Association between nutritional profiles of foods underlying Nutri-Score front-of-pack labels and mortality: EPIC cohort study in 10 European countries [营养评分标签下食品营养状况与死亡率的关系：10个欧洲国家的EPIC队列研究]

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

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

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.