Modifying the Health Star Rating nutrient profiling algorithm to account for ultra-processing.

AIM: To modify the Australian and New Zealand Health Star Rating to account for ultra-processing and compare the alignment of the modified ratings with NOVA classifications and the current Australian Dietary Guidelines classifications of core (recommended foods) and discretionary (foods to limit). METHODS: Data was cross-sectionally analysed for 25 486 products. Four approaches were compared to the original Health Star Rating: (1) five 'negative' points added to ultra-processed products (modification 1; inclusion approach); (2) ultra-processed products restricted to a maximum of 3.0 Health Stars (modification 2; capping approach); (3 and 4) same approach used for modifications 1 and 2 but only applied to products that already exceeded 10 'negative' points from existing Health Star Rating attributes (modifications 3 and 4, respectively; hybrid approaches). Alignment occurred when products (i) received <3.5 Health Stars and were NOVA group 4 (for NOVA comparison) or discretionary (for Dietary Guidelines comparison), or (ii) received ≥3.5 Health Stars and were NOVA groups 1-3 or core. RESULTS: All Health Star Rating modifications resulted in greater alignment with NOVA (ranging from 69% to 88%) compared to the original Health Star Rating (66%). None of the modifications resulted in greater alignment to the Dietary Guidelines classifications overall (69% to 76%, compared with 77% for the original Health Star Rating), but alignment varied considerably by food category. CONCLUSIONS: If ultra-processing were incorporated into the Australian and New Zealand Health Star Rating, consideration of ultra-processing within the broader dietary guidance framework would be essential to ensure coherent dietary messaging to Australians.

Evaluation of the nutritional quality of French children breakfasts according to the Breakfast Quality Score (BQS).

Background: Breakfast meals provide essential nutrients and energy to children and adolescents. Based on recommendations from the International Breakfast Research Initiative (IBRI), the Breakfast Quality Score (BQS) was developed to assess breakfast nutritional value among the French adult population. However, its application to children remains unexplored. Objective: This study aimed to evaluate the BQS in assessing the nutritional quality of breakfasts consumed by French children aged 4-17 years. Methods: A total of 4,015 breakfasts, obtained from dietary recalls provided by 1,448 children participating in the French representative dietary survey (INCA3), were analyzed. As for adults, the performance of the BQS was tested through correlations with other nutritional indicators and comparison of nutrients and dietary components between tertiles of scores. The study examined the regularity of breakfast consumption and compared the BQS of children's breakfasts across socio-demographic modalities and breakfast categories distinguished by their primary grain component. Additionally, a predictive modeling using Partial Least Squares (PLS) regression identified influential INCA3 food groups. Results: The majority of children consumed solid breakfasts regularly. Socio-professional category, household income and food insecurity influenced BQS, revealing contradictory disparities. Ready-to-eat cereal (RTEC) breakfasts had the highest BQS (73.5% for children and 73.1% for adolescent), while biscuits and viennoiseries scored the lowest (52% for children and 49.1% for adolescent). PLS highlighted RTECs, milk, and hot beverages (mainly containing chocolate milk) as being positively associated with BQS, while sweet beverages and viennoiseries were negatively associated. Conclusion: The study demonstrates the effectiveness of the BQS in assessing children's breakfast quality, with RTEC breakfasts showing the highest nutritional value. The findings provide insights into factors influencing breakfast nutritional quality and underscore the importance of promoting healthier breakfast choices among all children.

What Is the Nutritional Quality of Pre-Packed Foods Marketed to Children in Food Stores? A Survey in Switzerland.

Food marketing targeting children influences their choices and dietary habits, and mainly promotes food high in fat, sugar, and salt as well as ultra-processed food. The aim of this study was to assess the nutritional quality of food and beverages marketed to children over the age of 3 and available on the Swiss market. Products with at least one marketing technique targeting children on the packaging were selected from five food store chains. Three criteria to assess nutritional quality were used: (1) nutritional composition (using the Nutri-Score), (2) degree of processing (NOVA classification), and (3) compliance with the World Health Organization (WHO) Nutrient Profile Model (NPM). A total of 735 products were found and analyzed. The most common marketing techniques used were childish names/fonts (46.9%), special characters (39.6%), and children's drawings (31.3%). Most products had a Nutri-Score of D or E (58.0%) and were ultra-processed (91.8%). Only 10.2% of products displayed the Nutri-Score. The least processed products generally had a better Nutri-Score (p < 0.001). Most products (92.8%) did not meet the criteria of the WHO NPM. Products that met the WHO NPM criteria, organic products, and products with a nutritional claim generally had a better Nutri-Score and were less processed (ps < 0.05). Pre-packaged foods and beverages marketed to children in the Swiss market were mostly of poor nutritional quality. Public health measures should be adopted to improve the nutritional quality of foods marketed to children in Switzerland and restrict the marketing of unhealthy foods to children.

Modelling Food Substitution Using the Ofcom Nutrient Profiling Model on Population Intakes from the Canadian Community Health Survey-Nutrition 2015.

This study aimed to model how substituting foods consumed by Canadians for alternatives with more favourable nutrient profiling (NP) scores would impact dietary intakes. The Ofcom NP system, developed to help the UK Office of Communication differentiate foods that can be advertised to children, was applied to foods consumed by Canadians aged 2 years and older in the 2015 Canadian Community Health Survey (CCHS) (n = 19,447). Foods were substituted for similar options from the Euromonitor branded food composition database (Scenario 1) or from the primarily aggregated food profiles in the CCHS survey food composition database (Scenario 2) with either the most favourable (optimistic; 1A and 2A) or a more favourable Ofcom score (realistic; 1B and 2B). Mean intakes of Ofcom scores, calories, saturated fat, sugars, and sodium from these scenarios were compared to baseline. Only 2.9% of foods consumed had a similar Euromonitor option with a lower Ofcom score. Scenarios 1A, 1B, and 2A had lower Ofcom scores, calorie, sodium, saturated fat, and sugar intakes compared to baseline. Scenario 2B had lower levels of all outcome measures, except for an increase in calories compared to baseline. Selection of foods with more favourable NP scores has the potential to decrease the Canadian intake of nutrients of concern.

Compliance of Australian commercial foods for young children (<36 months) with an international nutrient and promotion profile model.

OBJECTIVE: To assess how Australian infant and toddler foods compare to a nutrient and promotion profile model (NPPM) developed by the World Health Organization to support the appropriate promotion of commercial food products for children aged 6-36 months. METHODS: A cross-sectional audit of infant and toddler foods found at three major Australian supermarkets was conducted in September/October 2022. Using nutrition and promotional data extracted from the packaging, products were classified according to NPPM categories and assessed against relevant compositional, front-of-pack labelling and promotional requirements. RESULTS: Of 330 eligible products identified, just 28% met all NPPM compositional requirements. Toddler foods were less compliant than infant foods overall (18% vs. 31%; p=0.021), and for specific nutrients such as sodium (75% vs. 89%; p=0.003). No products met all NPPM front-of-pack labelling/promotional requirements. Only two-thirds and two-fifths of products were compliant with product name and ingredient list requirements, respectively. CONCLUSION: Australian infant and toddler foods do not fully comply with the NPPM requirements. While toddler foods performed comparatively worse in terms of their nutritional adequacy, there is considerable scope to improve the nutrient profile of both infant and toddler foods. IMPLICATIONS FOR PUBLIC HEALTH: To better support young children's health and development, the introduction of mandatory nutrition standards for Australian toddler foods, and the improvement of nutrition standards for Australian infant foods, in line with the NPPM, is needed. To be most effective, these should be combined with regulations for the labelling and promotion of these foods in line with the NPPM.

A novel Nutrient Rich Food (NRFa11.3) score uses flavonoids and carotenoids to identify antioxidant-rich spices, herbs, vegetables, and fruit.

Introduction: Nutrient profiling (NP) models designed to evaluate the healthfulness of plant-based foods ought to incorporate bioactive phytochemicals. Herbs and spices are one food group of current interest. Methods: Two new versions of the well-established Nutrient Rich Food (NRF) index were applied to spices, herbs, vegetables, fruit, and other plant-based foods. Analyses used the US Department of Agriculture (USDA) SR-28 nutrient composition database merged with the USDA Expanded Flavonoid database 3.3. The NRF4.3 model was based on protein, fiber, potassium, and vitamin C. The NRFa11.3 model was based on micronutrients with reported antioxidant activity (vitamin C, vitamin E, selenium, copper, and zinc), carotenoids (alpha and beta carotene, beta-cryptoxanthin, lycopene, lutein/zeaxantin) and flavonoids. Saturated fat, added sugar, and sodium were nutrients to limit. The NRF algorithm was based on sums of percent daily values (%DVs) capped at 100%. Results: The NRF4.3 model awarded high scores to herbs and spices, cocoa powder, and nuts, but did not discriminate well among vegetables and fruit. The NRFa11.3 model performed better. Green leafy, red orange and cruciferous vegetables had the highest carotenoid content. Highest in flavonoids were cocoa powder, herbs and spices, and berries. Highest combined NRFa11.3 values were observed for herbs and spices, green leafy vegetables, cocoa, nuts, and red-orange and cruciferous vegetables. Discussion: Fresh and dry herbs and spices, often ignored by NP models, were particularly nutrient-rich and may provide non-negligible amounts of key phytonutrients to the human diet.

Development and Validation of the Meiji Nutritional Profiling System (Meiji NPS) to Address Dietary Needs of Adults and Older Adults in Japan.

This study introduces the Meiji Nutritional Profiling System (Meiji NPS), which was specifically designed to respond to age-related shifts in nutrient requirements among Japanese adults (<65 years old) and older adults (≥65 years old). Japan has one of the most aged societies in the world. The health issues of interest are malnutrition and lifestyle-related diseases among adults and frailty among older adults. Two versions of the NPS were developed based on nutrients to encourage (protein, dietary fibers, calcium, iron, and vitamin D), food groups to encourage (fruits, vegetables, nuts, legumes, and dairy), and nutrients to limit (energy, saturated fatty acids, sugars, and salt equivalents). The Meiji NPS for older adults did not include iron or saturated fatty acids. The algorithms were based on the Nutrient-Rich Foods Index (NRF). The convergent validity between the Meiji NPS and the existing NPSs for the same foods was confirmed using Spearman's correlation coefficients (NRF: r = 0.67 for adults and r = 0.60 for older adults; Health Star Rating: r = 0.64 for adults and r = 0.61 for older adults). The Meiji NPS may be useful for nutritional evaluation and reformulation of food products, tailored to adults and older adults to ameliorate health issues in Japan.

Aligning front-of-pack labelling with dietary guidelines: including whole grains in the health star rating.

PURPOSE: Front-of-pack labelling systems, such as the Health Star Rating (HSR), aim to aid healthy consumer dietary choices and complement national dietary guidelines. Dietary guidelines aim to be holistic by extending beyond the individual nutrients of food, including other food components that indicate diet quality, including whole grains. We aimed to test the feasibility of including whole grains in the HSR algorithm, to better inform dietary guidance in Australia coherent with existing dietary guidelines. METHODS: We assigned whole-grain points as a favourable component of the HSR based on the whole-grain content of foods. We compared the original, and three modified HSR algorithms (including altered thresholds for star ratings) using independent-samples median tests. Finally, we used Spearman's correlation to measure the strength of association between an item's nutritional composition (all components of the HSR algorithm including all favourable and unfavourable components) and their HSR using each algorithm. RESULTS: Up to 10 points were added for products with ≥ 50% whole-grain content, with no points for products with < 25%. Adjusting the HSR score cut-off by 3 points for grain products created the greatest difference in median HSR between refined and whole-grain items (up to 2 stars difference), compared to the original algorithm (a maximum of 1 star). CONCLUSIONS: The addition of whole grains to the HSR algorithm improved the differentiation of refined and whole-grain items, and therefore better aligned with dietary guidelines. Holistic approaches to food guidance systems are required to provide consistent messaging and inform positive food choices.

Influencing intertidal food web: Implications of ocean acidification on the physiological energetics of key species the 'wedge' clam Donax faba.

Ocean acidification has become increasingly severe in coastal areas. It poses emerging threats to coastal organisms and influences ecological functioning. Donax faba, a dominant clam in the intertidal zone of the Bay of Bengal, plays an important role in the coastal food web. This clam has been widely consumed by the local communities and also acts as a staple diet for shorebirds and crustaceans. In this paper, we investigated how acidified conditions will influence the physiology, biochemical constituents, and energetics of Donax faba. Upon incubation for 2 months in lowered pH 7.7 ± 0.05 and control 8.1 ± 0.05 conditions, we found a delayed growth in the acidified conditions followed by decrease in calcium ions in the clam shell. Although not significant, we found the digestive enzymes showed a downward trend. Total antioxidant was significantly increased in the acidified condition compared to the control. Though not significant, the expression level of MDA and antioxidant enzymes (SOD, CAT, GST, GPX, and APX) showed increasing trend in acidified samples. Among nutrients such as amino acids and fatty acids, there was no significant difference between treatments, however, showed a downward trend in the acidified conditions compared to control. Among the minerals, iron and zinc showed significant increase in the acidified conditions. The above results suggest that the clam growth, and physiological energetics may have deleterious effects if exposed for longer durations at lowered pH condition thereby affecting the organisms involved in the coastal food web.

Availability and properties of commercially produced food products offered in European public universities: A North-South comparison.

To date, there are no studies that have compared university food environments (FEs) with different sociocultural contexts. Therefore, we analyzed differences in the availability and properties of commercially produced foods, in a northern and a southern European university (located in Norway and Spain, respectively). A cross-sectional observational study was conducted at OsloMet-Oslo Metropolitan University and at the University of the Basque Country UPV/EHU. The nutritional quality of food products was estimated through the following nutrient profiling models (NPMs): those proposed by the Spanish Agency for Consumer Affairs, Food Safety and Nutrition (AECOSAN), the UK nutrient profiling model (UK NPM), the Norwegian Food and Drink Industry Professional Practices Committee (Matbransjens Fagligle Utvalg [MFU]), and a combination of them. In addition, food items were classified using the NOVA system. A total of 251 and 1051 products were identified at OsloMet and the UPV/EHU, respectively. The percentage categorized as low nutritional quality (LNQ) was higher at the UPV/EHU (almost 54.5% of the total products) compared with at OsloMet (almost 40%) (p < 0.001). Most of the products were categorized as ultra-processed, and there were no differences in the percentage of ultra-processed foods between the two universities (OsloMet 86.1%, UPV/EHU 83.3%, p > 0.05). A higher proportion of LNQ products was found at the UPV/EHU than at OsloMet, probably due to the government policies and actions for creating healthy FEs. Consequently, there is a need to develop interventions to improve the FE at the UPV/EHU, adapted to its sociocultural context. PRACTICAL APPLICATION: This study reveals north-south differences in terms of the availability of low nutritional quality food products. In particular, a higher proportion of this type of product was found at the University of the Basque Country UPV/EHU than at OsloMet-Oslo Metropolitan University. Our exploratory hypothesis is that this phenomenon is a consequence of the Nordic government policies that have great potential to create healthy FEs.

Evaluation of the Nutritional Quality of Chinese Processed Meat Products: Comparison of Two Nutrient Profile Models.

Processed meat products are one of the most consumed pre-packaged foods in China. They are also group-1 carcinogens, whose consumption has proved to be positively associated with the risk of noncommunicable diseases (NCDs). The purpose of this study is to analyze the nutrient content on the food label of processed meat products based on the China Standardized Database for the Composition of Pre-packaged Food and the National Open Database of the UK and France. The Chilean front-of-pack warning label (FOPWL) and the Chinese Healthier Choice Logo were used to compare the nutrient content of processed meat products from the three countries. It was found that cured meat products have the highest median energy (483 kcal/100 g), total fat content (38.7 g/100 g), and sodium content (2076 mg/100 g) and dried meat products have the highest median protein content (30.2 g/100 g) and carbohydrate content (38.2 g/100 g). In addition, there were significant differences in energy content and contents of total fat, protein, and carbohydrate across different products of the three countries (p < 0.001). A large number of processed meat products currently collected did not meet the criteria of the Chilean FOPWL and the Chinese Healthier Choice Logo. This study provided information on the healthiness of Chinese processed meat products and provided data for improving food formulations for different categories of processed meat products.

Food Compass and the challenge of sustainability on the route towards healthful diets.

In order to tackle the global increase in overweight and obesity prevalence, several nutrient profiling systems have been developed; among others, Food Compass Score (FCS) has been designed to encompass multiple domains of food healthfulness. However, environmental sustainability of healthy diets is another crucial dimension which should not be overlooked in the context of human health. The aim of the present study is to assess the association between healthiness and environmental sustainability of food items, using the FCS and Agribalyse databases, respectively. A total of 806 matching food items were identified, grouped in 12 food categories; within each category, differences in median Z-scores between FCS and Single Environmental Footprint (EF) Score were assessed. While Fruits, Legumes and Nuts, Mixed foods, Meat Poultry and Eggs (MPE), Savory and Sweets, and Vegetables showed statistically significant differences (all p < 0.001), Beverages (p = 0.361), Dairy (p = 0.092), Fats and Oils (p = 0.594), Grains (p = 0.436), Sauce and Condiments (p = 0.093), and Seafood (p = 0.241) had similar Food Compass and Single EF Z-scores distributions. These findings underscore a relevant lack of difference between healthfulness and environmental impact of some prominent food categories, such as Grains and Seafood. Therefore, we suggest matching nutrient profiling systems with adequate environmental sustainability indices.

Perspective: Potatoes, Quality Carbohydrates, and Dietary Patterns.

Potatoes have long been a staple food in many cultures and cuisines, but they have gained a reputation as a low-quality carbohydrate source that should be avoided in the diet. Historically, this view has been justified by citing the glycemic index of potatoes as the main indicator of their quality. However, their nutrient composition should also be considered. The association of potatoes with energy-dense Western dietary patterns has also contributed to a perception that potatoes are inherently unhealthy. Although some studies have suggested an association between potato consumption and increased risk of health problems, such as type 2 diabetes, these associations may be confounded by fried potato intake and are strongest at intake levels higher than average consumption rates. Epidemiologic data suggest total potato intake is not a health risk in Eastern populations and can be consumed as part of a healthy diet. Furthermore, clinical trial data demonstrate that potatoes' health impact, irrespective of preparation, is similar to legumes and comparable with refined grains, with few deleterious effects found. These findings highlight the importance of moving beyond the glycemic index and adopting a more nuanced evaluation of the epidemiologic data to better understand the health impact of potato intake. Ultimately, the negative reputation of potatoes stems from an overinterpretation of their glycemic index and association with unhealthy Western dietary patterns, as well as oversimplification of the epidemiologic data. By considering carbohydrate quality, it becomes clear that potatoes can be part of a healthy diet given the proper consideration.

Complementarity between the updated version of the front-of-pack nutrition label Nutri-Score and the food-processing NOVA classification.

OBJECTIVE: To compare the initial and the updated versions of the front-of-pack label Nutri-Score (related to the nutritional content) with the NOVA classification (related to the degree of food processing) at the food level. DESIGN: Using the OpenFoodFacts database - 129,950 food products - we assessed the complementarity between the Nutri-Score (initial and updated) with the NOVA classification through a correspondence analysis. Contingency tables between the two classification systems were used. SETTINGS: The food offer in France. PARTICIPANTS: Not applicable. RESULTS: With both versions (i.e. initial and updated) of the Nutri-Score, the majority of ultra-processed products received medium to poor Nutri-Score ratings (between 77·9 % and 87·5 % of ultra-processed products depending on the version of the algorithm). Overall, the update of the Nutri-Score algorithm led to a reduction in the number of products rated A and B and an increase in the number of products rated D or E for all NOVA categories, with unprocessed foods being the least impacted (-3·8 percentage points (-5·2 %) rated A or B and +1·3 percentage points (+12·9 %) rated D or E) and ultra-processed foods the most impacted (-9·8 percentage points (-43·4 %) rated A or B and +7·8 percentage points (+14·1 %) rated D or E). Among ultra-processed foods rated favourably with the initial Nutri-Score, artificially sweetened beverages, sweetened plant-based drinks and bread products were the most penalised categories by the revision of Nutri-Score while low-sugar flavoured waters, fruit and legume preparations were the least affected. CONCLUSION: These results indicate that the update of the Nutri-Score reinforces its coherence with the NOVA classification, even though both systems measure two distinct health dimensions at the food level.

Consistency of the Initial and Updated Version of the Nutri-Score with Food-Based Dietary Guidelines: A French Perspective.

BACKGROUND: To help consumers to make healthier food choices, 7 European countries have implemented the front-of-pack nutrition label Nutri-Score. The algorithm was updated in 2022-2023 by the Nutri-Score European scientific committee, based on the current scientific knowledge. OBJECTIVES: The aim of this study was to investigate the consistency of the newly internationally developed algorithm with the French food-based dietary guidelines (FBDG) and compare the respective performances of the initial and updated algorithm. METHODS: Three complementary French food composition databases were used to access extensive coverage of the food supply in France (n = 46,752): the Oqali, OpenFoodFacts, and CIQUAL databases. Based on the French FBDG, a list of 41 criteria was defined by which the consistency between French FBDG and the Nutri-Score was assessed (eg, consumption of fresh vegetables is promoted in FBDG, thus the Nutri-Score should rate favorably such products). RESULTS: Of all criteria, the initial algorithm met 63% (26/41) of them, whereas the revised algorithm met 85% (35/41) of them. Improvements achieved by the updated version of the Nutri-Score in alignment with the FBDG were particularly observed for high-fat products (ie, fatty fish, nuts, and seeds), sweet products (ie, ice creams and sweet spreads), salty products (ie, savory snacks and salted nuts), dairy beverages, and beverages with artificial sweeteners. CONCLUSIONS: The Nutri-Score's updated nutrient profiling system appears to rate foods more consistently regarding the French dietary guidelines and improved the currently existing system. This work supports the implementation of the updated nutrient profiling system underlying Nutri-Score.

Criterion validation of nutrient profiling systems: a systematic review and meta-analysis.

BACKGROUND: Nutrient profiling systems (NPSs) use algorithms to evaluate the nutritional quality of foods and beverages. Criterion validation, which assesses the relationship between consuming foods rated as healthier by the NPS and objective measures of health, is essential to ensure the accuracy of NPSs. OBJECTIVE: We examined and compared NPSs that have undergone criterion validity testing in relation to diet-related disease risk and risk markers. METHODS: Academic databases were searched for prospective cohort and cross-sectional studies published before November, 2022. NPSs were eligible if they incorporated multiple nutrients or food components using an algorithm to determine an overall summary indicator (e.g., a score or rank) for individual foods. Studies were included if they assessed the criterion validity of an eligible NPS. Validation evidence was first summarized in narrative form by NPS, with random effects meta-analysis where ≥2 prospective cohort studies assessed the same NPS and outcomes. RESULTS: Of 4519 publications identified, 29 describing 9 NPSs were included in the review. The Nutri-Score NPS was assessed as having substantial criterion validation evidence. Highest compared with lowest diet quality as defined by the Nutri-Score was associated with significantly lower risk of cardiovascular disease (hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.59, 0.93; n = 6), cancer (HR: 0.75; 95% CI: 0.59, 0.94; n = 5), all-cause mortality (HR: 0.74; 95% CI; 0.59, 0.91; n = 4) and change in body mass index (HR: 0.68; 95% CI: 0.50, 0.92; n = 3). The Food Standards Agency NPS, Health Star Rating, Nutrient Profiling Scoring Criterion, Food Compass, Overall Nutrition Quality Index, and the Nutrient-Rich Food Index were determined as having intermediate criterion validation evidence. Two other NPSs were determined as having limited criterion validation evidence. CONCLUSIONS: We found limited criterion validation studies compared with the number of NPSs estimated to exist. Greater emphasis on conducting and reporting on criterion validation studies across varied contexts may improve the confidence in existing NPSs.

Food Compass Score predicts incident cardiovascular disease: The ATTICA cohort study (2002-2022).

BACKGROUND: The Food Compass Score (FCS) is a novel nutrient profiling system, which evaluates food and diet quality. The present study aimed to prospectively assess the relationship of FCS with short-term (10 years) and long-term (20 years) cardiovascular disease (CVD) incidence and to explore whether this relationship is modified by long-term adherence to a Mediterranean type diet (MTD). METHODS: Volunteers of the ATTICA cohort study, with complete data for the calculation of FCS and incident CVD were included (n = 759). Development of CVD was determined at 10 and 20 years after baseline. Dietary intake was assessed through a validated food frequency questionnaire. The FCS was calculated for each participant based on the published algorithm. Long-term adherence to a MTD was evaluated through MedDietScore. RESULTS: FCS was inversely associated with CVD incidence (hazard ratio [HR] for 20-year follow-up = 0.97, 95% confidence interval [CI] = 0.95-0.99; HR for 10-year follow-up = 0.98, 95% CI = 0.96-1.01) in the total sample, as well as in those with a high baseline adherence to a MTD (HR for 20-year follow-up = 0.96, 95% CI = 0.93-0.99; HR for 10-year follow-up = 0.98, 95% CI = 0.95-1.02). FCS was also inversely associated with CVD risk in those who went away from the MTD (HR = 0.97, 95% CI = 0.96-0.99). CONCLUSIONS: FCS, a novel tool for assessing overall diet quality, was also found to be useful in identifying potential CVD candidates in a long-term period, even in populations with good background dietary habits, such as those following a MTD.

Dietary indices underpinning front-of-pack nutrition labels and health outcomes: a systematic review and meta-analysis of prospective cohort studies.

BACKGROUND: Nutrient profiling systems are increasingly used to characterize the healthfulness of foods for front-of-package (FOP) labeling, which have been proposed as an effective public health strategy to help people make healthier food choices. OBJECTIVE: This study aimed to review available evidence from cohort studies that evaluated the association of dietary indices underpinning FOP nutrition labels with all-cause mortality and incidence of cardiovascular diseases (CVDs) or cancer. METHODS: PubMed, Web of Science, and Scopus were systematically searched up to October 2023. We included articles if they were prospective cohort studies, if the exposure was any dietary index underpinning FOP nutrition labels [e.g., the modified Food Standard Agency-Nutrient Profiling System (FSAm-NPS) and the Health Star Rating System], and if outcomes were all-cause mortality or incidence of or mortality due to CVD and cancer. Random-effects models were used to calculate the pooled hazard ratios (HRs) and 95% CIs. RESULTS: We identified 11 records (7 unique prospective studies), which were included in the systematic review. The meta-analysis comprised 8 studies analyzing the FSAm-NPS dietary index (DI) as exposure. The pooled HRs associated with a 2-unit increase in the FSAm-NPS DI of all-cause mortality, CVD, and cancer risk were 1.06 (95% confidence interval [CI]: 0.99, 1.13; I2: 80%), 1.08 (95% CI: 1.00, 1.18; I2: 70%), and 1.09 (95% CI: 1.00, 1.19; I2: 77%), respectively. The Chilean Warning Label score and the Health Star Rating systems were examined by 1 study each and were significantly associated with the outcomes. CONCLUSIONS: DIs underpinning most common FOP nutrition labels and reflecting nutrient-poor diets show a tendency toward an increased incidence of CVD and cancer, but the observed effects are quite modest in magnitude. Further studies at the population level are needed to support the widely shared hypothesis that FOP labels, possibly in conjunction with other interventions, may contribute to reduce noncommunicable disease risk. This meta-analysis was registered at PROSPERO as CRD42021292625.

Improving the nutrient quality of foods and beverages using product specific standards for positive nutrients and ingredients will help to increase mean population intakes toward dietary guidelines.

Background: A shift toward more sustainable diets, rich in plant-based foods and with fewer animal-derived foods, is needed and will lead to improved health and environmental benefits. Food industry needs to play a part and broaden the scope of product reformulation beyond the reduction of nutrients to limit to increasing ingredients and nutrients in line with dietary recommendations for a healthy sustainable diet. Methods: The Positive Nutrition Standards (PNS) were defined to increase the consumption of recommended ingredients and nutrients. The PNS were set by translating WHO and Codex guidance into product group standards, considering the role of the product group in the diet. The potential impact of the PNS for vegetables, wholegrain and fibre was modeled using data from the US NHANES 2017-2018 survey, assuming that, foods consumed would be reformulated to meet the standards where relevant. Results: The modeling showed that application of the PNS could increase mean population intakes by 30% for fibre, by more than 50% for vegetables and even double the intake of wholegrain. However, reformulation alone would not be sufficient to reach recommended intake levels. Conclusion: The PNS described in this paper can help to increase intakes of relevant positive nutrients and ingredients. However, a multistakeholder approach is needed to encourage consumers to make additionally required dietary shifts to meet the recommendations for positive nutrients and ingredients.

Comparing product healthiness according to the Health Star Rating and the NOVA classification system and implications for food labelling systems: An analysis of 25 486 products in Australia.

We investigated the extent of alignment between 'healthiness' defined by a food classification system that classifies foods and beverages primarily by their nutrient composition, the Health Star Rating (HSR) and a system that considers only the degree of processing of the product, the NOVA classification system. We used data for 25 486 products contained within the George Institute for Global Health's Australian 2022 FoodSwitch Dataset. Agreement between the two systems in the proportion of products classified as 'healthier' (HSR ≥3.5 or NOVA group 1-3) or 'less healthy' (HSR <3.5 or NOVA group 4) was assessed using the κ statistic. There was 'fair' agreement (κ = 0.30, 95%CI: 0.29-0.31) between both systems in the proportion of all products classified as healthier or less healthy. Approximately one-third (n = 8729) of all products were defined as 'discordant', including 34.3% (n = 5620) of NOVA group 4 products with HSR ≥3.5 (commonly convenience foods, sports/diet foods, meat alternatives, as well as products containing non-sugar sweeteners) and 34.1% (n = 3109) of NOVA group 1-3 products with HSR <3.5 (commonly single-ingredient foods such as sugars/syrups, full-fat dairy and products specially produced to contain no ultra-processed ingredients). Our analysis strengthens the evidence for the similarities and differences in product healthiness according to a nutrient-based classification system and a processing-based classification system. Although the systems' classifications align for the majority of food and beverage products, the discordance found for some product categories indicates potential for confusion if systems are deployed alongside each other within food policies.