DR MATHILDE TOUVIER, INSERM (FRENCH NATIONAL INSTITUTE FOR HEALTH AND MEDICAL RESEARCH) – SUPPLEMENTARY WRITTEN EVIDENCE (FDO0143)

Audition – House of Lords – 25/03/2024

Dr Mathilde Touvier, MSc, MPH, PhD

Research Professor, Inserm (French National Institute for helath and Medical Research)

Head, Nutritional Epidemiology Research Team (EREN-CRESS), France

PI of the NutriNet-Santé cohort (https://etude-nutrinet-sante.fr/)

What are the main challenges in enabling people to eat healthily and tackling obesity, in your country and around the world?

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• In 2022, 890 million were living with obesity, which represents, 16% of adults aged 18 years and over (43% overweight)[1].
• In France, 54% of men et 44 % of women are overweight or obese (BMI ≥25 kg/m2) and 17 % live with obesity (same in men and women, BMI ≥30 kg/m2)[2].
• Obesity is a multifactorial disease, with non-modifiable risk factors such as genetics, but also modifiable risk factors, among which nutrition, which includes, diet and physical activity.
• These factors (unbalanced diet, lack of physical activity, sedentary behaviours, and also obesity itself) are also known to be major determinants of non-communicable diseases such as cancers, cardiovascular diseases, type 2 diabetes, but also mental, respiratory, osteoarticular health and other health outcomes.
• It is well illustrated by the figures of the Global Burden of Disease showing how these factors come high in the hierarchy for determinants of premature death globally (slide below).
• In France, more than 40% of cancers could be avoided, since they are directly linked to our lifestyle. In the top tier of causal factors, just after smoking, we find a number of nutritional factors: alcohol, unbalanced diet, obesity, lack of physical activity and lack of breastfeeding (slide below).

• Thus, improving these modifiable determinants is a challenge indeed.
• And it is all the more urgent that diet, nutritional status, obesity are strong markers of social inequalities. In France: 16% of working-class children are overweight and 6% are obese, compared to 7% and 1% respectively for the children of managers (Esteban 2015).
• So, years and years of research in nutrition science combining epidemiological studies (observational and interventional) and experimental (in vivo, in vitro, toxicological) studies allowed the scientific community, through collective expertise, to identify several risk and protective factors for obesity and other chronic diseases with a high level of evidence.
• For obesity for instance the World Cancer Research Fund[3] concluded that (slide below):

• Based on all this knowledge, public health nutrition policies have been set up. In France it is the National Nutrition and Health Program (PNNS) launched in 2001. An important part of this program is the dissemination of recommendations for the population.
• We have the famous “at least 5 servings of fruit and vegetables per day”, but also :
• pulses at least twice a week
• a small handful of nuts per day
• at least one wholegrain food per day
• fish twice a week, 1 of which should be fatty fish
• two dairy products a day
• prefer fats such as olive, walnut or rapeseed oils
• no more than 500g of red meat and 150g of processed meats per week, etc.
• at least 30 minutes of moderate to dynamic physical activity per day for adults.
• …(slide below)

• These recommendations are overall consistent globally (despite some variations)

• These recommendations primarily target the “nutritional” dimension of diet, which is very important.
• Besides, we have evolved in the last years towards a 3D vision of the impact of foods on health[4]:

1. The nutritional dimension (amount of salt, sugar, saturated fats, dietary fibers…) = the dimension for which the level of proof regarding their impact on health is the highest.
2. The food processing / food formulation dimension (we are going to talk about that)
3. The dimension associated with environmental contamination, in particular pesticide residues.

• Mounting evidence suggests that these three dimensions are complementary and altogether impact health.
• The challenge is thus to reduce exposure to products that are not favourable to health regarding one or several of these dimensions are on the contrary to increase exposure to favourable foods.
• This is challenging in a context where, in France and in most countries in the world, the quality of the food offer on these 3 dimensions is very heterogeneous. While some industrials are truly trying to improve the quality of their products, many others massively commercialize and push with intensive marketing for children and adults some foods that are definitely not healthy. This is the case for ultra-processed foods for instance.
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What are ultra-processed foods (UPFs)? How useful is this term for the purposes of policy and regulation, and what is the overlap with foods high in fat, salt and sugar?

• The idea of a potential health effect of food processing and food formulation, in addition to their energy and nutrient composition emerged with the publication in 2009 of the NOVA classification from Carlos Monteiro and colleagues from the University of Sao Paolo.
• This NOVA classification groups foods and beverages into 4 categories: Unprocessed or minimally processed foods, Processed culinary ingredients, Processed foods (which are basically products manufactured with the addition of salt, sugar or other substances of Group 2 ingredients to Group 1 foods) and UPF, as defined by (slide below):

• The proportion of energy intake from UPF is very variable across countries, and reaches nearly 60% in the UK and the US (in France this proportion is about 30-35%) (slide below)[5].

• As we are going to see after, there is a massive accumulation of scientific studies linking UPF to adverse health outcomes. Thus, even if we still need additional research to better understand factors and mechanisms that underly these links, this should not be an excuse to delay public health action to reduce the exposure to UPF5.
• In that sense, the concept of UPF is relevant for policy and regulation.
• Regarding the question about the overlap between the “food processing” and “nutritional” dimensions (“foods high in fat, salt and sugar”):
• On average, UPF have a lower nutritional quality[6].
• We have recently published a study[7] on about 130 000 products of the French market from the OpenFoodFacts database that showed that 63.2% of UPF were scored D or E by the Nutri-Score and only 5.3% were scored A.

• Thus there is a correlation. But these two dimensions remain not colinear and are complementary. For instance, some cakes found in supermarkets may not be “ultra-processed,” but they present a limited nutritional quality, with high amounts of sugar, fat and energy. Conversely, a diet soda does not have a bad nutritional quality (none-to-low calories and sugar), but it is typically ultra-processed (containing artificial sweeteners, dyes, etc.).
• Besides, the majority of epidemiological studies that found association between UPF and adverse health effects accounted for these nutritional factors. Associations were significant despite adjustment for salt, sugar, energy, fiber…intakes.

What evidence is there that consuming ultra-processed foods is harmful (compared to consuming foods high in fat, salt and sugar)?

• Etiological studies investigating the potential impact of UPF on chronic disease risk are recent. When we started to publish on this topic in 2018 with my team, based on the NutriNet-Santé cohort, there was no previous data on UPF and cancer, cardiovascular disease or type 2 diabetes risk.
• We launched NutriNet-Santé[8] in France in 2009:
• It was the first 'Web cohort' of its size globally. It includes today more than 176,000 participants aged 15 and over, and the recruitment is still ongoing. Its originality and strength lie in its highly detailed assessment of dietary exposure and emerging nutritional behaviours. These are measured using validated tools, in particular 24-hour dietary records repeated every six months (including the commercial name / brand of industrial products), plus a number of additional questionnaires on organic food consumption, food packaging, cooking practices, dietary supplements and physical activity, as well as information collected on factors not directly linked to diet, such as environmental exposure at home or at work, smoking and other lifestyle parameters. This enables us to characterize in detail the exposome of the participants.
• We are constantly trying to innovate to make it easier for participants to enter the data and to improve the quality of the information collected. For instance, we have added a module that allows participants to scan the barcodes of foods consumed, providing a direct link with the Open Food Facts database. This enables us to collect a wealth of valuable information on the composition of products, the presence of certain additives, and even their packaging.
• We have also set up a biobank for a sub-sample of 20,000 Nutrinautes, containing serum, plasma, buffy coat (with DNA) and urine. We are now starting to collect faeces from 8,000 to 10,000 volunteers as part of the NutriGut project.
• Participants are followed over time (including a link with medico-administrative databases).
• The Belgian part of the study has already been launched and is directly linked to our platform, and we are now happy to share our experience and know-how with PIs in other countries in order to set up similar NutriNet studies, as it is the case for example in Brazil under the coordination of Professor Carlos Monteiro.
• NutriNet is therefore a unique infrastructure for multidisciplinary research into nutrition and health.

• In NutriNet-Santé, we showed that participants who had a higher proportion of UPF in their diet had a higher risk of cardiovascular diseases, type 2 diabetes, obesity (and weight gain), cancers (overall and breast), depressive symptoms, gastrointestinal disorders (cross-sectional) and premature death (slide below for references)

• Evidence has intensively accumulated in the last years. Now, more the 75 prospective cohort studies consistently showed associations between consumption of UPF and adverse health outcomes. Important points are that:
• They were large-scale studies, with even 17 on more than 100 000 participants in adults
• Studies from all continents -> great geographical diversity both in adults and children and pregnant women studies
• With careful adjustment for various sociodemographic, lifestyle and anthropometric potential confounders, and, very importantly, adjustment in the majority of studies for energy intakes and nutrients intake indicators (such as sugar, salt, fat or fiber intakes). The fact that results were significant even when the nutritional quality of the diet was accounted for strongly suggests that other factors and mecanisms are also at play.

• Several meta-analyses of these studies have been performed and we recently published an umbrella review of them, led by Melissa Lane and colleagues in Deakin University, Australia[9]. It included 45 unique pooled analyses, on more than 9 million participants. It showed that greater exposure to ultra-processed food was associated with a higher risk of adverse health outcomes, especially cardiometabolic, common mental disorder, and mortality outcomes.

• An important and complementary piece of evidence comes from randomized controlled trials (RCT) examining intermediate health markers, such as the famous one conducted by Kevin Hall et al[10]. This crossover trial allocated participants to an ad libitum ultra-processed or unprocessed diet for two weeks each and found that the ultra-processed diet led to increased energy intake and weight gain, while the unprocessed diet resulted in lower energy intake and weight loss. Very instructive. I will not enter into details since he will be presenting it and subsequent ones himself very well I am sure, in this same audition session.
• Although randomised trials have been small and short term, they have also shown harms of ultra-processed foods, including weight gain, metabolic perturbations, and changes in the gut microbiota (for some additives emblematic of ultra-processed foods)[11]. Long term clinical trials of dietary interventions on hard endpoints (e.g. cancer, CVD or mortality risks) are not always feasible or ethical, especially when deleterious effects are expected. Triangulation of multiple study designs has previously been used to show causality[12] by combining well conducted large scale observational and mechanistic epidemiological studies on long term health outcomes with short term trials studying intermediate metabolic endpoints and with in vivo and in vitro experimental studies.
• On this later aspect, there is mounting evidence regarding mechanisms and factors that contribute to explain health impacts of UPF, beyond their nutritional profile only.

What is the evidence on the mechanisms by which ultra-processed foods may cause harm (such as nutrient profile, harmful additives, palatability or convenience)?

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•               We provided an overview of potential mechanisms in a paper published late 2023 in the BMJ[13] (figure below).

• The precise factors associated with disease risk (eg, food ingredients, nutrient profiles, specific additives, contaminants) and their causal mechanisms are not yet fully understood.
• However, evidence suggests that diets with high and low proportions of ultra-processed foods differ in several aspects that could drive adverse health effects in humans[14]. Analyses show that the nutrient quality of diets with large amounts of ultra-processed foods are on average poorer, containing more added sugars, refined grains, saturated fat, and sodium, energy density, and less fibre, protein, and micronutrients [15]. The food ingredients used in ultra-processed foods are on average of poorer quality, and ultra-processed foods also displace minimally processed, nutritious foods such as fruit, vegetables, legumes, nuts, and seeds from the diet and thereby limit intake of plant based bioactive compounds such as polyphenols.
• Changes to the food matrix during processing may affect satiety, transit time, digestibility, the absorption kinetics and bioavailability of ingested nutrients (such as the glycaemic response) [16], as well as partitioning of energy and nutrients between digestion by the host versus the gut microbiota. In particular, the concept of “acellular nutrients” is gaining ground, identifying starches, sugars, and proteins that have been rendered completely devoid of any natural intact food structure. Such nutrients are rapidly digested and absorbed in the mouth, stomach, and small intestine, leaving little nutrition for microbiota bacteria in the large gut [17]. This may also contribute to a faster rate of energy intake than with unprocessed foods[18], although the type of energy source (solid foods or beverages) should be considered[19].
• Ultra-processed foods are also generally aggressively marketed, with attractive packaging that includes animal and cartoon characters, images, and health related claims. Although studies of the effect of packaging and marketing are limited, they may encourage overconsumption [20].
• But as explained before, increased energy intake and nutritional aspects (salt, sugar, fiber intakes etc.) are not the only factors involved.
• Indeed, food processing can produce potentially toxic compounds such as furans, heterocyclic amines, polycyclic aromatic hydrocarbons, acrolein, advanced glycation end products, industrial trans-fatty acids, and acrylamide. Ultra-processed foods also generally have a long shelf life, which could result in migration of contaminants such as phthalates, bisphenols, mineral oils, and microplastics from contact packaging [21]. Studies have suggested that these contaminants may have carcinogenic properties and increase the risk of cardiovascular disease, obesity, insulin resistance, and type 2 diabetes [22].
• Accumulating evidence also suggests that several food additives found in ultra-processed foods (eg, some sweeteners, emulsifiers, preservatives, dyes) may also have detrimental effects on health.
• Previous food additive assessments were based on focused toxicological metrics (eg, cytotoxicity, genotoxicity), with no consideration of the latest epidemiological results or experimental data on metabolic or microbiota perturbations nor potential cocktail effects.
• Several in vitro and animal studies, as well as short-term RCT in humans have now suggested deleterious health effects for some of the roughly 330 additives currently approved for use in Europe, for instance through gut microbiome dysbiosis, inflammation and DNA damage [23].
• In NutriNet-Santé, the level detail in the dietary data collected allowed us to quantify for the first time the exposure to the broad spectrum of additives available on the European market and to identify the main mixtures to which are exposed. This work was part of an ongoing project funded by the European Research Council (ERC ADDITIVES, PI M Touvier). Indeed, a great strength is that we have collected the commercial name/brand of the products consumed since the launch of the cohort, which is fundamental here given the wide variation in composition between brands for a same generic food. A chocolate biscuit can contain from 0 to 10 different additives, for instance. We observed associations between exposure to several food additive types (nitrites, artificial sweeteners, some emulsifiers) and increased risk of several chronic diseases (e.g. cancer, CVD, type 2 diabetes, hypertension), references on the slide below.
• This supports the need for reevaluation of controversial “cosmetic” additives, as done recently for TiO2 [24] and aspartame (now considered “possibly carcinogenic to humans” by IARC-WHO) [25].
• We are now starting to study the links between the main mixtures of food additives, their possible cocktail effects and the risk of various chronic pathologies.

How should policymakers respond to that evidence?

It is time to inform consumers about adverse effects of ultra-processed foods consumption and to urge governments to take ambitious and decisive structural measures to enable healthy, less processed foods to be the easiest choice. Existing evidence is sufficiently strong to warrant immediate public health actions on two levels[26]:

1. A key point is the empowerment of citizens with better information to allow them to chose healthier food products on the three dimensions: favourable nutritional profile / non-to-minimally processed foods / with limited environmental contaminants. This can be achieved by:

• Recommendations to the population (such as the one we have in France with the PNNS). Regarding UPF for instance, several countries officially started to promote healthy, seasonal and affordable non-UPF diets in their official food policies (Brazil, Ecuador, Peru, Uruguay, Chile, Mexico, France, Belgium, Cataluña, Israel, Malaysia, Zambia, Sri Lanka, Canada). Other countries should also include promotion of non/minimally processed foods in their official dietary guidelines and disseminate them through communication campaigns.
• Another key measure is a clear and mandatory front-of-pack label to facilitate consumer identification of healthier products in supermarkets and online retailing.
• In this objective, we created the Nutri-Score:
• This is a 5-letter / 5-colour logo on the front of packaging, which gives an idea at a glance of the overall nutritional quality of the food.
• Its transparent and validated algorithm translates the mandatory information on the packaging, in a way that is simple and accessible to everyone.
• It takes into account, per 100g of product, the elements - nutrients and foods - to be favored (fibre, proteins, fruit, vegetables, pulses) and, conversely, it penalizes those to be limited (energy, saturated fatty acids, sugars, salt).
• More than 130 international publications [27] validated:
• The algorithm underlying the Nutri-Score by showing in the SU.VI.MAX, NutriNet-Santé, EPIC and several other cohorts that people consuming better classified foods had a lower risk of cancer, metabolic syndrome, CVD, and premature mortality from chronic diseases.
• The high objective understanding and impact of this logo in the general population and within different groups of people (students, patients, disadvantaged citizens) was also demonstrated (randomized trials in experimental supermarkets, online supermarket, real life experimentation, etc.), showing that it efficiently improved the quality of shopping baskets and performed better than other tested labels (e.g. multiple traffic lights, key hole, GDA…).
• It therefore became the official logo in France since 2017 (with already >1350 brands involved), as well as in 6 other European countries.
• The European Commission is now supposed to decide on a harmonized, compulsory logo. But a number of powerful manufacturers whose product portfolios are predominantly in the warmer colors of the Nutri-Score are firmly opposed to it and perform intensive lobby[28].
• In this tough battle between public health and economic interests, the Nutri-Score receives strong support from the international scientific community, from learned societies, and health professionals. IARC, for example, took a stand in favour of the Nutri-Score in 2021[29], along with more than 320 scientists, who signed a recent report summarizing all the scientific evidence surrounding the Nutri-Score[30].
• In its current version, Nutri-Score primarily targets the “nutritional dimension”. Given the extended correlation with UPF/NOVA (as seen before), it also partially indirectly covers the food processing dimension. An international scientific committee regularly proposes improvements to the algorithm to account for advances in science (for instance, in now included since 2024 penalization of artificially sweetened beverages). Among the next evolutions of the logo, we proposed to integrate a black banner with an inscription “ultra-processed food” to the Nutri-Score whenever the food is ultra-processed (figure below). We tested this upgraded Nutri-Score in a randomised trial and found that it increased objective understanding of the overall nutrient profile and ultra-processing dimension of foods, with downstream effects on purchasing intentions and perceptions of product healthfulness [31]. We are also currently working on scenarios for integration of food processing into the calculation of the Nutri-Score algorithm itself.

• To be able to use this Nutri-Score/UPF logo in practice and more generally for regulatory purposes, there is a need for an operationalization of the UPF definition, e.g. derived from NOVA and specifying an official positive list of processes and ingredients defining UPF. This work should be conducted in the framework of a collective expertise by public health authorities, independent academic experts
• The third dimension (environmental contamination – pesticides’ residues) is at least partly covered by the Organic food label already in use in Europe.
• Other measures would be to financially support the development of concrete tools for citizens:
• Food profiling smartphone apps (barcode scanning), e.g. Open Food Facts (https://world.openfoodfacts.org/)
• Websites with official guidelines and practical tools, e.g. Mangerbouger.fr with meal simulator, tips, recipes…
• The importance of education, starting early in childhood with mandatory nutrition training to improve literacy.

2. The first level (consumer level) is necessary but not sufficient. Indeed, it is extremely difficult not to say impossible, to make the right choices in an environment that pushes individuals to consume salty, sugary, fatty, and/or ultra-processed foods, with intense, massive marketing and plethoric offer of appealing and affordable ultra-processed foods and beverages. Thus, there is an urgent need to change the environment in which people live and the food supply to which they have access, to limit exposure to unhealthy foods and support informed decision making through policy measures that work ecologically throughout food systems[32]:

• Law and regulation to reduce marketing for unhealthy products
• Protection of schools and other learning environments,
• Government policies and rewards to increase availability, accessibility, and affordability of nutritionally health and minimally processed foods from farms and manufacturers to retail outlets and restaurants (fiscal policies)
• Fiscal interventions that target deeper structural and commercial drivers of production, distribution, and promotion of unhealthy products
• New government and international policies, standards, and investments in public research are also needed for re-evaluating the public health risks of industrial food additives, processes and packaging

These measures aim at deeply transforming current food systems so that healthy, sustainable, minimally processed foods become the easiest choice.

On what terms should government and the scientific community engage with the food industry in enabling people to eat healthy diets and tackling obesity?

• Food processing, including at the industrial scale, has enabled humans for millennia to produce safer, more nutritious, and palatable foods. The food industry is essential to ensure a safe and sufficient food supply, and for providing diets rich in minimally or appropriately processed foods, with a favourable nutritional profile; it is essential to healthy and sustainable food systems, and to food security.
• However, the business operating models and financial incentives driving many of today’s largest food corporations and their upstream and downstream supply chains are pushing sugary, fatty, salty foods and/or ultra-processed products onto consumers using intense, targeted, and highly effective marketing strategies[33],[34].
• By funding nutrition research and government lobbying, these companies often influence dietary recommendations and food policies, and avoid regulation[35]. Numerous studies demonstrated the links between financing a study and the orientation of its results (slide below). For instance, reviews with conflicts of interest were five times more likely to present a conclusion of no positive association between sugar-sweetened beverages and weight gain than those without financial conflict.

• Thus, it is crucial to dedicate budget to allow future nutrition research to be publicly funded and totally independent from the food industry. Results from this research will guide manufacturers towards innovative, technologically relevant, yet safe and sustainable processes and substances, towards more optimal food processing (but not “ultra-processing”) for health.
• Similarly, all decisions to shape the operational definition of UPF or food policies should be made free from commercial conflicts of interests[36]. Independent academic experts and public health authorities should be involved in the process, through collective expertise. Input from industry can be solicited but should not be binding, and final decisions should be taken without industry involvement or commercial conflicts of interest.
• The example of Nutri-Score is striking in this field: despite >130 scientific publications demonstrating its relevance for public health, a large support from the scientific, medical and public health communities, and from consumer associations, it is still not mandatory in Europe because of intensive industrial lobby from firms (Coca-Cola, Pespi, Mondelez, Ferrero…) that refuse this tool that would provide consumers with (too) transparent information on the nutritional quality of their products. This intensive lobby is illustrated in the report published in October 2023 by the European Consumer Organisation (BEUC) based on an access-to-documents request by Foodwatch EU. It is called “Food Label Ambush: How intense industry lobbying halted EU plans”[37].
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What strategies for enabling people to eat healthy diets and tackling obesity have been adopted in your country, and what is the evidence on their effectiveness? What strategies are most likely to be effective in the future?

• In France, we launched the National Nutrition and Health Program (PNNS) in 2001, it has been regularly updated, the last version dating 2019 and the following one been in preparation.
• An important part of this program is the dissemination of recommendations for the population (“at least 5 portions of F&V a day, etc., as see previously), including official advice on the 3 dimensions of food impact on health, such as limiting foods with Nutri-Score D or E (in terms of frequencies and quantities), preferring non-to-minimally processed food and home cooking, and favouring organic versions of foods whenever possible.
• Several of these recommendations also aim at limiting environmental impact of our food systems to increase their sustainability (limiting red and processed meat, favouring vegetable oils, fruits, vegetables and pulses, local and seasonal products, etc.).
• These recommendations are disseminated by the Public Health France Agency through multiple channels:
• Communication campaigns
• Mandatory messages within food advertisements
• A website (Mangerbouger.fr) including a meal simulator, recipes, tips adapted to all ages and personal situations (including for physical activity of course)
• But as said previously, it is not sufficient to inform and educate citizens, it is also crucial to modify their environment to allow them to make healthier choices. Thus, several measures were also introduced in this direction, such as:
• the ban on vending machines in schools since 2004
• a tax on sugary drinks (and now also artificially sweetened beverages), from 2012, which is indexed on the content of sugar since 2018.
• Other plans complement this strategy, such as the National Food Program (PNA), the Obesity plan (PO), the Cancer plan, etc., with consistent strategy overall.
• In terms of impact, some measures or recommendations are relatively recent, thus it is still difficult to measure an objective impact (for UPF for instance). Our last nationally representative nutrition surveys (Esteban and INCA3) were performed around 2015 and the next one is going to be launched next year. But we already have some indicators of success in different fields, for instance:
• In 30 years, between 1992 and 2021, the proportion of adults declaring that they drink alcohol every day has been divided by 3 (among both men and women) [38].
• The prevalence of overweight and obesity among both adults and children has stabilized since the mid-2000s [39].
• Nutri-Score:
• The introduction of the front-of- package labelling Nutri-Score seems to have had a positive impact on the quality of the food offer, initiating a shift of the market from unhealthy to healthy foods[40]: for example, Bauner at al in 2024 showed that “products introduced or altered after the adoption of Nutri-Score in 2017 in France receive better Nutri-Score ratings than those introduced before the adoption, indicating a shift to items that are healthier overall. In addition, there is some evidence of bunching at the cut-offs for better Nutri-Score grades, which suggests that the improvements are at least in part a strategic reaction to the Nutri-Score introduction”. This trend is confirmed by several panel data (e.g. ScanUp) is several countries (e.g. France and Spain in the Figure on the right).

• A study published in 2024 by the OECD (Health Division, Directorate for Employment, Labour and Social Affairs)[41] compared the effectiveness of four types of front-of-pack nutrition labels. They concluded that:
• Nutri-Score displays higher potential for yielding positive health and economic outcomes, compared with other FoPLs.
• Across EU countries, Nutri-Score is projected to avert nearly 2 million cases of non-communicable diseases, in total, between 2023 and 2050.
• Nutri-Score is projected to significantly lower annual healthcare expenses by 0.05%, whereas the other labels have negligible impacts.
• By reducing cases of disease, it has the potential to improve employment and work productivity. In this domain, Nutri-Score surpasses the other labels with an estimated annual gain of 10.6 full-time equivalent workers per 100,000 individuals of working age across EU countries.
• Mandatory implementation would lead to greater effects than those obtained with a voluntary implementation, providing evidence to inform legislation proposal for an EU-wide nutrition labelling system.
• We lack of proper evaluation of the impact of the soda tax in France. But it has been specifically evaluated in other countries such as Mexico and proved its efficiency, especially when the benefits of the tax are reinjected in public health measures such as water fountains in school (which also increases the public acceptance of the tax)[42].
• A report that came out last week from the French Food Safety Agency (ANSES-Oqali) examined the nutritional composition of more than 54,000 products on the market between 2008 and 2020, and showed that the majority of products contained at least one sweetening or sweet-taste-enhancing ingredient, even in savoury products. However, there was a decline in the use of sweetening ingredients (such as sugar syrups) over the past 10 years[43].
• There is still a long way to go…For instance, 72% of French people aged 18 to 54 eat fewer than 5 portions of fruit and vegetables a day, 85% do not eat nuts at all, 63% eat more than 150g/week of processed meat, etc.[44]
• So, to move forward: solutions are currently being discussed in France as part of the preparation of our National Strategy for Food, Nutrition and Climate last year and this year, which is giving rise to fascinating debates and key contributions, notably from the French High Council for Public Health (HCSP), with a gold mine of ideas for our future policies. I will not detail them all here but I provide the reference to the English version of the opinion report here[45].
• Just a few leads based on the Nutri-Score for instance:
• The HCSP recommends to make it mandatory on all food packaging in Europe to ensure greater transparency for consumers.
• Its use in catering establishments and on bulk products is planned in the coming months/years.
• But it could also be displayed in all food advertising.
• It could also be used for economic regulation purposes, on the model of the current tax on sugary drinks: the tax could be broadened and indexed to the Nutri-Score (there is an example of publication that tested this experimentally and suggested the relevance of this measure and its superior efficiency compared to just taxing sugary drinks[46]).
• Work on its evolution to include the very important and complementary dimension of ultra-processing.
• A great deal also remains to be done in terms of regulating advertising in particular aimed at children. Food advertisement is forbidden on TV during kids’ programs but in fact there are massively exposed to food advertisement on TV (with non-kid specific programs), on the internet and on social networks. A report from Public health France showed that 53.3% of food advertisements seen by children are for products of poor nutritional quality (Nutri-Score D or E)[47]. This agency recommends banning advertising for these products during the hours when the greatest number of minors watch television, not forgetting the regulation of digital marketing on the internet and social networks, to which teenagers are exposed for almost 2 hours a day in average.
• And of course, it will be crucial to dedicate sufficient budget for public research, independent from the food industry, to allow to better identify the specific processes and substances (additives, other industrial ingredients, contaminants from processing or packaging, pesticides…) that positively or negatively impact health. Multidisciplinary collaboration will be key to success, with approaches combining epidemiology, data science, high quality dietary data collection, toxicology, experimental and interventional research, food technology, as well as public policy, food systems, and social marketing research.
• Political measures should be taken and should be compelling, otherwise always the same manufacturers will play the game, while others (always the same) will not…An example is the proposal that has been made to industrials in the food sector to sign renewed collective agreements, in order to improve the nutritional quality of the food supply, and to promote the sustainability of the industry. But several years after the launching of the call, nothing really happened. Thus, strong political decisions need to be taken if we want to move forward to improve public health through nutrition.

• + Additional information can be found here:
• https://www.college-de-france.fr/fr/agenda/colloque/nutritional-determinants-of-health-recent-research-discoveries-and-translation-into-public-health

• 25 March 2024