Chantal Julia, Food Composition Data for Food Labelling and Public Health -seminar (NordCoLa), 17.4.2019

1. History and Implementation of
the Nutri-Score
Dr. Chantal Julia
Département de Santé Publique, Hôpitaux Paris Seine-
Saint-Denis, AP-HP, Bobigny
Equipe de Recherche en Epidémiologie Nutritionnelle
(EREN), Université Paris 13, Inserm, INRA, CNAM

2. Context
• Front-of-pack nutrition
labels (FOPL)
• Complementary to the
nutrition declaration
– Considered as difficult to
understand
• FOPL
– Help consumers in decision
making
• Orient towards healthier
foods
– Entice
reformulation/innovation
towards healthier foods
1989
Sweden
2000
Finland
2005
UK
2006
Netherlands
2014
NZ-Aus
2016
Chile

3. Context
• Report to the French
Minister of Health
– Jan 2014
• New proposals in Public
Health Nutrition
– Consumer information
– Nutritional education
– Improvement of food
supply

4. FOPL proposal
• Based on scientific
literature
– Summary labels > nutrient-
based labels
• In particular for vulnerable
populations
– Affixed on all foods >
Affixed on a fraction of
foods
– Colour-coded schemes >
numerical information
• Use of ‘semantic’ colours
 Development of a graded
coloured summary label

5. Nutrient profiling system :
FSA/ofcom score
Nutrient/100g Points
Energy (KJ) 0-10
Sugars (g) 0-10
Saturated fat (g) 0-10
Sodium (g) 0-10
Element/100g Points
Fruit, vegetables and nuts (%) 0-5
Fibres (g) 0-5
Proteins (g)* 0-5
A Points
0-40 points
C Points
0-15 points
—
FINAL SCORE
Arambepola, C., Rayner et al. Pub Health Nutr 11(4), 371-378. 2008.
Julia, Kesse-Guyot et al. Br J Nut, 112(10), 1699-1705. 2014.
Julia, Kesse-Guyot et al., Nutrition Journal, (2015) 14:100
Higher nutritional
quality
Lower nutritional
quality
-15 40Adaptations for
Cheese
Beverages
Fats and oils

6. Theoretical framework
Nutrient profiling system
Adapted from Townsend et al., 2010
Application
Transposition to diet
Prospective association
health
Graphical design
Adapted from Grunert et al., 2007
Perception
Understanding
Use in purchasing situation
Potential impact on health
Attitude

7. Classification of foods – FSA score
Julia. Kesse-Guyot et al. Br J Nutr. 112(10).
1699-1705. 2014.
Julia. Hercberg et al. Obésité 2015
Julia et al.. BMC Pub Health. 2015Julia et al.. Nutrition Journal. 2015
Julia et al. Cah Diet Nut. 2015
ANSES, 2015
• Test in 4 food composition tables
• NutriNet-Santé
• Open Food Facts
• Breakfast cereals
• OQALI (ANSES)
• Hierarchy between food groups
• Fruits and vegetables vs.
• Snacking products
• High variability within food
groups
• Substitution of foodsFatand sauces
Saltysnacks
Sugarysnacks
FishMeatEggs
Dairyproducts
Cereals and potatoes
Fruits and Vegetables
-10 0 10 20
OfCom score
Higher
nutritional
quality
Lower
nutritional
quality
-
15
40

8. Transpose to the diet of individuals
• Development of the FSA-NPS DI
• Based on the FSA score of foods and beverages
consumed
• Transposition to the diet of individuals
Application in cohort and cross-sectional studies
NutriNet-Santé – SU.VI.MAX cohorts
ENNS cross-sectional study
Meilleure
Qualité nutritionnelle
Moins bonne
Qualité nutritionnelle
Foods Diets

9. Cancer
CVD
Obesity Men
Obesity Women
Metabolic syndrome
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Quartile 1
Quartile 2
Quartile 3
Quartile 4
0.5 2
P=0.03
P=0.03
P=0.01
P=0.39
P=0.02
Foods Diets Health
Prospective association health
Donnenfeld. Touvier et al. Br J Nutr 2015;1-9
Adriouch. Fezeu. Touvier et al.. EJ Prev Card, 2016
Julia. Kesse-Guyot et al.. Prev Med 2015;81:189-94
Julia. Kesse-Guyot et al.. J Nutr. 2015 Oct;145(10):2355-61
Prospective cohorts
• SU.VIMAX
• Randomized trial
• 13y of follow-up
• NutriNet-Santé
• Web-based prospective
cohort
• 4y of follow-up
Results
• Q5 vs. Q1
+ 34% cancer
+ 52% breast cancer
• Q4 vs. Q1
+ 61% overweight and
obesity (men)
+43% MetS
+ 40 / 63% MCV

10. Perception – Objective understanding
PERCEPTION
• Self-administered questionnaire
• Three aspects of perception
– Acceptability
– Liking
– Perceived cognitive workload
Cod, carrots and fennel Cod with butter sauce and
risotto
Salmon with mashed
potatoes with olive oil (2%)
Ducrot, Péneau et al, Plos One 10(10), e0140898. 2015
Ducrot, Péneau et al., Nutrients. 7(8), 7106-7125. 2015
OBJECTIVE UNDERSTANDING
• Classification of 3 products
• According to the information
provided by the simplified FOP
nutrition labelling
• 5 Categories of products testedGDA
5-CNL
MTL
Tick

11. Ducrot et al. Nutrients. 2015
Objective understanding
• Ability to rank products according to their overall
nutritional quality
– No label situation
– Comparison across labels
• Results
– All labels improve understanding in consumers
– The magnitude of effect differs across labels
• Nutri-Score: improvement up to 20 times compared to a no
labels situation
– Differences across sub-groups of the population
• Nutri-Score: the most efficient in particular in vulnerable
populations

12. International comparative study
• Assessment of consumers’ response to
five FoPLs currently
in use in the world
– Objective Understanding
– Attitudes
– Effect on food choice
• International comparison across 12 countries: Argentina, Australia,
Bulgaria, Canada, Denmark, France, Germany, Mexico, Singapore, Spain,
United Kingdom, United States
12

13. • Participants
 12,015 adults recruited in twelve countries (~1000/country) using an internation web
panel provider
 Quota sampling on:
 Sex: 1/1 ratio
 Age: 1/3 in 18-30 years, 31-50 years and over 51 years
 Socioeconomic status: 1/3 in high, medium, low income households
 Regular consumers of the food categories tested
• Design and stimuli
 3 food categories (pizzas, cakes, cereals) with high variability in nutritional quality within
the category and consumed in all 12 countries
 Within each food category: 3 products with distinct nutritional profiles (lower,
intermediate, and higher nutritional quality)
 Creation of mock packages
13

14. • Results of the associations between FoPLs and the ability of correclty rank
products
14Odd Ratios and 95% confidence intervals of the association between FOP labels and improvement of ranking ability compared to RIs
* Significant associations after multiple testing correction

15. Comparative studies
• Alternatives proposed during
the concertation process
• Graphical formats compared
– Nutriscore
– SENS
– MTL
– Modified Reference Intakes
– Control : no label
• Modification of purchasing
behavior
– Overall nutritional quality of
the items in the shopping cart
(FSA score)
• Types of studies
– Large scale experimentation
– Experimental economy
SENS
NUTRI-REPERES
MTL=‘Nutri-Couleurs
NUTRISCORE

16. Large scale experimentation
• 60 supermarkets
– 10 for each label
– 20 controls
• 4 regions
• 10 weeks
• Intervention
– Limited to 4 shelves
• Fresh deli
• Bread
• Pastries
• Canned prepared meals
– Voluntary
• Between 63% et 86% of labeled
products
• Data collected: receipts

17. Large scale experimentation
• Improvement of the
shopping cart
+ 4,5%
+ 3,9%
3,3 %
• Sub-group analysis
– Nutri-Score: Higher impact in
subjects buying discount
brands
– Nutri-Score: No deterioration
of the nutritional quality of
the shopping cart in any
subgroup

18. Experimental economy study
• Intervention in controlled
setting
– Controlled and reproducible
experimental food store of
290 foods
– 691 participants
– Constitution of a shopping
cart before an after exposure
to a label
• Results
– The Nutri-Score is associated
with the highest
improvement
– Nutri-Score performs best in
households with lower
incomes
Crosetto et al., 2017
Nutritional quality
Overall <2000€/m
+9,3% +9,4%
+6,6% +6,5%
+4,8% +3,6%
+3,6% +2,1%
+2,9% +2,2%
Control
-0,2% -0,2%

19. Nutri-Score as official FOPL
• Signature on Oct 2017
• On Jan 2019
– >110 brands registered
– ≈20% market share
– Large and small brands
• Reformulation
strategies based on the
Nutri-Score
• Adoption by Belgium
and Spain

20. Thank you
Nutritional quality
+ -
To encourage To limit

21. Review of the studies performed on 5-CNL and Nutri-Score
Published in Dec 15th, 2017
http://www.euro.who.int/en/publications/public-health-panorama/journal-issues/volume-
3,-issue-4,-december-2017/review3