutritional labeling ; food choices ; comprehension ; front-of-pack nutrition label ; Italian consumers ; Nutri-Score

Maroc

- Comparison of appropriateness of Nutri-Score and other front-of-pack nutrition labels across a group of Moroccan consumers : awareness, understanding and food choices
Archives of public health-BMC (May 2021)

Abstract
Background : The front of pack nutrition label Nutri-Score, intended to help consumers orient their choices towards foods that are more favorable to health, was developed in France and applied in several European countries. Consideration is underway for its use in Morocco. This study aims to assess Moroccan consumers’ perception and objective understanding of Nutri-Score and 4 other nutritional information labels (Health Star Rating, Health warning, Reference Intakes and Multiple Trafic Light) and their impact on purchase intentions.

- Le logo nutritionnel Nutri-Score : un outil au service du consommateur marocain.
Revue Marocaine des Sciences Agronomiques et Vétérinaires 6, no 3 (2018).
Aguenaou H, Julia C, El Hajjab A, Galan P, El Berri H, Brahimi M, Belkhadir J, Heikel J, Hercberg S.


Mexique

- Impact of different front-of-pack nutrition labels on foods according to their nutritional quality : a comparative study in Mexico
Salud Publica Mex. oct 2019 ;61(5):609‑18
Hernández-Nava LG, Egnell M, Aguilar-Salinas CA, Córdova-Villalobos JÁ, Barriguete-Meléndez JA, Pettigrew S, et al.

Abstract
Objective : This study aimed to compare consumers’ objective understanding of five FoPLs [Health Star Rating system(HSR), Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes (RIs), Warning Symbol] in Mexico. Materials and
Methods : 1 001 Mexican consumers were recruited and asked to rank three sets of label-free products according to
their nutritional quality, via a survey. Upon completion of this task, participants were randomized to one of five FoPL conditions and were again asked to rank the same sets of products, this time with a FoPL displayed on pack. Change in ability to correctly rank products across the two tasks was assessed by FoPL using ordinal logistic regression. Results. Nutri-Score and MTL performed best, followed Warning Symbol, HSR and RIs.
Conclusion : Nutri-Score and MTL appear as efficient schemes to inform consumers on the nutritional quality of foods, in particular in Mexico, where it would

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Pays-Bas



- The impact of the nutri-score on food choice : A choice experiment in a Dutch supermarket
Elsevier, 25 August 2021
Karolien van den Akker, Dimona Bartelet, Lotte Brouwer, Syrah Luijpers, Tobias Nap, Remco Havermans

Abstract
Front-of-package (FOP) nutrition labels are placed on products to help consumers make healthy food choices. A lab-in-field experiment was conducted to test the effectiveness of two FOP labels in promoting healthy food choices among Dutch consumers, and to examine whether dieters and health conscious shoppers are more likely to use the FOP labels. In addition, it was examined whether the placement of relatively “good” FOP label scores on products might inadvertently lead to increases in serving sizes. Participants (N = 300) consisted of Dutch consumers shopping for groceries in a local supermarket. They were randomly assigned to one of three conditions (Nutri-score, Multiple Traffic Light (MTL) label, or no label control condition), presented with six different (labeled) cereals, and asked to make a choice. Next, participants were shown a product with a relatively good label score and selected their desired serving size. The results show that the Nutri-score promotes choice of the healthiest cereal. Dieting behaviour and health conscious shopping did not moderate this effect, and the labels did not affect serving size selection. Overall, the study provides evidence for the Nutri-score to promote healthy food choices among Dutch consumers.

- Consumer’ Responses to Front-of-Pack Nutrition Labelling : Results from a Sample from The Netherlands
Nutrients. 6 août 2019 ;11(8):1817.
Egnell, Talati, Gombaud, Galan, Hercberg, Pettigrew, et al.

Abstract
Front-of-pack labels (FoPLs) are efficient tools for helping consumers identify healthier food products. Although discussions on nutritional labelling are currently ongoing in Europe, few studies have compared the effectiveness of FoPLs in European countries, including the Netherlands.
This study aimed to compare five FoPLs among Dutch participants (the Health Star Rating (HSR) system, Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes (RIs), and Warning symbols) in terms of perception and understanding of the labels and food choices. In 2019,
1032 Dutch consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles, and then rank the products within the sets according to their nutritional quality. These tasks were performed with no label and then with one of the five FoPLs on the package, depending on the randomization arm.
Finally, participants were questioned on their perceptions regarding the label to which they were exposed. Regarding perceptions, all FoPLs were favorably perceived but with only marginal differences between FoPLs.
While no significant difference across labels was observed for food choices, the Nutri-Score demonstrated the highest overall performance in helping consumers rank the products according to their nutritional quality.

Portugal

- Nutri-Score : A Public Health Tool to Improve Eating Habits in Portugal
Acta Med Port 2019 Mar ;32(3):175-178
Goiana-Da-Silva F, Cruz-E-Silva D, Gregório MJ, Nunes AM, Calhau C, Hercberg S, Rito A, Bento A, Cruz D, Almeida F, Darzi A, Araújo F.


Singapour

- A Randomized Controlled Trial Evaluating the Relative Effectiveness of the Multiple Traffic Light and Nutri-Score Front of Package Nutrition Labels
Nutrients. 17 sept 2019 ;11(9).
Finkelstein EA, Ang FJL, Doble B, Wong WHM, van Dam RM.

Abstract
The objective of this trial was to test two promising front-of-pack nutrition labels, 1) the United Kingdom’s Multiple Traffic Lights (MTL) label and 2) France’s Nutri-Score (NS), relative to a no-label control. We hypothesized that both labels would improve diet quality but NS would be more effective due to its greater simplicity. We tested this hypothesis via an online grocery store using a 3 × 3 crossover (within-person) design with 154 participants. Outcomes assessed via within person regression models include a modified Alternative Healthy Eating Index (AHEI)-2010 (primary), average Nutri-Score, calories purchased, and singular measures of diet quality of purchase orders. Results show that both labels significantly improve modified AHEI scores relative to Control but neither is statistically superior using this measure. NS performed statistically better than MTL and Control based on average Nutri-Score, yet, unlike MTL it did not statistically reduce calories or sugar from beverages. This suggest that NS may be preferred if the goal is to improve overall diet quality but, because calories are clearly displayed on the label, MTL may perform better if the goal is to reduce total energy intake.

Suisse

- Compared to other front-of-pack nutrition labels, the Nutri-Score emerged as the most efficient to inform Swiss consumers on the nutritional quality of food products
PLOS ONE (2020)
Egnell M, Galan P, Farpour-Lambert NJ, Talati Z, Pettigrew S, Hercberg S, et al.

Abstract
Background : Switzerland, like other high-income countries, is facing a major public health challenge with the increasing burden of non-communicable diseases. Discussions are currently on-going in Switzerland regarding the implementation of a Front-of-Pack nutrition label (FoPL) as a public health measure to guide consumers towards healthier food choices, and the Nutri-Score represents an alternative supported by multiple actors. To date, no studies have investigated the performance of the Nutri-Score among Swiss consumers. This study aimed to compare the response of Swiss consumers to five FoPLs (Health Star Rating system, Multiple Traffic Lights, Nutri-Score, Reference Intakes and Warning symbol) in terms of perception and understanding of these labels and effects on food choices.
Methods :In 2019, 1,088 Swiss consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles and then classify the products within the sets according to their nutritional quality. Tasks were performed in situations without a label and then with one of the five FoPLs–depending on the group in which they were randomized–on the pack. Finally, participants were questioned on their perceptions regarding the label to which they were exposed.
Results :All FoPLs were favorably perceived, with marginal differences between FoPLs. The Nutri-Score demonstrated the highest percentage of improvement in food choices and the highest overall performance in helping consumers rank the products according to their nutritional quality.
Conclusion :Overall, the Nutri-Score was the most efficient FoPL in informing Swiss consumers of the nutritional quality of food products, and as such could be a useful tool to improve food choices and reduce the burden of chronic diseases in Switzerland.