In 2017, the European region was the most affected World Health Organization (WHO) region by non-communicable diseases (e.g., diabetes, cardiovascular diseases, cancer, chronic respiratory diseases and mental disorders), accounting for approximately 77% of the burden of disease and 88% of deaths [1
]. Nutrition and physical activity have rapidly become major thrusts of public health action [2
]. Despite nutritional recommendations and the various health actions taken by public authorities at national, European and international levels, the mortality rate and prevalence of these diseases continue to rise [3
]. In this context, new public health approaches have been set up, including notably the implementation of nutritional information systems on the front of pack of food products. In recent years, the implementation of front-of-pack nutrition labels (FoPLs) has been identified to be of major interest by expert committees in charge of nutrition labelling policies in many countries, by the WHO [4
] and the Organization for Economic Co-operation and Development [5
]. Indeed, FoPLs aim to improve the nutritional status of populations, both by encouraging consumers to make healthier food choices at the point of purchase [6
], and by enticing manufacturers to improve the nutritional quality of food offered [9
However, in view of the plurality of FoPLs on the European market, potentially leading to confusion for consumers, the European Commission has launched discussions among member states on the potential reopening of the INCO regulation [11
], including a reflection on the harmonization of FoPLs [12
]. Several schemes of FoPLs have been developed worldwide and notably in Europe, including nutrient-specific systems providing information at the nutrient level (e.g., the multiple traffic lights implemented in the United Kingdom since 2004 [13
], or the reference intakes adopted by multiple European food manufacturers in 2006 [14
] or their variants such as the Italian battery system [15
]) and summary indicators synthetizing the overall nutritional quality of foods (e.g., the Keyhole in Scandinavian countries [16
] or a graded scale such as the Nutri-Score, first adopted in France in 2017 [17
], then in Belgium, Spain, Germany, the Netherlands, Switzerland and Luxembourg between 2018 and 2020).
More specifically, the Nutri-Score is a color-coded graded scale of five letters based on the United Kingdom’s Food Standards Agency (FSA) nutrient profiling system (NPS), adapted to the French context by the French High Council for Public Health (HCSP), namely the FSAm-NPS [18
]. The validation of a FoPL requires validating the graphical format of the system as well as its underlying NPS [20
]. Numerous studies in the French context, and one study in other countries including some European countries, have been carried out to validate the graphical format of the Nutri-Score, regarding several dimensions of its effectiveness. First, the Nutri-Score has been shown to be well perceived and understood by consumers to compare the nutritional quality of foods [22
], two prerequisites for the FoPL use. Further, this FoPL has also been demonstrated to encourage consumers towards healthier food choices and improve the nutritional quality of their shopping carts [28
], and finally to potentially decrease the mortality from nutrition-related chronic diseases through healthier dietary intakes, according to a simulation study [32
]. Regarding the FSAm-NPS underpinning the Nutri-Score, several validation studies testing the Nutri-Score discriminating performance against food composition have been conducted in particular in the French context, and have notably demonstrated its capacity to discriminate the nutritional quality of food products across and within food groups [33
], and its consistency with French nutritional recommendations [33
]. A scientific report has also suggested consistent results in some European countries [35
]. However, no formal study has yet been conducted to investigate the discriminating capacity of the Nutri-Score in several European countries, while it constitutes an important aspect of its transferability to other food contexts and that a growing number of European countries are considering its implementation. Thus, the present study aimed to investigate the discriminating performance of the Nutri-Score in terms of the food offered in different European countries, as well as the consistency of the classification with nutritional recommendations of these countries.
Overall, a final sample of 11,347 foods and beverages was used, including 1800 fresh or processed fruits, vegetables and nuts, seeds or kernels; 1898 breads and cereal products; 2506 meat, fish and egg products; 906 milk and dairy products; 336 fats or oils; 2655 composite products; 614 sugar or sugar products; and 632 beverages.
Overall, for the eight countries combined, the distribution of the different Nutri-Score classes for each main food group and subgroup is displayed in Table 1
, and results by country are described in the tables from Supplemental Material 3
and Figure 1
. The distribution of the various main groups and subgroups within the Nutri-Score classes was globally consistent with dietary guidelines [41
], overall and for each of the eight countries. Indeed, 96.4% of foods from “vegetable or vegetable product” and 91.1% of foods from “fruit or fruit product” were classified in the two healthiest Nutri-Score classes (“A” and “B”). In addition, 55.4% of the products from “grain or grain product” and 71.2% of the products from “nut, seed or kernel” were generally distributed between classes “A” to “C”. In addition, more than three-quarters of the products from “fish or related organisms” (88.4%) and “pulse or pulse product” (100%) were classified into the first two classes of Nutri-Score (“A” and “B”). On the contrary, 87.8% of the products from “sugar or sugar product” were classified between “C” and “E”, and 82.4% of the products from “fat or oil” were classified in the categories “D” and “E” of the Nutri-Score (i.e., to be limited), with a better ranking for vegetable fats (24.8% in “C”, 66.4% in “D”, and 8.9% in “E”) compared to animal fats (1.6% in “C”, 68.8% in “D”, and 18.8% in “E”). Similar trends were observed in the analyses by country (Figure 1
, Supplemental Material 3
). Indeed, for example, for the “fruit or fruit product” category, 97.3% were classified as “A” or “B” with the Nutri-Score in Finland, 95.9% in France, 97.1% in Norway, 92.6% in Poland, 77.8% in Portugal, 87.5% in Slovakia, 89.3% in Sweden, and 91.4% in Switzerland. For the “sugar and sugar product” category, 66.1% of products were classified “C”, “D” or “E” with the Nutri-Score in Finland, 88.3% in France, 96.3% in Norway, 98.0% in Poland, 97.6% in Portugal, 97.2% in Slovakia, 88.3% in Sweden, and 97.4% in Switzerland. Only a few disparities were found between countries regarding the variability in the FSAm-NPS score within some of the main food groups (e.g., “seafood and related product”, “composite food product”). Nevertheless, for the main food groups “meat or meat product” and “milk, milk product or milk substitute”, differences were observed across countries regarding the distribution of the FSAm-NPS score of products, which may be partly explained by the large diversity of products in these food categories.
Overall, in the eight countries combined, at least three classes of the Nutri-Score were observed for all main groups and subgroups, except in the “pulse and pulse product” subgroup, where only two classes of the Nutri-Score (“A” and “B”) were represented. The results on the overall discriminating performance of the Nutri-Score in each country are displayed in Table 2
. For each main group and subgroup, differences in the nutritional quality of products were grasped by the Nutri-Score classification, with a good discriminating performance in the eight countries. Indeed, for each country, 70% to 88% of the subgroups (excluding “Water”) contained food products categorized in at least three classes of the Nutri-Score, except for Poland (55%) and Switzerland (59%), containing fewer food products overall. In addition, the classification with the Nutri-Score allowed discriminating the wide variability in the nutritional quality of manufactured foods. Indeed, in the category “grain or grain product” for example, from 81% to 100% (depending on the country) of pasta and rice products were mainly identified in categories “A” and “B”, while more than half of the subgroup “breakfast cereal”, which are considered as highly processed manufactured foods, were classified in categories “C” and “D” for most of the countries. Within food categories, the Nutri-Score seemed to discriminate between refined and whole products. Indeed, for example, wholegrain breads were better classified than white breads.
In this study, the distribution of foods within the Nutri-Score classes showed a good performance of the FoPL to discriminate the nutritional quality of products within main food groups and subgroups, and across relevant food groups in terms of purchase, use or consumption, with high consistency with official dietary guidelines in the eight countries tested—Finland, France, Norway, Poland, Portugal, Slovakia, Sweden and Switzerland.
These results are consistent with other studies using food composition databases of manufactured foods from the French and German markets, therefore validating the ability of the Nutri-Score to discriminate the nutritional quality of products in various sociocultural contexts [33
]. A scientific report has also suggested a good discriminating performance of the Nutri-Score for the food offered in Belgium, Italy, Netherlands, Spain, Sweden, Switzerland and United Kingdom, using the data from the Open Food Facts database, a collaborative online project gathering food composition data on manufactured foods from many countries worldwide [36
]. Furthermore, our findings showed good consistency between the classification of the Nutri-Score and the general recommendations of dietary guidelines [41
]. Indeed, the vast majority of fruit, vegetable, legume and nut products for which consumption is encouraged had a better ranking with the Nutri-Score (mainly “A” and “B”) compared to sweet, fatty or salty products for which consumption should be limited (mainly “D” and “E”). The composite dishes showed a wide distribution (often 4 or 5 Nutri-Score classes represented in the food subgroups), which highlighted the large variability in prepared products in terms of nutritional quality, for which the Nutri-Score is a very useful tool to identify healthier options. Beverages such as water and unsweetened drinks were classified as healthier than sweetened drinks such as soft drinks and fruit nectars. All these findings are therefore in line with international key messages encouraging the consumption of fruits and vegetables, basic starches and whole cereals products, and limiting the consumption of fats, salt and sugar [4
]. Our results also highlighted the fact that the Nutri-Score could allow discriminate between manufactured and raw foods. Indeed, processed foods from the various European countries were mainly distributed in classes “C”, “D”, or “E”, while raw products were usually classified in “A” or “B”, which is consistent with new public health messages encouraging the consumption of these products [41
]. Moreover, the Nutri-Score appeared to allow discrimination between refined and whole foods. For example, in most European countries included in the study, wholemeal bread was classified as better with the Nutri-Score than white bread. Finally, the Nutri-Score also seemed to be consistent for products specific to a food context for which consumption is encouraged. This was notably the case for rye breads—rich in fibers—specific to Nordic countries and classified as “A” with the Nutri-Score, while key messages encourage diet oriented towards the consumption of whole seeds [44
]. Thus, our findings suggest good consistency between food classification by the Nutri-Score and overall as well as some specific nutritional recommendations at the European level, in line with previous studies that have been carried out [33
The validation of the ability of the Nutri-Score to discriminate the nutritional quality of products in different markets using the FSAm-NPS profile is particularly important to assess its transferability given the current European context. Beyond the country-specific food database, the concordance of our results confirms the performance of the Nutri-Score system in achieving product discrimination in various European countries [20
]. Only a few disparities were found between countries regarding the variability or the distribution of the FSAm-NPS score within some of the main food groups, which might be partly explained by the structure of the original food databases and the specific food offered and contexts of the different countries included in the study. Nevertheless, it is important to notice that even if some disparities can be observed regarding the classification of foods by a front-of-pack nutritional labelling system in various food environments, it does not necessarily imply that adaptations of the underlying profiling system are required, as disparities in the distribution of foods are not necessarily inconsistencies. These findings are complementary to the results of an international comparative study, which found that the Nutri-Score was an effective tool to help consumers identify the nutritional quality of products and potentially improve their food choices in multiple countries, including European countries—Bulgaria, Denmark, France, Germany, the Netherlands, Spain, and the United Kingdom [26
Dietary guidelines and FoPLs such as the Nutri-Score are complementary and synergic measures, based on different approaches and principles. Dietary guidelines aim to provide consumers practical guidelines to adopt a healthy diet, by helping them identifying the food groups that should be encouraged (e.g., fruits, vegetables, legumes, etc.) and those that should be limited (e.g., sweet and salty products, fats and especially animal fats, etc.) [41
]. Nevertheless, the consumption of manufactured foods has increased substantially [46
], and the food offered currently, notably in Europe, are characterized by a large variability in nutrient profiles of pre-packed foods within food groups. Thus, to allow consumers to identify healthier products within a main food group or subgroup, the Nutri-Score appears to be an efficient tool to help consumers discriminate nutritional quality across and within food groups in multiple European countries, as well as between similar products from different brands in French supermarkets [33
]. So, the Nutri-Score provides supplementary information to guide consumers toward foods with a better nutritional composition (with less unfavorable or more favorable elements). Nevertheless, consistent communication and specific education strategies are needed in each country to explain the complementarity and the synergic use of dietary guidelines and the Nutri-Score.
The use of the EUROFIR database, including both generic and specific food and beverages of multiple European countries, is the main strength of the present study. Indeed, it allowed us to perform cross-cultural comparisons of the discriminating performance of the Nutri-Score, particularly important in the current European context of front-of-pack nutritional labelling harmonization. This comparative study across eight European countries remains the first study in terms of the validation of the NPS underlying the Nutri-Score in different sociocultural contexts on a large variety of generic foods. These findings are complementary to studies conducted in other food databases such as Open Food Facts providing data on multiple industrial foods of different brands. However, some limitations should be acknowledged. First, data from EUROFIR were retrieved from different sources (e.g., universities, research institutes, food technology institutes, food quality organizations and commercial organizations) and did not allow us to analyze the representativeness of the sample of foods collected in our database. Nevertheless, our objective was to assess the discrimination capacity of the Nutri-Score; we did not need to be exhaustive and the EUROFIR database provided a large number of food products for each country. In addition, some disparities were observed between countries regarding the number of foods available, or even the composition of foods or both. Given these heterogeneities of the database structures, we elected not to perform statistical tests to determine the significance of the intercountry differences. However, only a few countries (Poland, Portugal, and Switzerland) were concerned, and their results remain consistent with the literature mentioned above. Moreover, several procedures were applied to verify the validity of the data and optimize the number of products in each database. In addition, results on the distribution of foods in the different Nutri-Score classes depended on the EUROFIR classification that was used in the present study. Another limitation of the present study remains the somewhat arbitrary aspect of the measurements of the discriminating performance of the FoPL and the consistency with dietary guidelines. Nevertheless, in the absence of a consensual indicator to which to compare the performance of nutrient profiling, we used a similar methodology to previous studies [33
]. Finally, given the current European context, the present study focused on the Nutri-Score discriminating performance in multiple European countries. Nevertheless, it would be interesting to replicate this type of study to investigate and compare the discriminating performance of various FoPL schemes implemented worldwide.
Our results provide additional evidence of the relevant application of the Nutri-Score and its adaptability to the European context, particularly in Finland, France, Norway, Poland, Portugal, Slovakia, Sweden, and Switzerland, with regard to discrimination within main food groups and subgroups. This FoPL is notably strongly supported by European consumer associations who launched a petition (“PRO-NUTRISCORE”) in order to encourage the European Commission to change the regulation and make the label mandatory. This study supports the Nutri-Score as an interesting alternative for European countries wishing to implement complementary nutrition labelling on the front of food packaging, and ultimately avoid confusion among consumers through the coexistence of several systems on the European market.