Association between nutritional profiles of foods underlying Nutri-Score front-of-pack labels and mortality: EPIC cohort study in 10 European countries
Authors: Deschasaux Mélanie , Huybrechts Inge , Julia Chantal , Hercberg Serge , Egnell Manon , Srour Bernard , Kesse-Guyot Emmanuelle , Latino-Martel Paule , Biessy Carine , Casagrande Corinne , Murphy Neil , Jenab Mazda , Ward Heather A , Weiderpass Elisabete , Overvad Kim , Tjønneland Anne , Rostgaard-Hansen Agnetha Linn , Boutron-Ruault Marie-Christine , Mancini Francesca Romana , Mahamat-Saleh Yahya , Kühn Tilman , Katzke Verena , Bergmann Manuela M , Schulze Matthias B , Trichopoulou Antonia , Karakatsani Anna , Peppa Eleni , Masala Giovanna , Agnoli Claudia , De Magistris Maria Santucci , Tumino Rosario , Sacerdote Carlotta , Boer Jolanda MA , Verschuren WM Monique , van der Schouw Yvonne T , Skeie Guri , Braaten Tonje , Redondo M Luisa , Agudo Antonio , Petrova Dafina , Colorado-Yohar Sandra M , Barricarte Aurelio , Amiano Pilar , Sonestedt Emily , Ericson Ulrika , Otten Julia , Sundström Björn , Wareham Nicholas J , Forouhi Nita G , Vineis Paolo , Tsilidis Konstantinos K , Knuppel Anika , Papier Keren , Ferrari Pietro , Riboli Elio , Gunter Marc J , Touvier Mathilde 
Published: September 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.