The World Health Organization (WHO), as well as several other international health authorities and regulatory bodies, are developing and supporting the implementation of various “nutrient (or nutritional) profiling” approaches to assess the healthfulness of foods for a wide variety of applications, which may be associated with improved health [1
]. Nutrient profiling is designed to globally evaluate the healthfulness of food products, based on transparent nutritional composition criteria [1
]. Common applications of nutrient profiling include the regulation of front of pack food labeling, health and nutrition claims and food procurement for public institutions (such as schools and hospitals) [1
]. With the development in 2014 of Health Canada Surveillance Tool (HCST) [9
], the first Canadian nutrient profiling system, there is a potential to broaden the scope of nutrient profiling to assess dietary patterns at a population level. However, this approach has yet to be applied to the dietary intakes of Canadian adults to assess its applicability and relevance.
The HCST aims to assess the food intakes of Canadians relative to the guidance provided by Eating Well with Canada’s Food Guide (EWCFG) [10
], based on the classification of foods in the Canadian Nutrient File (CNF) [9
]. The HCST is the first government-developed nutrient profiling system in Canada and evaluates Canadians’ adherence to EWCFG in terms of amount and type of foods (i.e.
, number of servings from each food group, and within these, the quality of food choices) [9
]. Details regarding this tool have been previously reported by Health Canada [9
]. Generally, HCST is a categorical nutrient profiling system that classifies foods within each food group into four Tiers according to their adherence with EWCFG recommendations [9
]. The HCST system can then be used to assess Canadians’ eating patterns, based on the proportion of food choices that fall within each Tier [9
]. The objectives of the present study were to: (a) assess the quantity and quality of food choices of Canadian adults relative to the HCST Tier system using the Canadian national nutrition survey; and (b) evaluate the applicability and relevance of the HCST as a dietary assessment tool on a population basis.
The present study provides the first assessment of the 2014 HCST Tier system based upon national Canadian nutrition data. Assessment of eating habits using this nutrient profiling system revealed that the quality and quantity of Canadian adults’ eating patterns are not meeting Health Canada’s recommendations. Specifically, Canadian adults are not meeting Health Canada’s recommended number of food group servings, and there is a high prevalence of consumption of Tier 4 classified foods among this population, especially Tier 4 processed meats and potatoes. Importantly, one-third of daily calories were consumed from Tier 4 and “other” food/beverage sources not recommended in the EWCFG. Using this nutrient profiling system, the majority of food choices of Canadians (except for vegetables and processed meats) were categorized as either Tiers 2 or 3, despite the large variation among the food items reported. This lack of specificity questions the validity of HCST and discriminative ability of its thresholds for use to evaluate national eating patterns. These findings may also justify the lack of significant associations between adherence to HCST and obesity among CCHS 2.2 participants. However, closer compliance to HCST system indicated increased probability of meeting DRI nutrient recommendations, which is expected since the HCST was developed to evaluate adherence to EWCFG, which itself is modeled based on achieving DRI recommendations [10
]. Similarly, since HCST is in line with EWCFG, it does not address recommendations for obesity and chronic disease prevention [36
], which may also explain lack of significant associations between HSCT compliance and obesity risk in this study.
In 2015, the World Health Organization (WHO) published a report developing a common nutrient profiling model for Europe based on review of existing nutrient profiling models [2
], including those published by the governments of the United Kingdom, Australia and New Zealand, and the United States [4
]. The WHO model consists of 17 food categories with pre-defined thresholds for the contents of energy, total fat, saturated fat, total sugars, added sugars, and sodium to help authorities identify unhealthy foods [2
]. Compared to the HCST with 9 food categories, the WHO model consists of 17 food categories, even though both systems use pre-defined thresholds for classifying different foods [2
]. The HCST food categories contain a large variation within each Tier subgroup due to the broad discrete definitions used for defining the thresholds for Tiers 1 and 4, and the lenient adjustable criteria used to categorize foods into Tiers 2 and 3 [9
]. In the present study, a consequence of HCST limitations was categorization of the majority of foods into Tiers 2 and 3, except for fruits and vegetables where the majority were classified as Tier 1 and 2 as well as processed meats, despite large product differences. As an example, foods categorized by the BNS Food Group Descriptions [19
] as “jello, dessert toppings and pudding mixes-commercial” could fall within both Tier 2 and Tier 3 of the HCST. In addition, the limited range of thresholds in HCST results in a small percentage of products to be categorized as Tiers 1 or 4, especially in sub-groups such as fluid milk and fortified soy-based beverages and fruit juice, with more similarities among products. This is in contrast to the United Kingdom’s Ofcom Model, which calculates a total score for food items based on the total points for “negative” nutrients (energy, total sugar, saturated fat, and sodium) subtracted by points obtained for “positive” nutrients (fruits, vegetables and nuts, fiber, and protein) [4
]. Based upon the Ofcom model, the Nutrient Profiling Scoring Criterion (NPSC), developed by Food Standards Australia New Zealand (FSANZ), not only considers sodium, saturated fat, and sugar content of foods, but it also accounts for ingredients such as dietary fiber, protein and fruit and vegetables and calculates a total nutrient profiling score for a food [8
Since 2010, the United States NuVal Nutritional Scoring System has been used on the basis of the Overall Nutritional Quality Index (ONQI) algorithm [5
]. The ONQI incorporates over 30 nutrients and food properties, in addition to weighting coefficients (energy density, glycemic load, protein quality, and fat quality) representing epidemiologic associations between nutrients and health outcomes [5
]. ONQI summarizes comprehensive nutritional information into a single score ranging from 1 to 100 based on their relative nutrition and healthfulness [5
]. Adherence to the ONQI has previously been associated with lower risk of total chronic diseases and total mortality during over 20 years of follow-up, although the lack of transparency of this tool has remained controversial [5
In the present study, the HCST was able to distinguish the diet quality of compliers, intermediate compliers, and non-compliers, which is in line with the findings of previous research using other indexes [39
]. Favorable diet quality in terms of lower consumption of Tier 4 and “other” foods/beverages was associated with higher intakes of vitamins and minerals, and lower intakes of energy, fats, added sugars, alcohol, glycemic index, and energy density, even though these nutritional components were not considered in the quartile categorization of individuals.
In addition, our results confirm previous research indicating that older, female, physically active, and non-smoker individuals have healthier dietary quality, which is also an indication of the face validity of HCST in the Canadian population [39
]. In particular, lower diet quality was seen among smokers, who have been previously shown to be less physically active, and have high alcohol intakes and low consumption of fruits and vegetables [46
], which may be due to taste modifications, dysregulation of appetite, and unhealthy lifestyle among this group [47
In this research, we failed to observe a significant association between adherence to a nutrient profiling system and BMI, which is in line with some previous studies [42
]. This lack of association may be explained by the focus of the EWCFG and HCST on meeting the DRI nutrient requirements rather than disease prevention [36
]. Our group recently published a critical analysis of the EWCFG concluding that adherence to the EWCFG does not necessarily guarantee a reduced risk of obesity or other chronic diseases [36
], since the EWCFG has been modeled to strictly meet the DRI nutrient recommendations. Even though some a priori
diet quality indexes have been negatively associated with the risk of obesity (including healthy eating index and dietary quality index among CCHS 2.2 participants [49
]), others have found neutral [48
] or even inverse [50
] associations. These inconsistent results may also be related to the cross-sectional nature of studies, or the observation that overweight and obese individuals are more likely to watch their nutritional intake or to be dieting [51
To our knowledge, this is the first study to investigate the application of a nutrient profiling system in characterizing the diet quality of Canadians, which is of high public health importance. Nutrient profiling systems as well as dietary quality scores aim to evaluate overall diet quality of individuals using available scientific evidence about the role of diet in health promotion [53
]. Considering the correlation between foods and nutrients and totality of diet are important advantages of using diet quality indexes and nutrient profiling systems [53
]. Strengths of our study include the use of a large nationally-representative sample, including several covariates, having measured anthropometry, and use of the USDA AMPM which minimized misreporting bias as a result of missing items or eating occasion.
This study is not without its limitations. One limitation is the day-to-day variation (random non-differential error) associated with 24-h dietary recalls. Another disadvantage common among all diet quality index analyses is the subjectivity surrounding the selection of nutritional components, threshold values, and scoring criteria [54
]. The major limitation of HCST is the strict focus on 4 “negative” nutrients (total fats, saturated fat, sodium, and sugars) and lack of calculation of a total dietary score, which prevents direct comparisons across groups. Finally, owing to the cross-sectional design of the national Canadian nutrition survey, the causal inference is limited.