Effect of a new graphically modified Nutri-Score on the objective understanding of foods' nutrient profile and ultra-processing: a randomised controlled trial

Abstract

Context and objective: When considering the health-related impact of foods, nutrient profile (content in salt, sugar, fibre, etc.) and (ultra-)processing are two complementary dimensions. The Nutri-Score, a summary graded front-of-pack label, already used in seven European countries, informs on the nutrient profile dimension, i.e. the one with the strongest evidence. Recently, mounting evidence linked ultra-processed food consumption to various adverse health outcomes, independently of their nutrient profile. To inform consumers about each of these two health-related dimensions of food (i.e., nutrient profile and ultra-processing), we aimed to test, in a randomised controlled trial, if a graphically modified version "Nutri-Score 2.0", including a black "ultra-processed" banner, would improve the capacity of consumers to rank products according to their nutrient profile but also to detect those ultra-processed, compared to a no-label situation. Methods: A total of 21,159 participants included in the NutriNet-Sante web-cohort were randomly assigned to a control arm (no front-of-pack label) or an experimental arm (Nutri-Score 2.0), and were presented an online interactive questionnaire with 3 sets of food products (8 cookies, 7 breakfast cereals, and 7 ready-to-eat meals) to rank according to their nutrient profile, and to identify ultra-processed foods. The primary outcome was the objective understanding of nutrient profile and ultra-processing, represented by a score of correct answers. Secondary outcomes were purchasing intentions and the healthiest-perceived product. Multinomial logistic regressions were performed. Results: The Nutri-Score 2.0 increased significantly the objective understanding of both the nutrient profile dimension of food products from 0.9% to 24.2% (OR = 29.0 (23.4 - 35.9), p<0.001), and the ultra-processing dimension from 4.4% to 77.7% (OR = 174.3 (151.4 - 200.5), p<0.001), compared with no front-of-pack label. The results followed similar trends for cookies, breakfast cereals, and ready-to-eat meals. The Nutri-Score 2.0 also had a positive impact on purchasing intentions and on the products perceived as the healthiest, guiding consumers towards a better nutrient profile and non-ultra-processed products. Conclusion: This randomised controlled trial demonstrates the interest of a front-of-pack label combining the Nutri-Score (informing on the nutrient profile dimension) with an additional graphic mention indicating when the food is ultra-processed, compared to a no-label situation. Our results show that participants were able to independently identify and understand these two complementary dimensions of foods. Keywords: Nutri-Score, randomised controlled trial, ultra-processed foods, nutrient profile, front-of-pack label Trial registration number: NCT05610930

Competing Interest Statement

The authors have declared no competing interest.

Clinical Trial

NCT05610930

Funding Statement

The NutriNet-Sante study was supported by the following public institutions: Ministere de la Sante, Sante publique France, Institut National de la Sante et de la Recherche Medicale (INSERM), Institut National de la Recherche Agronomique (INRAE), Conservatoire National des Arts et Metiers (CNAM) and University Sorbonne Paris Nord. Researchers were independent from funders. Funders had no role in the study design, the collection, analysis, and interpretation of data, the writing of the report, and the decision to submit the article for publication.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study was approved by the Institutional Review Board of Inserm (IRB Inserm n IRB0000388 FWA00005831) and the National Commission for Data Protection and Liberties (CNIL n 909216), and registered at: https://clinicaltrials.gov/show/NCT05610930. Electronic consent was obtained from all participants. The NutriNet-Sante study is conducted according to the Declaration of Helsinki guidelines, approved by the IRB of Inserm (n 0000388FWA00005831) and the National Commission for Data Protection and Liberties (n 908450/n 909216), and registered at: https://clinicaltrials.gov/ct2/show/NCT03335644.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.

Yes

Data Availability

Data described in the manuscript, code book, and analytic code will be made available upon request pending application and approval. Researchers from public institutions can submit a collaboration request including information on the institution and a brief description of the project to collaboration@etude-nutrinet-sante.fr. All requests will be reviewed by the steering committee of the NutriNet-Sante study. If the collaboration is accepted, a data access agreement will be necessary and appropriate authorizations from the competent administrative authorities may be needed. In accordance with existing regulations, no personal data will be accessible.

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