Research Article: Nutritional quality of food as represented by the FSAm-NPS nutrient profiling system underlying the Nutri-Score label and cancer risk in Europe: Results from the EPIC prospective cohort study

Date Published: September 18, 2018

Publisher: Public Library of Science

Author(s): Mélanie Deschasaux, Inge Huybrechts, Neil Murphy, Chantal Julia, Serge Hercberg, Bernard Srour, Emmanuelle Kesse-Guyot, Paule Latino-Martel, Carine Biessy, Corinne Casagrande, Mazda Jenab, Heather Ward, Elisabete Weiderpass, Christina C. Dahm, Kim Overvad, Cecilie Kyrø, Anja Olsen, Aurélie Affret, Marie-Christine Boutron-Ruault, Yahya Mahamat-Saleh, Rudolf Kaaks, Tilman Kühn, Heiner Boeing, Lukas Schwingshackl, Christina Bamia, Eleni Peppa, Antonia Trichopoulou, Giovanna Masala, Vittorio Krogh, Salvatore Panico, Rosario Tumino, Carlotta Sacerdote, Bas Bueno-de-Mesquita, Petra H. Peeters, Anette Hjartåker, Charlotta Rylander, Guri Skeie, J. Ramón Quirós, Paula Jakszyn, Elena Salamanca-Fernández, José María Huerta, Eva Ardanaz, Pilar Amiano, Ulrika Ericson, Emily Sonestedt, Ena Huseinovic, Ingegerd Johansson, Kay-Tee Khaw, Nick Wareham, Kathryn E. Bradbury, Aurora Perez-Cornago, Konstantinos K. Tsilidis, Pietro Ferrari, Elio Riboli, Marc J. Gunter, Mathilde Touvier, Wei Zheng

Abstract: BackgroundHelping consumers make healthier food choices is a key issue for the prevention of cancer and other diseases. In many countries, political authorities are considering the implementation of a simplified labelling system to reflect the nutritional quality of food products. The Nutri-Score, a five-colour nutrition label, is derived from the Nutrient Profiling System of the British Food Standards Agency (modified version) (FSAm-NPS). How the consumption of foods with high/low FSAm-NPS relates to cancer risk has been studied in national/regional cohorts but has not been characterized in diverse European populations.Methods and findingsThis prospective analysis included 471,495 adults from the European Prospective Investigation into Cancer and Nutrition (EPIC, 1992–2014, median follow-up: 15.3 y), among whom there were 49,794 incident cancer cases (main locations: breast, n = 12,063; prostate, n = 6,745; colon-rectum, n = 5,806). Usual food intakes were assessed with standardized country-specific diet assessment methods. The FSAm-NPS was calculated for each food/beverage using their 100-g content in energy, sugar, saturated fatty acid, sodium, fibres, proteins, and fruits/vegetables/legumes/nuts. The FSAm-NPS scores of all food items usually consumed by a participant were averaged to obtain the individual FSAm-NPS Dietary Index (DI) scores. Multi-adjusted Cox proportional hazards models were computed. A higher FSAm-NPS DI score, reflecting a lower nutritional quality of the food consumed, was associated with a higher risk of total cancer (HRQ5 versus Q1 = 1.07; 95% CI 1.03–1.10, P-trend < 0.001). Absolute cancer rates in those with high and low (quintiles 5 and 1) FSAm-NPS DI scores were 81.4 and 69.5 cases/10,000 person-years, respectively. Higher FSAm-NPS DI scores were specifically associated with higher risks of cancers of the colon-rectum, upper aerodigestive tract and stomach, lung for men, and liver and postmenopausal breast for women (all P < 0.05). The main study limitation is that it was based on an observational cohort using self-reported dietary data obtained through a single baseline food frequency questionnaire; thus, exposure misclassification and residual confounding cannot be ruled out.ConclusionsIn this large multinational European cohort, the consumption of food products with a higher FSAm-NPS score (lower nutritional quality) was associated with a higher risk of cancer. This supports the relevance of the FSAm-NPS as underlying nutrient profiling system for front-of-pack nutrition labels, as well as for other public health nutritional measures.

Partial Text: About a third of the most common cancers in Western countries are estimated to be preventable through appropriate nutritional behaviours (World Cancer Research Fund [WCRF]/American Institute for Cancer Research [AICR]) [1]. If nutrition can be modified at the individual level and therefore targeted by public health policies, informing the general population to make healthy, evidence-based nutritional decisions remains an important challenge. Among the promising strategies proposed to promote a healthier dietary environment [2,3], simplified front-of-pack nutrition labels, providing summarized, easy-to-use information on the nutritional quality of food products, have the potential to help consumers make healthier food choices and to encourage the food industry to improve the nutritional quality of the food supply [4,5]. The Nutri-Score five-colour labelling system (see S1 Fig) [3] uses a modified version of the British Food Standards Agency Nutrient Profiling System (original version) (FSA-NPS) [6,7], considered a promising nutrient profiling system for use in a broad international context [6,8], to categorize food products into 5 colours reflecting their nutritional quality (see examples in S1 Text). The FSA-NPS was built in a perspective of prevention of a large range of chronic diseases. It allocates a score to a given food/beverage from its content per 100 g of energy, saturated fatty acids, sugar, sodium, dietary fibres, proteins, and fruit/vegetables/legumes/nuts. It was initially developed and validated in the United Kingdom, where it has been used for advertising regulation (Ofcom) [6,7,9] and was transposed in France (FSAm-NPS) [10–12].

After a median follow-up time of 15.3 y (between 1992–2000 and 2009–2014), 49,794 incident invasive cancer cases were recorded (cancer incidence by country is shown in S1 Table). The most common cancers were breast (n = 12,063), prostate (n = 6,745), colon-rectum (n = 5,806), and lung (n = 3,654).

In this large multinational European cohort, participants with the highest FSAm-NPS DI scores, i.e., those consuming on average food products with a lower nutritional quality, were at higher risk of developing cancer overall. Stronger associations were observed for colorectal, upper aerodigestive tract, and stomach cancers, for lung cancer in men, and for liver and postmenopausal breast cancers in women.



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