Nutritional quality of diet characterized by the Nutri-Score profiling system and cardiovascular disease risk: a prospective study in 7 European countries

Abstract

Background: Nutri-Score is a scientifically validated 5-color front-of-pack nutrition label reflecting the nutrient profile of foods. It has been implemented in several European countries on a voluntary basis, pending the revision of the European labeling regulation. Hence, scientific evidence is needed regarding the ability of the nutrient profile underlying the Nutri-Score (uNS-NPS, 2023-updated version) to characterize healthier foods. Our objective was therefore to study the prospective association between the nutritional quality of diet characterized by the uNS-NPS and the risk of cardiovascular diseases in a large European population.

Methods: Our analyses included 345,533 participants from the European Prospective Investigation into Cancer and Nutrition study (EPIC, 1992-2010, 7 European countries). Food intakes were assessed at baseline using country-specific dietary questionnaires. The uNS-NPS was calculated as a continuous scale for each food, based on its 100 g content of energy, sugars, saturated fatty acids, salt, fibre, and protein and percentage content of fruit, vegetables, and pulses. A dietary index was derived at the individual level (uNS-NPS DI: energy-weighted mean of uNS-NPS scores of all foods consumed by a participant). Cardiovascular events during follow-up were retrieved using country-specific methods (self-report, registry data). Multi-adjusted Cox models were computed.

Findings: Overall, 16,214 first cardiovascular events were reported (median follow-up: 12.3 years; 4,103,133 person-years). The consumption of foods with a higher uNS-NPS score (reflecting a lower overall nutritional quality of diet) was associated with higher risks of total cardiovascular events (Hazards Ratio (HR) for an increment of 1 standard deviation: 1.03 (95% Confidence Interval 1.01-1.05)), especially myocardial infarction (HR = 1.03 (1.01-1.07)), and stroke (HR = 1.04 (1.01-1.07)).

Interpretation: In this large prospective study among European adults, a higher risk of cardiovascular diseases (total and several subtypes) was observed in individuals consuming a diet with a lower nutritional value, as graded by the uNS-NPS score. This brings new evidence on the relevance of the updated nutrient profile underlying the Nutri-Score to characterize foods with a healthier nutrient profile.

Funding: EPIC-CVD was supported by EU FP7, ERC, UK MRC, British Heart Foundation, and UK NIHR.

Keywords: Cardiovascular disease risk; Europe; Food labelling; Nutrient profile; Nutrition; Prospective study.

Fig. 1

Associations between the uNS-NPS DI and cardiovascular diseases, multivariable Cox proportional hazards regression models^a, EPIC cohort study, 1992–2010. The models used age as the time scale and were stratified by age (1-y interval) and study centre and adjusted for gender, body mass index, educational level (longer education, including university degree; technical/professional school; secondary school; primary school; none), total physical activity (Cambridge index based on occupational physical activity and other physical exercise, including cycling; gender-specific categories: active; moderately active; moderately inactive; inactive), smoking status, duration and intensity (current, 1–15 cigarettes/d; current, 16–25 cigarettes/d; current, ≥26 cigarettes/d; current, pipe/cigar/occasional; current/former, missing intensity; former, quit ≤10 y; former, quit 11–20 y; former, quit >20 y; never smoker), alcohol and energy intakes (continuous), and personal history of high blood pressure, high cholesterol and diabetes. A higher uNS-NPS DI indicates a lower nutritional quality of the foods consumed. The SD for the uNS-NPS DI was 2.4. Abbreviations: CI, confidence interval; DI, Dietary Index; EPIC, European Prospective Investigation into Cancer and Nutrition; uNS-NPS, Nutrient Profiling System underlying the Nutri-Score; HR, hazard ratio; py, person-years; SD, standard deviation.

Fig. 2

Associations between the uNS-NPS DI and Cardiovascular diseases(A), Coronary heart diseases (B), Myocardial infarction (C), Cerebrovascular diseases (D), and Stroke (E), non-linear modelling using restricted cubic splines, EPIC cohort study, 1992–2010. A higher uNS-NPS DI indicates a lower nutritional quality of the foods consumed. The Cox proportional hazards model used age as the time scale and was stratified by age (1-y interval) and study centre and adjusted for gender, body mass index (continuous), height (continuous), educational level (longer education, including university degree; technical/professional school; secondary school; primary school; none), total physical activity (gender-specific categories: active; moderately active; moderately inactive; inactive), smoking status, duration and intensity (current, 1–15 cigarettes/d; current, 16–25 cigarettes/d; current, ≥26 cigarettes/d; current, pipe/cigar/occasional; current/former, missing intensity; former, quit ≤10 y; former, quit 11–20 y; former, quit >20 y; never smoker), alcohol and energy intakes (continuous), and personal history of high blood pressure, high cholesterol and diabetes. Abbreviations: DI, Dietary Index; EPIC, European Prospective Investigation into Cancer and Nutrition; uNS-NPS, Nutrient Profiling System underlying the Nutri-Score; HR, hazards ratio. The 3 knots were set at the 5th, 50th (reference value), and 95th percentiles, as described in Desquilbet and Mariotti, of the uNS-NPS DI distribution. The dashed lines are 95% confidence intervals.