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

Authors:
  • Faculty of Nutrition and Food Sciences of the University of Porto
  • Universidade de Lisboa - Instituto Superior de Ciências Sociais e Políticas

Abstract and Figures

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.
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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-SILVA1,2, 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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... So far, appeals have been made by academics and other representatives of public health entities regarding the need to regulate this area and to endorse the use of a unique/single FOP-NL by the F&B industry operating in Portugal [37]. However, these positions have proposed the endorsement of a given FOP-NL system (the NS, in this case) whose effects on promoting healthier food choices were not studied for Portuguese consumers yet [38]. Consequently, evidence to sustain the decision-making process is still lacking. ...
... In that study, NS was the most effective system in improving participants' ranking ability [63]. Notwithstanding, and before the conduction of these two studies about the effectiveness of FOP-NL for the Portuguese population, appeals [37,38] were made to proceed with the endorsement, in Portugal, of the NS (i.e., without previous evidence about its effect on promoting healthier choices in the Portuguese population). Similar to the no-evidence discussions previously observed before or during the implementation of a FOP-NL system [64], this discussion can be a driver of positions polarization and can act as a barrier to define and implement an evidence-based FOP-NL policy. ...
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This study aimed to describe the underlying process, used methods and major recommendations emerging from a comprehensive and prospective health impact assessment of the endorsement of a front-of-pack nutrition labelling (FOP-NL) system by the Portuguese health authorities. A mixed-methods approach was used to gather information on the impact of four FOP-NL schemes on consumers’ selection of food products according to the perception of their nutritional quality, combining a systematic literature review, focus groups (FG), in-depth individual interviews, and an open-label crossover randomized controlled study. The relevance of FOP-NL as a public health promotion policy has emerged as a consensual idea among either FGs’ participants (i.e., consumers and experts), or interviewed stakeholders. Although all of the evaluated FOP-NLs result better than no system on promoting the choice of the healthiest product, the effectiveness of easy-to-interpret FOP-NL among vulnerable groups raised concerns related to the need of integrating specific nutritional information to promote a better self-management of chronic diseases, and related to the level of literacy of consumers, which could impair the usage of FOP-NL. Educational campaigns addressing skills to use FOP-NL is recommended. Furthermore, a monitoring strategy should be considered to evaluate the long-term effectiveness of this policy in promoting healthier food choices, and in reducing diet-related non-communicable diseases burden.
... It has been selected by several countries (France, Belgium, Spain) as a voluntary front-of-package (FOP) labeling system, because it is considered by consumers comparatively more efficient than other systems available in the world, such as the Modified Reference Intake (MRI), Multiple Traffic Light (MTL), or The Simplified Nutrition Labelling System (SNLS) [46][47][48]. The Nutri-Score indicates the overall nutritional quality of a given food product, through a color-coded scale from green to red (green indicating the highest nutritional quality and red indicating the lowest nutritional quality), with each color having a corresponding letter from A (dark green) to E (dark orange), meant to increase the label's readability [49,50]. ...
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... (2017) introduced in France has shown great promise in a number of studies conducted in various countries [15,[17][18][19]. A particular strength of this system is that unlike the UK traffic light, it also accounts for beneficial aspects of foods, namely the content of dietary fiber, protein and components of the vegetable, fruit and nut group [20]. ...
... Goiana-da-Silva et al, 40 em revisão publicada em 2019, recomendam que Portugal adote o sistema Nutri-Score por considerá-los o mais adequado e, adicionalmente, por terem recebido do diretor regional da OMS a informação oficial de que "... o acúmulo de evidências de vários estudos mostra que o sistema Nutri-Score atende a todos os critérios de um sistema eficaz de rotulagem nutricional..." Galan, 41 em 2019, por ocasião da adoção do Nutri-Score na Espanha, publicou extensa revisão sintetizando as melhores evidências científicas que respaldam a validação desse sistema e sua melhor performance quando comparado a outros modelos de FoP. ...
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Resumo Sociedades organizadas, governo e indústria têm buscado formas de garantir ao consumidor informações nutricionais confiáveis e de fácil interpretação. Um dos aspectos que se tem discutido refere-se à possibilidade de oferecer um número maior de dados, em relação a aspectos críticos à saúde, que possam decodificar, sem substituir, aqueles já presentes na lista de ingredientes e na tabela de informação nutricional, de forma a permitir rápida interpretação. Nesse sentido, a Associação Brasileira de Nutrologia está buscando colaborar com essa iniciativa propondo a utilização do modelo Nutri-Score, em forma adaptada, como um método de informação do perfil nutricional. O presente documento revisa esse modelo, demonstra sua validação científica e sugere adaptações a fim de torná-lo mais informativo.
... Several studies have validated the Nutri-score system's effectiveness by analyzing its applications in different countries like France and, recently, Belgium, Germany and Portugal, which are in the process of introducing it [34][35][36][37][38][39][40]. ...
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Spain ranks fifth among European countries for childhood obesity. Sugar-sweetened beverages (SSBs) and soft drinks (SDs) are consumed by 81% of the Spanish children weekly. Advertising is one of the factors that contributes to an obesogenic environment. This study correlated longitudinally the nutritional values of SSBs and SDs and advertising discursive strategies between 2013 and 2018 for all media. A mixed-methods approach was applied that included a quantitative analysis of advertising spend data, a content analysis and a study of the discursive strategies used in advertisements. In addition, the Nutri-score system was used in order to determine the nutritional quality of the beverages. The results were analyzed applying the Spanish advertising regulatory framework for obesity prevention. The main findings indicate an association between low nutritional value beverage advertisements and a discourse based on hedonistic elements. In order to prevent childhood obesity in Spain, a stricter regulation of advertising is necessary, especially in aspects such as the language used to present products and celebrity endorsements.
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Several studies have identified Front-of-Pack Nutrition Labels (FoPLs) as a promising strategy to improve the nutritional quality of consumers’ food choices and encourage manufacturers to offer healthier products. This study aims to fill the evidence gap regarding the most effective FoPL among the Portuguese population. In total, 1059 Portuguese participants were recruited through a web panel provider and asked to declare their intended food choices and to rank three sets of products (pizza, cakes and breakfast cereals) according to their nutritional quality, first in the absence of any labelling, and then with a FoPL displayed on-pack (five FoPLs tested). Finally, participants were asked to answer nine statements related to perceptions of FoPLs. Results showed that participants improved their food choices, depending on the FoPL and the food category. All FoPLs led to a higher percentage of correct responses on the ranking task compared to the no label condition. The Nutri-Score was among the FoPLs producing the greatest improvement across all food categories compared to the reference intakes (OR = 6.45 [4.43–9.39], p-value < 0.0001) and facilitating the highest percentage to correctly rank products according to nutritional quality. This study suggests that, among the available options, Nutri-Score is the most efficient FoPL to inform Portuguese consumers of the nutritional quality of foods and help them identify healthier options in mock purchasing situations.
Thesis
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This PhD dissertation studies the economic opportunities of preventive health care in the context of non-communicable diseases (NCDs). The level of preventive health care remains low in European countries, even though this type of care could serve an important role when it comes to the challenges posed by NCDs. Not only does preventive care have the possibility to improve quality of life and prevent premature deaths, it could also reduce health care expenditure and government spending, as well as avert economic losses. In this dissertation, the connection between preventive health care and four main NCDs – cancer, cardiovascular disease, chronic respiratory disease and type-2 diabetes – is approached in two parts. In the first part, the focus lies on exploring the economic challenges posed by NCDs and preventive health care. In the second part, the focus turns to economic opportunities in prevention for NCDs: existing and potential prevention efforts are evaluated in their ability to decrease the economic burden of NCDs. We address which tools of preventive care can be effective as well as affordable. In the first chapter, the financial burden of the four main NCDs in the European Union (EU) is studied based on a systematic review of the literature. We find that at least 25% of the total health care budget is spent on cancer, cardiovascular disease, chronic respiratory disease and type-2 diabetes; these diseases cause an additional economic loss worth almost 2% of EU GDP. Chapter 2 elaborates on the question why preventive health care does not have a more prominent role in the health care system today, considering its large potential to tackle NCDs. Through a literature review we cover market and behavioural failures that improve our understanding on the state of prevention today. Taking these barriers into account, can yield more effective policy design for preventive interventions. In the third chapter, the focus is steered towards the future by assessing the evolution of NCD prevalence and costs in the EU, until 2040. We develop a dynamic, non-homogeneous Markov model that is able to simulate the disease and financial burden of cancer, cardiovascular disease, type-2 diabetes and their co-morbidities. We find that population aging and multi-morbidity will remain important drivers behind the number of NCDs as well as their cost to the health care system and society. The second part of this dissertation, covering chapters 4 to 6, starts by evaluating the existing framework of prevention in the context of smoking behaviour. We assess the effectiveness of the anti-smoking policies in European countries in decreasing smoking prevalence among elderly individuals. We confirm the effectiveness of pricing policies, but indicate a need for more policy attention and research for this group of smokers. In Chapter 5, we create a semi-Markov model to assess the cost-effectiveness of primary health care interventions for prediabetic individuals in Belgium. We address two interventions: an intensive lifestyle intervention and a medical intervention with metformin, both preceded by screening. While both types of interventions are cost-effective for the health care system and even cost-saving for society, lifestyle interventions realize higher gains in quality of life and could therefore be more appropriate. In the sixth and final chapter, we address the fact that health benefits can also occur through NCD prevention outside of the health care sector. An exercise of demand modelling is undertaken in which Belgium implements carbon taxation to achieve environmental benefits. We study the potential health-related co-benefits that this type of policy; these benefits occur through reduced air pollution and a shift towards a more sustainable and balanced dietary pattern. This study indicates that policies or interventions outside of the health care sector may also create health gains by preventing risk factor exposure. These gains should be taken into account by policymakers. In conclusion, this dissertation indicates the economic challenge as well as opportunities for preventive health care in the context of non-communicable diseases. We established the current and future economic burden of several main NCDs (i.e. cancer, cardiovascular disease, type-2 diabetes and chronic respiratory disease), and the important role of population aging and multi-morbidity. Aside from pointing to the need for prevention, we also clarify the impact of several market and individual barriers in preserving the currently low levels of preventive health care across Europe. The economic opportunity of prevention lies in well-designed policies that address both economic incentives – e.g. pricing policies – as well as influential behavioural factors – e.g. group support and habit formation for behavioural change. For preventive health care to be implemented on a larger scale, it is important that the economic incentive structure in health care and government institutions encourages this. Finally, gains from NCD prevention can also be realized outside of the health care sector, for example in the energy sector. These benefits should be taken into account in policy decisions as well.
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Front-of-pack nutrition labels (FOP-NL) are efficient tools for increasing consumers' awareness of the nutritional quality of food products, prompting healthier food choices. The main goal of this study was to evaluate the impact of four FOP-NL schemes - Traffic Light label (TL), Guideline Daily Amounts (%GDA), Nutri-Score (NS) and Health Star Rating (HSR) - on consumers' selection of food products according to perceived nutritional quality. A cross-sectional open-label crossover randomized controlled study was carried out among Portuguese consumers. A web-based questionnaire was used to assess participants' a) preferences regarding FOP-NLs and b) capacity to select healthy products in a food selection task using the information from FOP-NL schemes. When performing the selection task, participants had the option to indicate that they could not decide simply based on the presented FOP-NL (requiring more information). Overall, 357 adults participated in the study. Regarding consumers' preferences, TL received the most favorable responses, while NS received the fewest. All FOP-NLs performed better than the no-nutritional label control condition in the food selection task. The highest proportion of correct choices was obtained for TL (72.3%), followed by HSR (70.9%), %GDA (70.0%) and NS (62.2%), though no significant differences were found among FOP-NLs. Percentages of respondents indicating not being able to answer due to lack of information affected the proportion of correct choices, with 10.3% for TL, 12.9% for %GDA, 14.6% for HSR, and 25.8% for NS, indicating they were unable to choose without additional information. Although no particular FOP-NL system stood out as the most significantly effective, TL was the most preferred by Portuguese adults. Long-term real-world evidence is necessary to assess the impact of FOP-NL systems on individuals’ food choices.
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Food labels are a challenge for most consumers, and the development of easily understandable labelling is essential when it comes to empowering consumers in making healthier food choices. Countries across Europe (such as France and the UK) have adopted approaches to convey additional nutritional information in an easy-to-understand way. Evidence suggests that the uniform colour-coded interpretative labelling, which has been implemented in the UK and France, can improve people's ability to understand nutritional information and make healthier food choices. Additionally, signposting foods that might be considered less healthy enable more nutritionally-balanced food baskets. The French Ministry of Health (MOH) developed the Nutri-Score model and defined it as the national reference model for food labelling. To date, more than 90 food manufacturers and retailers have committed to use the Nutri-Score labels on their products. The Belgian and Spanish MOH have also announced their endorsement of this model. However, in other countries little progress to standardise food labelling has been made. This inertia is because policy and regulatory levers lie outside the health sector, with scarce collaboration between different areas of government, and a strong opposition to some labelling schemes from the food manufacturing and retail sectors. In these countries, the absence of national and uniform food labelling schemes and the presence of several non-coherent interpretative food labelling models hinders the efforts towards improved understanding and use of food labels. For example, Portugal has a diversity of interpretative food labelling models on the market. It is therefore urgent to clarify the scientific evidence behind each model and to clearly identify the best approach towards an evidence-based national labelling strategy. Countries, including Portugal, have asked for stewardship and technical support from WHO Regional Office for Europe regarding the development of an evidence base framework for front-of-pack labelling. The recent WHO report5 on labelling schemes is very timely and represents an opportunity for governments to act. With an improved evidence base on the effectiveness of food labelling models, it should become easier for countries to define their national policies and regulations, including a single coherent nutritional information model. Until now, most governments argued that the scarcity of robust evidence would deeply hamper objective policies regarding food labelling systems, and several countries postponed decision making and put the onus of responsibility on an absence of guidance from the European Commission. The first EU joint meeting on front-of-pack nutritional labelling only took place mid-2018. Economic and political interests are delaying action. The absence of leadership allows retailers and manufacturers to use and develop their own front-of-pack labelling systems, probably without health outcomes considerations. The WHO report puts an end to the pre-existing evidence gap and provides governments and the European Commission the knowledge to produce a single front-of-pack labelling system that best promotes public health with no further unnecessary delays.
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Objective Four formats for a front-of-pack (FOP) nutrition label are currently considered in France: the Nutriscore (or 5-Colour Nutrition Label, developed by a public research team), the SENS (supported by retailers), Multiple Traffic Lights (MTL, currently used in UK) and a modified version of the Reference Intakes (mRIs, supported by industry). Our objective was to investigate the perception of these FOP labels, according to sociodemographic, lifestyle and dietary factors. Design Cross-sectional study. Setting Web-based French cohort. Main outcome measure FOP labels perception. Participants Participants in the NutriNet-Santé cohort received a specific questionnaire on the perceptions of the four label formats identified. Sociodemographic, lifestyle and dietary data (three 24-hours dietary records) were collected through self-administered questionnaires. Mutually exclusive clusters of FOP labels perception were identified through a multiple correspondence analysis followed by a hierarchical clustering procedure. Sociodemographic, lifestyle and dietary factors associated with the clusters were explored using multivariable multinomial logistic regression. All analyses were weighted according to 2009 French census data. Results Among the 21,702 participants in the study, the Nutriscore received the most important number of favourable responses on positive perception dimensions by participants, followed by MTL and SENS. The five identified clusters were characterised by marked preferences for Nutriscore (cluster 1, 43.2% of participants, crude n=9,399), MTL (cluster 2, 27.3%, crude n=6,163), SENS (cluster 3, 17.05%, crude n=3,546), mRIs (cluster 4, 7.31%, crude n=1,632) and none of the presented formats (cluster 5, 5.10%, crude n=965). The cluster 1 (Nutriscore) was associated with lower adherence to nutritional recommendations, while cluster 2 (MTL) was associated with younger age and higher level of education. Conclusion The Nutriscore appears to have a wide reach in the population and to appeal to subjects with lower adherence to nutritional recommendations.
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Dans un magasin expérimental, nous étudions la réponse comportementale en termes d’achats et son impact sur la qualité nutritionnelle des caddies alimentaires des ménages de l’apposition de trois systèmes d’étiquetage nutritionnel différents apposés en face avant des produits. Ces systèmes sont les apports de référence, les Traffic Lights multiples et le « 5C ». On utilise un protocole d’économie expérimentale permettant d’observer pour chaque participant à une cohorte l’écart entre un caddie élaboré sans système d’étiquetage et un caddie élaboré avec l’un des trois systèmes. Nous observons alors, en comparant les cohortes, l’efficacité relative des systèmes. Les trois systèmes améliorent la qualité nutritionnelle, mais avec plus ou moins d’efficacité. Les systèmes d’étiquetage 5C et Traffic Lights ont un impact significativement meilleur que les apports de référence.
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In the ongoing debate about front-of-package (FOP) nutrition labels, little data exist regarding nutritionally at-risk populations, although they are critical targets of prevention programs. This study aimed to compare the impact of FOP labels on the ability to rank products according to their nutritional quality among French adults potentially at risk of poor dietary quality (N = 14,230). Four labels were evaluated: Guideline Daily Amounts (GDA), Multiple Traffic Lights (MTL), 5-Color Nutrition Label (5-CNL), Green Tick (Tick), along with a reference without label. Mixed models were used to assess how individual characteristics and FOP labels were associated with the ability to rank products. Older participants and those with a lower educational level, income, nutritional knowledge, and likelihood of reading nutrition facts were less skilled at ranking food products according to nutritional quality. Compared with individual characteristics, nutrition labels had an increased impact on food product ranking ability. Overall, 5-CNL corresponded to the highest rate of correct responses, followed by MTL, GDA, and Tick (p < 0.0001). The strongest impact of 5-CNL was observed among individuals with no nutritional knowledge (odds ratio (OR): 20.24; 95% confidence interval (CI): 13.19-31.06). Therefore, 5-CNL appeared to be effective at informing consumers, including those who are nutritionally at-risk, about the nutritional quality of food products.
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The aim of this study was to review research conducted in 2003–2006 in the EU-15 countries on how consumers perceive, understand, like and use nutrition information on food labels. Based on a search of databases on academic publications, Google-based search, and enquiries directed to a range of food retailers, food companies, consumer associations and government agencies, a total of 58 studies were identified. These studies were summarised using a standard format guided by a model of consumer information processing, and these summaries were subsequently processed using the MAXqda software in order to identify key findings and common themes across the studies. The studies show widespread consumer interest in nutrition information on food packages, though this interest varies across situations and products. Consumers like the idea of simplified front of pack information but differ in their liking for the various formats. Differences can be related to conflicting preferences for ease of use, being fully informed and not being pressurised into behaving in a particular way. Most consumers understand the most common signposting formats in the sense that they themselves believe that they understand them and they can replay key information presented to them in an experimental situation. There is, however, virtually no insight into how labelling information is, or will be, used in a real-world shopping situation, and how it will affect consumers’ dietary patterns. Results are largely in line with an earlier review by Cowburn and Stockley (Public Health Nutr 8:21–28, 2005), covering research up to 2002, but provide new insights into consumer liking and understanding of simplified front of pack signposting formats. There is an urgent need for more research studying consumer use of nutritional information on food labels in a real-world setting.
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Front-of-package nutrition labelling policy: global progress and future directions - Rebecca Kanter, Lana Vanderlee, Stefanie Vandevijvere
Chapter
The possibility that a French perspective might contribute to and benefit the Mediterranean diet is illustrated by its low obesity prevalence: amongst European countries France has the lowest numbers of overweight and obese people. There are many common traits between French habits and those in Mediterranean countries, not only with regards to food, but also in the organization and structure of meals during the day. Also, France, because of its cultural attachment to its gastronomy, has better resisted the “westernization” of food habits compared to Mediterranean countries. The main characteristics of the French food habits, namely, no snacking, three meals a-day, a three course meal, eating together, cooking practices and avoidance of “junk food”, are listed, together with their potential health implications. This is followed by a discussion on how to implement these characteristics, and the possible difficulties that can be encountered when these principals are applied to other cultures.
Bringing government sectors together to address noncommunicable diseases -Portugal's interministerial healthy eating strategy
  • F Goiana-Da-Silva
  • D Cruz-E-Silva
  • M J Gregório
  • M Miraldo
  • A Darzi
  • F Araújo
Goiana-da-Silva F, Cruz-e-Silva D, Gregório MJ, Miraldo M, Darzi A, Araújo F. Bringing government sectors together to address noncommunicable diseases -Portugal's interministerial healthy eating strategy. WHO Public Health Panorama. 2018;4;426-34.