Nutri-Score: A Public Health Tool to Improve Eating Habits in Portugal

Abstract

Non-communicable diseases (NCDs) are associated with avoidable behavioural risk factors and several opportunities for intervention - such as unhealthy diets, lack of physical activity, tobacco use and excessive alcohol con-sumption - are available.

Unhealthy diets are among the most contributable risk factors to the decrease in healthy life years among the Portuguese population (15.8%). Furthermore, dietary habits are important determinants for NCDs, representing 86% of the burden of disease on the Portuguese National Health-care System (NHS).

Integrated strategies on prevention of NCDs which include the promotion of healthy lifestyles, including diet, and disease prevention measures must be a priority. In this context, the Portuguese Ministry of Health published the Integrated Strategy for the Promotion of Healthy Eating (Estratégia Integrada para a Promoção da Alimentação Saudável – EIPAS).

A recent study showed that 40% of all people surveyed in Portugal do not understand nutritional information on food labels. With this in mind, one of the strategic axes of EIPAS is to “Improve the quality and accessibility of the information available to consumers”. In order to pursue this strategic objective, several measures have been mapped out, including promoting the usage of front-of-pack (FOP) labelling.

This article intends to help filling the existing gap in guidance for the implementation of FOP labelling systems. As such, the following sections present the growing evidence on the impact of the Nutri-Score labelling scheme in promoting healthier eating behaviours and informs health professionals, as well as decision makers, on the way forward.

Full text

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175
Nutri-Score: A Public Health Tool to Improve Eating Habits
in Portugal
Nutri-Score: Uma Ferramenta de Saúde Pública para
Melhorar os Hábitos Alimentares da População Portuguesa
1. Centre for Health Policy. Institute of Global Health Innovation. Imperial College London. London. United Kingdom.
2. Faculdade de Ciências da Saúde. Universidade da Beira Interior. Covilhã. Portugal.
3. Center for Innovation, Technology and Policy Research, IN+. Instituto Superior Técnico. Universidade de Lisboa. Lisboa. Portugal.
4. Health Directorate-General. Lisboa. Portugal.
5. Faculty of Nutrition and Food Sciences. University of Porto. Porto. Portugal.
6. EpiDoC Unit. Chronic Diseases Research Center (CEDOC). NOVA Medical School. Lisboa. Portugal.
7. Centro de Administração e Políticas Públicas. Instituto Superior de Ciências Sociais e Políticas. Universidade de Lisboa. Lisboa. Portugal.
8. Department of Nutrition and Metabolism.. NOVA Medical School. Lisboa. Portugal.
9. CINTESIS, Center for Health Technology Services Research, Porto, Portugal
10. Equipe de Recherche en Epidémiologie Nutritionnelle (EREN). Inserm, Inra, Cnam. Université Paris 13. Paris. France.
11. Département de Santé Publique. Hôpital Avicenne (AP-HP). Bobigny. France
12. Instituto Nacional de Saúde Doutor Ricardo Jorge. National Institute of Health. Lisboa. Portugal.
13. Portuguese Order of Nutritionists. Lisboa. Portugal.
14. Department of Surgery and Cancer. Faculty of Medicine. Imperial College London. London. United Kingdom.
15. Faculty of Medicine. Porto University. Porto. Portugal.
16. Serviço de Imuno-hemoterapia. Centro Hospitalar Universitário São João. Porto. Portugal.
 Autor correspondente: Francisco Goiana-da-Silva. franciscogoianasilva@gmail.com
Recebido: 03 de dezembro de 2018 - Aceite: 04 de fevereiro de 2019 | Copyright © Ordem dos Médicos 2019
Francisco GOIANA-DA-SILVA1,2, David CRUZ-E-SILVA3, Maria João GREGÓRIO4,5,6, Alexandre Morais NUNES7,
Conceição CALHAU8,9, Serge HERCBERG10,11, Ana RITO12, Alexandra BENTO13, Diogo CRUZ4, Fernando ALMEIDA12,
Ara DARZI14, Fernando ARAÚJO15,16
Acta Med Port 2019 Mar;32(3):175-178 ▪ https://doi.org/10.20344/amp.11627
INTRODUCTION
Non-communicable diseases (NCDs) are associated
with avoidable behavioural risk factors and several oppor-
tunities for intervention - such as unhealthy diets, lack of
physical activity, tobacco use and excessive alcohol con-
sumption1 - are available.
Unhealthy diets are among the most contributable risk
factors to the decrease in healthy life years among the Por-
tuguese population (15.8%). Furthermore, dietary habits
are important determinants for NCDs, representing 86% of
the burden of disease on the Portuguese National Health-
care System (NHS).1
Integrated strategies on prevention of NCDs which in-
clude the promotion of healthy lifestyles, including diet, and
disease prevention measures must be a priority. In this con-
text, the Portuguese Ministry of Health published the Inte-
grated Strategy for the Promotion of Healthy Eating (Estra-
tégia Integrada para a Promoção da Alimentação Saudável
– EIPAS).2
A recent study showed that 40% of all people surveyed
in Portugal do not understand nutritional information on
food labels.3 With this in mind, one of the strategic axes
of EIPAS is to “Improve the quality and accessibility of the
information available to consumers”. In order to pursue this
strategic objective, several measures have been mapped
out, including promoting the usage of Front-of-Pack (FOP)
labelling.2,4
This article intends to help lling the existing gap in
guidance for the implementation of FOP labelling systems.4
As such, the following sections present the growing evi-
dence on the impact of the Nutri-Score labelling scheme in
promoting healthier eating behaviours and informs health
professionals, as well as decision makers, on the way for-
ward.
FOP nutrition labelling systems
FOP labelling was initially introduced in the late 1980s
and, to date, several countries and companies have adopt-
ed it. Endorsement (Key Hole Healthy Choice), nutrient spe-
cic interpretative models (Trafc Light System), summary
interpretative models (Nutri-Score) and numeric informative
models (Guideline Daily Amount System) are among the
most popular examples of FOP labelling systems.
Research suggests that several criteria impact the ef-
cacy of FOP labelling systems. These criteria pertain, most-
ly, to acceptability, objective comprehension and the impact
of the labels’ usage on consumers’ buying decisions.5
Growing evidence that Nutri-Score is a scheme that
works for consumers
Nutri-Score consists of a graphical coloured representa-
tion, which also uses letters. The system classies the nu-
tritional prole of a food product into ve mutually exclusive
categories. An innovative algorithm based on nutritional
criteria, validated scientically, classies products between
Keywords: Consumer Behavior; Feeding Behavior; Food Labeling; Portugal; Public Health
Palavras-chave: Comportamento Alimentar; Comportamento do Consumidor; Portugal; Rotulagem de Alimentos; Saúde Pública

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Goiana-da-Silva F, et al. Nutri-Score: a public health tool to improve eating habits in Portugal, Acta Med Port 2019 Mar;32(3):175-178
green (associated to letter A) and red (associated to letter
E), as demonstrated in Fig. 1.
Recent studies conducted for the development of the
French FOP Nutrition Labelling Systems and that compared
Nutri-Score with other FOP nutrition labelling systems, sug-
gested that Nutri-Score is the easiest to understand. It is
easily recognized and interpreted regardless of socioeco-
nomic and demographic stratus, especially in comparison
with the Trafc Light System. Fig. 1 shows different FOP
labelling systems applied to different biscuits and illustrates
the previously mentioned ndings. All population subgroups,
in particular overweight and obese individuals, show posi-
tive appraisal towards Nutri-Score in detriment of other FOP
labelling systems.6,7
Even though many different systems allow consumers
to identify products with more adequate nutritional proles,
Nutri-Score shows the strongest evidence towards pro-
moting healthier choices by the consumer, namely among
those with unhealthier eating behaviours.8 Evidence shows
that Nutri-Score helps consumers to effectively classify food
products according to their nutritional characteristics, even
for individuals without technical knowledge on nutrition.
Additionally, communication and marketing initiatives on
Nutri-Score result in more nutritional adequate choices by
1
HEALTH STAR
RATING
2
HEALTH STAR
RATING
3.
5
HEALTH STAR
RATING
of an adult’s reference intake
Typical values per 100g: Energy 2034kJ / 486kcal
Each portion (35g) contains
Salt
0.3g
Sugars
12.3g
Saturates
3.5g
5%14%18%11%9%
Fat
7.3g
Energy
712kJ
170kcal
of an adult’s reference intake
Typical values per 100g: Energy 1949kJ / 465kcal
Each portion (35g) contains
Salt
0.2g
Sugars
11.2g
Saturates
2.0g
3%12%10%9%8%
Fat
6.1g
Energy
682kJ
163kcal
of an adult’s reference intake
Typical values per 100g: Energy 1609kJ / 384kcal
Each portion (35g) contains
Salt
0.1g
Sugars
11.5g
Saturates
0.9g
2%13%4%3%7%
Fat
2.2g
Energy
563kJ
134kcal
of an adult’s reference intake
Typical values per 100g: Energy 2034kJ / 486kcal
Each portion (35g) contains
Salt
0.3g
Sugars
12.3g
Saturates
3.5g
5%14%18%11%9%
Fat
7.3g
Energy
712kJ
170kcal
of an adult’s reference intake
Typical values per 100g: Energy 1949kJ / 465kcal
Each portion (35g) contains
Salt
0.2g
Sugars
11.2g
Saturates
2.0g
3%12%10%9%8%
Fat
6.1g
Energy
682kJ
163kcal
of an adult’s reference intake
Typical values per 100g: Energy 1609kJ / 384kcal
Each portion (35g) contains
Salt
0.1g
Sugars
11.5g
Saturates
0.9g
2%13%4%3%7%
Fat
2.2g
Energy
563kJ
134kcal
of an adult’s reference intake
Typical values per 100g: Energy 2034kJ / 486kcal
Each portion (35g) contains
Salt
0.3g
Sugars
12.3g
Saturates
3.5g
5%14%18%11%9%
Fat
7.3g
Energy
712kJ
170kcal
of an adult’s reference intake
Typical values per 100g: Energy 1949kJ / 465kcal
Each portion (35g) contains
Salt
0.2g
Sugars
11.2g
Saturates
2.0g
3%12%10%9%8%
Fat
6.1g
Energy
682kJ
163kcal
of an adult’s reference intake
Typical values per 100g: Energy 1609kJ / 384kcal
Each portion (35g) contains
Salt
0.1g
Sugars
11.5g
Saturates
0.9g
2%13%4%3%7%
Fat
2.2g
Energy
563kJ
134kcal
HIGH IN
SATURATED
FAT
HIGH IN
SUGAR
HIGH IN
CALORIES
HIGH IN
SATURATED
FAT
HIGH IN
SUGAR
HIGH IN
CALORIES
HIGH IN
SUGAR
HIGH IN
CALORIES
Figure 1 – Different FOP Labelling Systems applied to different biscuits. Detailled explanation of the classication process used by each
one of the referred FOPL systems can be found in Kanter et al.9
Source: Own authorship
Front-of-pack
nutrition labels
Nutri-Score
Health Star
Rating system
Multiple Trafc
Lights
Evolved
Nutrition Label
Reference
Intakes
Warning
symbol

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Goiana-da-Silva F, et al. Nutri-Score: a public health tool to improve eating habits in Portugal, Acta Med Port 2019 Mar;32(3):175-178
consumers. This is particularly evident in the sweets, bis-
cuits and cookies food category.8
In 2016, a study developed in over 60 supermarkets
for a 10-week period, covering around 1298 food products,
compared Nutri-Score to other FOP labelling systems. This
study concluded that Nutri-Score shows a clear superiority
when compared to all other FOP labelling systems and that,
unlike other similar systems, never leads to worse choices
from a nutritional perspective. In this context it is important
to note that Nutri-Score led to an average increase of 4%
in the nutritional quality of food products in shopping bas-
kets.10
These results are supported by a qualitative study,
carried out in over 20 stores, showing that summary FOP
nutrition labelling systems (such as Nutri-Score) are those
most effective in guiding consumer shopping and decision-
making towards food products with better global nutritional
proles.11 Moreover, a recent study on 809 individuals un-
der real life shopping environments, and using experimental
economy analyses and methodologies, had similar ndings,
thus reinforcing and supporting the previously mentioned
public health benets of Nutri-Score.12
CONCLUSION
Recent evidence suggests that Nutri-Score signicantly
improves consumers’ ability to better understand nutritional
information and make healthier food choices. Nutri-Score
has been developed by the French Ministry of Health and
dened as the national reference. More than ninety food
manufacturers and retailers have followed suit and de-
ployed (or committed to deploying) Nutri-Score on all their
products. Furthermore, other Ministries of Health (i.e. Bel-
gium and Spain) have published national recommendation
towards adopting Nutri-Score. Nutri-Score also counts with
the strong support of European consumers’ associations.
In contrast, little progress has been made in Portugal.
Lack of decisive action has been promoted by policy and
regulatory levers lying outside the health sector, limited
collaboration between different governmental areas, and
strong opposition by several food manufacturing companies
and retail sectors. As a result, several different FOP label-
ling systems are used at the national level without any type
of standardization. The overload of different FOP labelling
systems available in the market may confuse consumers
instead of improving their decision capacity. Therefore, a
national and harmonized FOP labelling system should be
implemented.4
In this context, the Portuguese Government, by the
hand of the Minister of Health has requested stewardship to
the Regional Ofce for Europe of the World Health Organi-
sation (WHO) regarding the development of an evidence
base framework for FOP labelling.
Better evidence on the effectiveness of FOP labelling
systems enables the denition of evidence-based national
policies and regulations, including a single national coher-
ent nutritional information model.
In response, the WHO produced a report on FOP label-
ling. Based on the evidence summarized in this report, a
number of considerations for adopting or reviewing of la-
belling policies at the national or regional level were identi-
ed. These considerations are key to ensuring that policies
achieve the intended health outcomes regarding FOP label-
ling. These considerations included:
• applying a single FOP labelling system to ensure
clear consumer understanding and usage;
• opting for government-led policy development rather
than a commercially based system, as consumers
perceive the latter as less credible;
• conducting stakeholder engagement and formative
research to ensure the selection of the most appro-
priate policy.
“There are many common traits between French habits
and those in Mediterranean countries, not only regarding
food, but also in the organization and structure of meals
during the day.”
The Portuguese population has several similarities with
the French population, not only regarding food, but also in
the structure and organization of meals.13 Building on these,
in October 2018, the Regional Director of the WHO ofcially
replied to the Portuguese Government guidance query. It
was mentioned that the accumulating evidence from several
studies shows that Nutri-Score FOP labelling system meets
all the criteria of an effective front of pack labelling system.
It is therefore safe to assume that Nutri-Score would be an
adequate FOP labelling system to be considered and en-
dorsed by Portugal. The evidence presented suggests that
Portugal and other countries shall consider the implementa-
tion of this work.
In parallel, it is essential to promote an integrated ap-
proach regarding healthy eating promotion policies. In
particular, Portugal shall keep the policy innovation trends
that characterized a growing intervention of the Ministry of
Health in the food sector between 2015 and 2018 as a way
to promote Public Health and ght NCDs.
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