Comparative Effectiveness in terms of Understanding of Nutri-Score and NutrInform in Spain

Background

Interpretive Front-of-Pack Labels (FoPLs) are supported by WHO as a key policy tool to promote healthy diets. At present, various FoPLs formats co-exist in the European Union (EU). However, as part of the Farm to Fork strategy, the European Commission stated it would adopt a single mandatory FoPL in 2022. The aim of this study was to analyze Spanish consumers reactions to Nutri-Score and NutrInform, two FoPLs that are currently the subject of debate in EU, testing preference through subjective understanding and perception but also performance through objective understanding of the FoPLs.

Methods

The experimental study was conducted in 2021 on a representative sample of 1026 Spanish adults (50% women, mean age±SD = 46±14 years), through an online randomized questionnaire where participants were exposed to Nutri-Score or NutrInform. Performance of and preference for these two FoPLs were assessed in three food categories (Breakfast Products, Breakfast Cereals and Added Fats). Performance was tested using multivariate logistic regression while preference using principal component analysis and t-tests.

Results

In terms of objective understanding, Nutri-Score was significantly associated with an increase in consumers’ ability to identify healthier food products across all food categories compared to NutrInform (OR = 19.1 [14.2-25.7], p < 0.0001). On the preference dimension, Nutri-Score was perceived as significantly easier to use and was more liked than NutrInform (standardized PCA dimension resp. 0.32±1.58 vs. -0.29±1.66, p < 0.0001 and 0.080±1.18 vs. -0.072±1.17, p = 0.039) and participants found Nutri-Score more helpful to discriminate the nutritional quality of Breakfast Products and Breakfast Cereals (resp. 1.32±1.00 vs. 1.14±1.02, p < 0.01 and 1.33±1.00 vs. 1.00±1.03, p < 0.0001).

Conclusions

Results of this study provide new evidence to support Nutri-Score in comparison with the NutrInform battery, on both performance and preference aspects.

Key messages

• Nutri-Score better helps participants identify healthier food products than NutrInform.

• European Commission should consider results of this study in its decision on a harmonized Front-of-Pack Label.

Circadian nutritional behaviours and risk of type 2 diabetes in NutriNet-Santé

 

Skipping breakfast and late-night-eating have been associated with risk factors for type 2 diabetes (T2D). However, less is known about the link between daily timing and frequency of food intake and risk of developing T2D. The objective of the present study is to investigate the associations between circadian nutritional behaviours, defined by meal timings and frequency, and risk of T2D. 103,312 adults (79% females, mean age at baseline=42.7) from the French NutriNet-Santé cohort were included. Participants’ circadian nutritional behaviours were assessed using repeated 24 h dietary records. Associations of time of first and last meal of the day, meal frequency and of nighttime fasting duration with risk of T2D were assessed by multivariable Cox proportional hazard models adjusted for known risk factors. During a median follow-up of 7.3 years, 963 new cases of T2D were ascertained. Compared with subjects reporting on average a first meal before 8AM, those having a first meal after 9AM had a higher risk of developing T2D, HR = 1.59 (1.30 to 1.94). A late time of last meal (after 9PM) was associated with a higher risk of T2D, HR = 1.28 (1.06 to 1.54), but this association was no longer significant after adjusting for time of first meal. Each additional eating episode was associated with a reduction of the risk of T2D, HR = 0.95 (0.90 to 0.99), p-value=0.01. Overall, nighttime fasting duration was not associated with risk of T2D, except in participants having breakfast before 8AM after a nighttime fasting duration of more than 13 hours (HR = 0.47, 0.27 to 0.82). In this large prospective study, circadian nutritional behaviours were associated with risk of T2D. Daytime nutritional behaviours and specifically an early first meal was associated with a lower risk of type 2 diabetes. If confirmed in other largescale studies, an early breakfast should be considered in preventive strategies for type 2 diabetes.

Key messages

• If confirmed in other largescale studies, an early breakfast could be considered in preventive strategies for type 2 diabetes.

• Beyond nutritional quality of meals, meal timing could also be a risk factor for type-2 diabetes.

Food choices characterized by the Nutri-Score nutrient profile and risk of cardiovascular diseases

Background

Nutrition is a well-established risk factor for cardiovascular diseases (CVD) that can be leveraged by public health prevention strategies. In addition to dietary guidelines, front-of-pack nutrition labels (FoPNL) can help consumers make healthier food choices. Nutri-Score, a scientifically validated 5-color FopNL based on the nutrient profile FSAm-NPS has been adopted by several European countries but remains optional under current EU labeling regulation, which is to be revised end of 2022. Scientific evidence is therefore needed on the relevance of the Nutri-Score at the European level. Our objective was to study the association between the consumption of food as graded by the FSAm-NPS and CVD risk in a large European population.

Methods

This prospective analysis was conducted on a case-cohort comprising 13,308 participants without CVD risk factors at baseline, among which 5,326 first incident cases of CVD from the EPIC-CVD study (8 European countries). Food intakes were assessed using country-specific dietary questionnaires. The FSAm-NPS was calculated for each food based on its 100g content in energy, sugar, saturated fatty acid, sodium, fibre, protein, and fruits/vegetables/legumes/nuts. Multi-adjusted Cox models were computed.

Results

Overall, associations were observed between the consumption of foods with a higher FSAm-NPS score (lower nutritional value) and a higher risk of myocardial infarction (MI; HR1-SD=1.12 [1.05,1.21]; HRQ5/Q1=1.23 [1.00,1.52]). Associations with stroke were not significant. Overall, associations were more particularly observed in men.

Conclusions

In this large European population, a higher risk of MI was observed in individuals consuming on average a diet with higher FSAm-NPS foods (reflecting consumption of foods with a lower nutritional value/less favourable Nutri-Score). This adds to the evidence on the relevance of Nutri-Score as a public health tool to help consumers choose healthier food products.

Key messages

• The consumption of foods with a lower nutritional quality as graded by the Nutri-Score was associated with a higher risk of myocardial infarction in the large European EPIC-CVD case-cohort study.

• This adds to the evidence supporting the relevance of the Nutri-Score as a complementary tool to dietary guidelines to help consumers make healthier food choices.

Nitrites and nitrates from additives and natural sources and risk of cardiovascular outcomes

 

Nitrates and nitrites are used as food additives in processed meats. They are also commonly ingested from water and several foods. Evidence suggests a beneficial role of dietary nitrites and nitrates in lowering blood pressure. However, associations between exposure to nitrites and nitrates from natural sources and food additives, separately, and risks of hypertension and cardiovascular disease (CVD) have not been investigated. We aimed to study these associations in the French population based prospective cohort NutriNet-Santé. Overall, 104,817 adults were included. Associations between exposure to nitrites and nitrates (evaluated using repeated dietary records, linked to a food composition database accounting for commercial brands of industrial products) and risks of hypertension and cardiovascular disease were assessed using multivariable Cox proportional hazard models. During follow-up, 3810 incident cases of hypertension were ascertained, and 2075 cases of CVD, 1004 of cerebrovascular diseases and 1079 or coronary heart diseases were diagnosed. Participants with higher exposure to nitrites from food additives and specifically those highly exposed to sodium nitrite (e250) had a higher hypertension risk compared with those who are not exposed to nitrites from food additives (HR = 1.19 (95% CI 1.08-1.31), P = 0.002, and 1.19 (95% CI 1.07-1.31), P = 0.002, P &lt; 0.001), respectively). There was no evidence for an association between total nitrites or nitrites from natural sources, or dietary nitrates with hypertension risk (all P-values&gt;0.3). There was no evidence for associations between dietary nitrites, or nitrates with risks of cardiovascular, cerebrovascular or coronary heart diseases (all P-values&gt;0.2). In conclusion, we found that higher exposure to nitrites from food additives was associated with higher risk of hypertension. Our results do not support a potential protective association between dietary nitrites or nitrates and cardiovascular outcomes.

Key messages

• These results provide additional evidence in the context of current discussions about updating regulations on the use of nitrites as food additives.

• Our findings do not support any protective impact of nitrites and nitrates on cardiovascular health.

Nitrites and nitrates dietary exposure from natural sources and additives and type-2 diabetes risk

 

Nitrates and nitrites occur naturally in water and soil and are commonly ingested from drinking water and dietary sources. They are also used as food additives. The epidemiological evidence linking exposure to nitrites/nitrates with type-2 diabetes (T2D) risk is scarce. We aimed to study these associations in a large population based prospective cohort study. Overall, 104,168 adults from the French NutriNet-Santé cohort study (median follow-up time 6.7 years) were included. Associations between intakes of nitrites and nitrates (evaluated using repeated 24h dietary records, linked to a comprehensive food composition database and accounting for details of commercial names/brands of industrial products) and risk of T2D were assessed using cause-specific multivariable Cox proportional hazard models adjusted for known risk factors (sociodemographic, anthropometric, lifestyle, medical history, and nutritional factors). During follow-up, 969 incident T2D cases were ascertained. Total nitrites and nitrites from natural sources were both positively associated with higher T2D risk (HRtertile 3 vs.1=1.29 (95% CI 1.06-1.56), Ptrend=0.004, and 1.27 (95% CI 1.05-1.54), Ptrend=0.01, respectively). Participants with higher exposure to nitrites from food additives (i.e. above the sex-specific median), and specifically those having higher exposure to sodium nitrite (e250) had a higher T2D risk compared with those who were not exposed to food additive nitrites (HRtertile 3 vs.1=1.58 (95% CI 1.28-1.94), Ptrend&lt;0.001, and 1.59 (95% CI 1.30-1.96), Ptrend&lt;0.001), respectively). There was no evidence for an association between nitrates of any source and T2D risk (all Ptrend&gt;0.4). In this large prospective cohort, a higher dietary exposure to nitrites (from both natural sources and food additives) was associated with higher T2D risk. These results provide additional evidence in the context of current discussions about updating regulations on the use of nitrites as food additives.

Key messages

• A high exposure to dietary nitrites (from both natural and food additive sources) is associated with an increased risk of type-2 diabetes.

• These findings support further regulations concerning the use of nitrites as food additives in processed meats.

Motivations and strategies underlying the adoption of the front-of-pack labelling scheme Nutri-Score

 

Front-of-pack nutrition labellings (FoPL) have gained traction in the European Union as tools to tackle the burden of nutrition-related chronic diseases. Multiple FoPL have been implemented by both governments and private actors. Under the European food labelling regulation, any FoPL is optional to display, although the legal framework is being revised for a harmonized FoPL to emerge. Since the implementation of the Nutri-Score in France in 2017, little data is available to understand the motivations and strategies underlying the adoption of the FoPL from a food business’ perspective. A cross-sectional study was conducted in March 2021 on food businesses having adopted the Nutri-Score in France through an online questionnaire. In total, 121 businesses completed the questionnaire, representing 32% of companies adopting the scheme and covering a variety of company types. Engaged businesses had a rather healthier portfolio of products according to the Nutri-Score (on average, 69% of engaged products were A or B and 12% were D or E), with disparities between retailers and national brands. Businesses mostly reported their engagement was motivated by a will to be transparent (76%) and to simplify nutritional information (67%) but still 19% reported that they engaged following external pressures. External pressures were more likely to play a role in the engagement if the company engaged in 2020 compared to those engaged before 2018 (P = 0.032), if the company was larger (P = 0.044) and if the scope of engagement included D or E products (poorer nutritional quality) (P = 0.033). Our study showed that the Nutri-Score, as an optional measure, is mainly used by businesses, especially national brands, as a tool to promote rather healthier products, while companies with products of lower nutritional quality are more likely to engage following external pressure. This highlights the relevance of enforcing a mandatory FoPL system, in line with the Farm to Fork strategy.

Key messages

Artificial sweeteners and risk of cardiovascular diseases in the prospective NutriNet-Santé cohort

Background

Artificial sweeteners are widely used today by the food industry as sugar alternatives. Potential adverse effects of these food additives on cardiovascular disease (CVD) have been suggested in experimental studies, but data from studies involving humans remain very limited. Previous cohorts have focused on artificially sweetened beverages. Our objective was to study the associations between artificial sweeteners from all dietary sources, overall and by molecule (aspartame, acesulfame-potassium and sucralose), and risk of CVDs (overall, coronary heart and cerebrovascular).

Methods

The study included 103,388 participants of the web-based NutriNet-Santé cohort (2009-2021). Artificial sweetener intakes were assessed using repeated 24h dietary records including names and brands of industrial products consumed. Multi-adjusted Cox proportional hazard models were performed. Exposure to artificial sweeteners were coded as 3-category variables: non-consumers, lower consumers (artificial sweetener intake below the sex-specific median) and higher consumers (above the sex-specific median).

Results

Compared to non-consumers, higher consumers of total artificial sweeteners had increased risk for CVD (n = 1502 incident cases, HR = 1.17 [1.01-1.35], P-trend=0.04) and more specifically cerebrovascular diseases (n = 777, HR = 1.34 [1.10-1.62], P = 0.004). Higher consumption of aspartame was associated with increased cerebrovascular diseases (HR = 1.29 [1.03-1.60], P = 0.01). Higher consumption of acesulfame-K was associated with a higher risk of CVD (HR = 1.24 [1.04-1.47], P = 0.02) and cerebrovascular diseases (HR = 1.29 [1.02-1.64], P = 0.1). No association was detected for coronary heart diseases (n = 730 incident cases).

Conclusions

These findings suggest a direct association between higher artificial sweetener consumption and increased CVD risk, in particular cerebrovascular. These results provide key novel information for the ongoing re-evaluation of sweeteners by the European Food Safety Authority.

Key messages

• In this large-scale prospective cohort (n = 103,388), artificial sweeteners (especially aspartame and acesulfame-K) were associated with increased risks of cardiovascular and cerebrovascular diseases.

• These results provide key insights to feed EFSA’s expertise for the ongoing risk assessment of artificial sweeteners.

Circadian nutritional behaviours and risk of cardiovascular disease in NutriNet-Santé

 

Meal timings and daily night-time fasting periods can synchronise the circadian system, which regulates the cardiovascular system. The present study aims to evaluate the prospective associations between circadian nutritional behaviours, defined by meal timing and frequency, and the risk of cardiovascular diseases. We used data from 103,389 adults (79% females) in the French NutriNet-Santé study, 2009-2021. Circadian nutritional behaviours were assessed using repeated 24h food records during the first two years of follow-up. We examined the associations between circadian eating behaviours and risk of cardiovascular, coronary heart and cerebrovascular diseases by multivariable Cox proportional hazard models. During a median follow-up of 7.2 years, 2036 incident cardiovascular diseases were diagnosed. A later first meal of the day was associated with a higher risk of cardiovascular diseases (HR per hour increase = 1.06, 95% CI 1.01 - 1.12). A later last meal of the day was associated with a higher risk of cerebrovascular diseases (HR per hour increase = 1.08, 95% CI 1.01 - 1.15). Among women, a later last meal was also associated with a higher risk of cardiovascular disease (HR per hour increase = 1.08, 95% CI 1.01 - 1.15). We found no evidence for an association between night-time fasting duration nor meal frequency, with risk of cardiovascular diseases. This study suggests that the habit of eating a later first meal, and a later last meal (in women) could be associated with a higher risk of developing circulatory diseases. These results need to be confirmed in other largescale studies before they can be transferable to clinical practice.

Key messages

• Beyond nutritional quality of meals, meal timing could also be a risk factor for cardiovascular disease.

• If confirmed in other largescale studies, early breakfast and dinner could be considered in preventive strategies of cardiovascular diseases.

Trans fatty acid intake and risk of type 2 diabetes in the NutriNet-Santé prospective cohort

 

Type 2 diabetes (T2D) is one of the most common noncommunicable diseases worldwide, with an increasing prevalence and a considerable global health burden. Substantial evidence has linked consumption of trans fatty acids (TFAs) to an increased risk of cardiovascular disease. However, the effects of T2D remain unclear. We aimed to investigate the associations between different types of TFAs (total, ruminant, industrial and corresponding specific isomers) and risk of T2D in the NutriNet-Santé prospective cohort. Overall, 105,551 participants aged 18 years or older from the French NutriNet-Santé cohort (2009-2021) were included (mean age at baseline=42.7y (SD = 14.6y), 79.2% women). Dietary intake data, including usual TFA intake, were collected using repeated 24-hour dietary records (n = 5.7 [SD = 3.1]). Associations between sex-specific quartiles of dietary intake of TFAs and type 2 diabetes risk were assessed using multivariable Cox proportional hazard models adjusted for known risk factors. A total of 969 incident type 2 diabetes cases occured during follow-up. Total TFAs was associated with higher T2D risk (HRfor quartile 4 versus 1=1.38; 95% CI = 1.11-1.73; Ptrend&lt;0.001). This association, specifically observed for industrial TFAs (HR = 1.45; 95% CI = 1.15-1.83; Ptrend&lt;0.001), was mainly driven by elaidic acid (HR = 1.37; 95% CI = 1.09-1.72; Ptrend&lt;0.001) and linolelaidic acid (HR = 1.29; 95% CI = 1.04-1.58; Ptrend=0.07). In contrast, ruminant trans fatty acids were not significantly associated with the risk of T2D. In this large prospective cohort, higher dietary intakes of total and industrial TFAs were associated with increased T2D risk. These findings support WHO's recommendation to eliminate industrially-produced TFAs from the food supply worldwide. As such, consumers should be advised to limit the consumption of food products containing partially hydrogenated oils (main vector of iTFAs) as this, specifically, may contribute to lower the substantial global burden of T2D.

Key messages

• Higher dietary intakes of total and industrial trans fatty acids were associated with increased type 2 diabetes risk.

• Our findings support WHO’s recommendation to eliminate industrially-produced TFAs from the food supply worldwide.

Dietary exposure to acrylamide and breast cancer risk: results from the NutriNet-Santé cohort

Background

Acrylamide is classified as a probable human carcinogen by the IARC but epidemiological evidence on the carcinogenicity of acrylamide from dietary sources is limited. This study aimed to investigate the associations between dietary acrylamide and breast cancer risk in the NutriNet-Santé cohort.

Methods

This prospective cohort study included 80,597 French women (mean [SD] age at baseline: 40.8 [14] years) during a mean (SD) follow-up of 8.8 (2.3) years. Acrylamide intake was evaluated using repeated 24h dietary records (n = 5.5 [SD 3.0]), linked to a comprehensive food composition database. Associations between acrylamide intake and breast cancer risk (overall, premenopausal and post-menopausal) were assessed by Cox hazard models adjusted for known risk factors.

Results

The mean (SD) dietary acrylamide intake was 30.1 (21.9) µg/d (main contributors: coffee, potato fries and chips, pastries and cakes, and bread). During follow-up, 1016 first incident breast cancer cases were diagnosed (431 premenopausal, 585 postmenopausal). A borderline significant positive association was observed between acrylamide intake and breast cancer risk overall (HRQ4 vs Q1= 1.21 [95% CI: 1.00-1.47]) and a positive association was observed with premenopausal cancer (HRQ4 vs Q1= 1.40 [95% CI: 1.04-1.88]). Restricted cubic spline analyses suggested evidence for non-linearity of these associations, with higher HR for intermediate (Q2) and high (Q4) exposures. Receptor-specific analyses revealed a positive association with estrogen receptor-positive breast cancer, which represented 86% of total cancer cases. Acrylamide intake was not associated with post-menopausal breast cancer.

Conclusions

Results from this large prospective cohort study suggest the potential deleterious role of dietary acrylamide in breast cancer etiology, especially in premenopausal women, and provide new insights that should encourage further mitigation strategies to reduce the content of acrylamide in food.

Key messages

Food additive emulsifiers and cancer risk: results from the French prospective NutriNet-Santé cohort

Background

Food additive emulsifiers are found in thousands of industrial foods and may exert deleterious effects on gut microbiota and carcinogenesis according to experimental studies. However, their associations with cancer risk has not been investigated yet. This study aimed to investigate these associations in a large population-based prospective cohort.

Methods

This study included 102,485 French adults from the NutriNet-Santé cohort (42.1y [14.5], 78.8% female, 2009-2021). Food additive emulsifier intakes were estimated using repeated 24h dietary records linked to brand-specific food composition databases on food additives. Associations with incident cancer risk were assessed using Multivariable Cox models.

Results

3,511 incident cancer cases were diagnosed during follow-up (1,026 breast, 431 prostate, and 279 colorectal cancers). Intakes of sodium citrate (E331, HR = 1.12 [1.02-1.23], p-trend=0.009), xanthan gum (E415, HR = 1.11 [1.02-1.21], p-trend=0.02), and mono- and diglycerides of fatty acids (E471, HR = 1.17 [1.06-1.28], p-trend=0.001 and total: E471, E472a-b-c-e, HR = 1.11, [1.02-1.22], p-trend=0.02) were associated with increased overall cancer risk. Higher intakes of E331 (p-trend = 0.046), sodium stearoyl-2-lactylate (E481, p-trend=0.01), total lactylates (E481-482, p-trend=0.01), total celluloses (E460-468, p-trend=0.03), carob bean gum (E410, p-trend=0.01), and E471 (p-trend=0.006) were associated with increased overall breast cancer risk. Higher intakes of carrageenan (E407, p-trend=0.04), E415 (p-trend=0.02), and triphosphates (E451, p-trend=0.03) were associated with increased post-menopausal breast cancer risk.

Conclusions

These results are the first to investigate and report direct associations between cancer risk and exposures to seven individual and three groups of food additive emulsifiers. If replicated, they may have an important public health impact, considering the omnipresence of these additives in industrial foods globally.

Key messages

• This study is the first to precisely assess exposures to food additive emulsifiers in a population-based study.

• Intakes of food additive emulsifiers were associated with increased risk of cancer.

Les traits psychologiques positifs sont associés aux changements de comportement alimentaire liés au confinement du COVID-19 dans la cohorte NutriNet-Santé

Introduction et but de l’étude

La propagation du coronavirus (COVID-19) a eue pour conséquence la mise en place de mesures strictes de confinement, ayant entraîné des changements dans les comportements alimentaires. Les traits psychologiques sont des déterminants bien connus du comportement alimentaire. L’objectif de cette étude était donc d’étudier les associations entre les traits psychologiques positifs et les changements dans le grignotage et la consommation de groupes alimentaires pendant la période du confinement.

Méthodes

En 2016, les niveaux d’optimisme, de résilience, d’estime de soi, de satisfaction de la vie, de pleine conscience et de maîtrise ont été mesurés chez 33 766 adultes de la cohorte NutriNet-Santé. Le grignotage et la consommation de groupes d’aliments ont été évalués en avril–mai 2020. L’association entre les traits psychologiques et les changements dans le grignotage et la consommation de groupes alimentaires a été évaluée à l’aide de régressions logistiques, ajustées sur les caractéristiques sociodémographiques et le mode de vie, l’anxiété et la symptomatologie dépressive.

Résultats

Les participants présentant des niveaux plus élevés d’optimisme, de résilience, d’estime de soi, de satisfaction de la vie, de pleine conscience ou de maîtrise étaient moins susceptibles d’avoir des changements dans leur comportement de grignotage et leur consommation de divers groupes alimentaires.

Conclusion

Les personnes présentant des niveaux de traits psychologiques plus élevés ont été moins affectées par le confinement en termes de comportement alimentaire, alors que les personnes ayant des niveaux plus faibles ont montré des changements favorables et défavorables dans leur comportement alimentaire global.

Fermentable Oligo-, Di-, Monosaccharides and Polyols and cancer risk in the NutriNet-Santé cohort

Background

Fermentable Oligosaccharides, Disaccharides and Monosaccharides And Polyols (FODMAPs), which are found in a variety of foods (dairy products, fruit, legumes, refined grains, sugary beverages, etc.) have been involved in risk for gastrointestinal disorders. In view of their pro-inflammatory potential and their interactions with the gut microbiota, their contribution to the etiology of other chronic diseases such as cancer has been postulated. However, no epidemiological study has investigated this hypothesis so far. Our objective was to investigate the associations between FODMAP intake (total and by type) and cancer risk (overall, breast, prostate and colorectal).

Methods

104,909 French adults from the NutriNet-Santé prospective cohort (2009-2020) were included (median follow-up time=7.7y). FODMAP intakes were obtained from repeated 24h-dietary records linked to a detailed food composition table. Associations between FODMAPs and cancer risks were assessed by Cox proportional hazard models adjusted for a large range of lifestyle, sociodemographic and anthropometric variables.

Results

Total FODMAP intake was associated with increased overall cancer risk (n = 3,374 incident cases, Hazard Ratio for quintile 5 vs quintile 1=1.21, 95% confidence interval 1.02-1.44, P-trend=0.04). Oligosaccharides seemed to be the FODMAP type particularly associated with cancer risk: a trend was observed for overall cancer (HR = 1.10 (0.97-1.25) P-trend=0.04) and colorectal cancer (n = 272, HR = 1.78 (1.13-2.79) P-trend=0.02). Associations remained stable across a series of sensitivity analyses.

Conclusions

Our findings suggest a potential role of FODMAPs in cancer onset. Further epidemiological and experimental studies are needed to confirm these results and provide data on the potential underlying mechanisms.

Key messages

In this large-scale prospective cohort of French adults, FODMAP intake was associated with increased cancer risk. These associations need to be studied in other prospective cohorts, in order to clarify FODMAPs role in cancer development.

Childhood consumption of ultra-processed foods and adiposity trajectories: a UK birth cohort study

Background

Worldwide consumption of ultra-processed foods (UPFs) is continued to rise. Growing evidence has linked higher consumption with elevated risks of obesity and non-communicable diseases in adults. However, the influence of UPFs on long-term adiposity trajectories have not been evaluated in children.

Methods

Prospective birth cohort data were obtained from the Avon Longitudinal Study of Parents and Children. English children with baseline dietary intakes from 3-day food diaries and repeated adiposity measures were followed up from ages 7-24 years. Outcomes included body mass index (BMI), weight, waist circumference (WC), fat mass index (FMI) and body fat percentage. UPFs were identified using the NOVA food classification. Child's consumption of UPFs was derived as a percentage of its weight contribution (gram per day) in the total diet and categorised into quintiles. Longitudinal associations were assessed using linear growth curve models and adjusted for study covariates.

Results

Of the 9025 children followed up over a median (IQR) of 10.2 (5.2-16.4) years. Trajectories of BMI, FMI, weight and WC increased by an additional 0.06 (95% CI, 0.04-0.08) kg/m2, 0.03 (0.01-0.05) kg/m2, 0.20 (0.11-0.28) kg and 0.17 (0.11-0.22) cm per year among those in the highest (vs. lowest) quintile of UPF consumption. Evidence of dose-response relationships were consistently observed with those in the two highest quintiles of UPF consumption showing significantly more rapid progression of BMI, weight, and WC.

Conclusions

Radical and effective public health actions that reduce children's exposure and consumption of UPFs are urgently needed to address the obesity epidemic in England and internationally.

Funding: CM and EV are funded by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR), Grant Reference Number PD-SPH-2015. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Key messages

Children with highest (vs. lowest) quintile of ultra-processed food consumption had more rapid regression of BMI, FMI, weight and waist circumference from ages 7-24 years. Dose-response relationships were consistently observed in the two highest quintile of ultra-processed food consumption showing more rapid progression of BMI, weight and waist circumference.

Nutritional risk factors for SARS-CoV-2 infection: prospective study from the NutriNet-Santé cohort

Background

Many hypotheses were raised regarding a role of nutrition in COVID-19 (susceptibility to infection, disease severity) based on the importance of macronutrients, vitamins or minerals for a proper functioning of the immune system. Our objective was to study the associations between dietary intakes and the seroprevalence SARS-CoV-2 infection in a large population-based sample.

Methods

Our analyses included 7766 adults from the French NutriNet-Santé cohort who provided at least 6 valid 24h dietary records in the two years preceding the start of the COVID-19 pandemic in France (February 2020). An ELISA assay was used to detect anti-SARS-CoV-2 antibodies: 311 participants were positive and 7455, negative. Associations between dietary intakes and the seroprevalence of anti-SARS-CoV-2 antibodies were investigated using multi-adjusted logistic regressions.

Results

A lower seroprevalence of SARS-CoV-2 infection was associated to higher intakes of vitamin B9 (HR = 0.84 (0.72-0.98)), vitamin C (HR = 0.85 (0.75-0.97)), vitamin K (HR = 0.86 (0.74-0.99)), dietary fibres (HR = 0.84 (0.72-0.97)), and fruit and vegetables (HR = 0.84 (0.74-0.97)). Higher intakes of calcium (HR = 1.17 (1.01-1.35)) and dairy products (HR = 1.19 (1.06-1.33)) associated to a higher seroprevalence of SARS-CoV-2 infection. No association was observed with other food groups or nutrients or with the overall diet.

Conclusions

Based on exhaustive seroprevalence data in a large population-based sample, our results suggested that higher intakes of vitamin C, folates, vitamin K, dietary fibres and fruit and vegetables were associated with a lower susceptibility to SARS-CoV-2 infection.

Key messages

Higher intakes of vitamin C, folates, vitamin K, dietary fibres and fruit and vegetables were associated to a lower susceptibility to SARS-CoV-2 infection, assessed with exhaustive seroprevalence data. Beyond its established role in the prevention of non-communicable diseases, nutrition could also contribute to prevent some infectious diseases such as COVID-19.

Body weight, body composition and risk of SARS-CoV-2 infection in a large population-based sample

Background

Obesity has been identified as an important risk factor for COVID-19 severity. Besides, several reports also suggested that obesity (or a higher BMI) may also be associated with a higher susceptibility to SARS-CoV-2 infection although this remains unclear. Going beyond BMI, our objective was to study several anthropometric characteristics in relation to the seroprevalence of SARS-CoV-2 infection in a large population-based sample.

Methods

21,376 participants from the French NutriNet-Santé cohort study were included in the main analyses. An ELISA assay was used to detect anti-SARS-CoV-2 antibodies: 1027 participants were positive and 20,349, negative. Associations between a wide range of anthropometric characteristics (body mass index but also waist and hip circumference and body composition) and the seroprevalence of anti-SARS-CoV-2 antibodies were investigated using multi-adjusted logistic regressions.

Results

A positive yet unclear association was observed between BMI and SARS-CoV-2 seroprevalence in women (positive linear trend (P = 0.07) that was significant using restricted cubic splines (P = 0.04), but no association with standard categories of BMI). No association was observed in men. Waist circumference (P = 0.04) and waist-to-hip ratio (P = 0.01) associated with a higher seroprevalence in women while opposite trends were observed in men (P = 0.08 and 0.03 respectively). Body, trunk and visceral fat (all P &lt; 0.05), but not lean or muscle mass, associated with higher seroprevalence, especially in women.

Conclusions

Our results highlight a higher susceptibility to SARS-CoV-2 infection in women with higher body fat, suggesting that central adiposity may be an important factor to consider for risk stratification in the population.

Key messages

A higher seroprevalence of SARS-CoV-2 infection was observed in women with a higher body fat, but not in men. Central adiposity may be a risk factor for SARS-CoV-2 infection and not only for COVID-19 severity.

Diet and physical activity during the first COVID-19 lockdown in France (March-May 2020)

Background

To counter the spread of COVID-19 and avoid overwhelmed health-care systems and numerous deaths, strict lockdown measures were adopted by many countries, causing an unprecedented disruption of daily life. Our objective was to explore the changes in dietary intakes, physical activity, body weight, and food supply occurring during the first lockdown in France (March-May 2020), in light of individual characteristics.

Methods

37,252 adults from the French web-based NutriNet-Santé cohort completed lockdown-specific questionnaires. Nutrition-related changes and their sociodemographic and lifestyle correlates were investigated using multi-adjusted logistic regressions. Clusters of participants were defined combining multiple correspondence analyses and an ascending hierarchical classification.

Results

During the lockdown, trends of unfavorable changes were observed: decreased physical activity (53% of the participants), increased sedentary time (63%), increased snacking, decreased consumption of fresh food (especially fruit and fish), and increased consumption of sweets, cookies, and cakes. Yet, the opposite trends were also observed: increased home cooking (40%) and increased physical activity (19%). Additionally, 35% of the participants gained weight (mean weight gain in these individuals:1.8kg (SD:1.3) and 23% lost weight (2kg (SD:1.4)). All of these trends displayed associations with sociodemographic and lifestyle characteristics.

Conclusions

These results suggest that nutrition-related changes occurred during the lockdown in both unfavorable and favorable directions, and differed according to individual characteristics.

Key messages

COVID-19-related lockdown in France led to nutritional changes in both unfavorable and favorable directions, linked to sociodemographic and lifestyle inequalities.

Unfavorable changes should be considered to inform future lockdown decisions and monitored to prevent a future increase in the nutrition-related burden of disease.

Prospective association between dietary pesticide exposure profiles and Type 2 Diabetes risk

Background

Many modifiable risk factors have been identified for type 2 diabetes. However, emerging risk factors such as food contaminants could also play a role and studies are lacking on the subject. We aimed to assess the prospective associations between dietary pesticide exposure profiles and Type 2 Diabetes (T2D) risk among NutriNet-Santé cohort participants.

Methods

In 2014, participants completed a Food Frequency Questionnaire, assessing conventional and organic food consumption. Exposures to 25 active substances were estimated using a residue database accounting for farming practices from Chemisches und Veterinäruntersuchungsamt Stuttgart, Germany. Exposure profiles were established using Non-Negative Matrix Factorization (NMF), adapted for sparse data. Cox models adjusted for confounding factors were used to estimate hazard ratios (HR) and 95% confidence interval (95% CI), for the association between the four obtained NMF components and T2D risk.

Results

The sample comprised 33,013 participants aged 53 years old on average, among which 76% of women. During follow-up (median: 5.95 years), 340 incident T2D cases were diagnosed. Positive associations were detected between NMF component 1 (reflecting high exposure to azoxystrobin, chlorpyriphos, imazalil, malathion, profenofos, thiabendazole) and T2D risk: HRQ5 vs Q1=1.47, 95% CI(1.00, 2.18). NMF Component 3 (reflecting low exposure to several synthetic pesticides) was associated with a decrease in T2D risk, among those with high dietary quality only (high adherence to French dietary guidelines): HRQ5vsQ1=0.31, 95%CI(0.10, 0.94). No associations were found for NMF Components 2 and 4.

Conclusions

These associations between some pesticide mixtures and T2D diabetes risk need to be confirmed in other types of studies and settings. These results could have important implications for developing prevention strategies, through regulations or dietary guidelines.

Key messages

Specific pesticide mixtures could play a role in increased type 2 Diabetes risk. Organic eaters were less exposed to most synthetic pesticides.

Artificial sweeteners and cancer risk in the prospective NutriNet-Santé cohort

Background

Added sugars' deleterious effects have been established for several chronic diseases, leading food industries to turn towards high-intensity sweeteners. Their safety is debated and findings remain contrasted regarding their role in the etiology of various diseases. In particular, their carcinogenicity has been suggested by several experimental studies but epidemiological data are lacking.

Thus, our objective was to investigate the associations between sweetener intakes (total from all dietary sources, and most frequently consumed: acesulfame-K e950, aspartame e951 and sucralose e955) and cancer risk (overall and by sites).

Methods

Overall, 102,046 adults from the French NutriNet-Santé prospective cohort (2009-2021) were included. Consumption of sweeteners was obtained by repeated 24h-dietary records including brands and commercial names of industrial products. Associations between sweeteners and cancer incidence were assessed by multi-adjusted Cox hazard models.

Results

Compared to non-consumers, high-consumers had higher risk of overall cancer (n = 2527, hazard ratio=1.12, 95% confidence interval=1.00-1.25, P-trend=0.005). In particular, acesulfame-K (HR = 1.18 [1.04-1.34] P = 0.003) and aspartame (HR = 1.20 [1.05-1.38] P = 0.001) were associated with increased cancer risk. Similarly, higher risks were observed for breast (n = 723, HR = 1.25 [1.02-1.53] P = 0.01, HR = 1.39 [1.11-1.74] P = 0.003 and HR = 1.33 [1.05-1.69] P = 0.007 for total sweeteners, e950 and e951, respectively) and obesity-related cancers (n = 1509, HR = 1.16 [1.00-1.33] P = 0.02, HR = 1.23 [1.04-1.45] P = 0.01 and HR = 1.22 [1.02-1.45] P = 0.01 for total sweeteners, e950 and e951, respectively).

Conclusions

These results suggest that artificial sweeteners (especially e950 and e951), which are found in &gt; 12,000 foods and beverage references worldwide, may be associated with increased cancer risk. These findings provide important and novel insights for the ongoing re-evaluation of sweeteners by the European Food Safety Authority.

Key messages

In this large-scale prospective cohort of French adults, intake of high-intensity artificial sweetener intake (especially acesulfame-K and aspartame) was associated with higher risk of cancer. These results provide novel insights to feed EFSA’s expertise for the ongoing risk assessment of artificial sweeteners.

Dietary trans fatty acid intakes and cancer risk: results from the NutriNet-Santé cohort

 

Dietary trans fatty acids (TFAs) are either natural (ruminant sources) or industrially generated by partial hydrogenation of vegetable oils. Increasing evidence demonstrated their role as cardiovascular risk factors. Their involvement in cancer etiology is suspected, but epidemiological evidence is limited so far. We aimed to investigate the associations between different types of TFAs (total, ruminant [rTFAs], industrial [iTFAs] and corresponding specific isomers) and the risk of cancer in the NutriNet-Santé prospective cohort (2009-2020). Overall, 104,909 participants were included. Usual TFA intake was estimated from validated repeated 24-h dietary records. Associations between sex-specific quartiles of dietary intake of TFA and cancer risk were assessed using multi-adjusted Cox proportional hazard models. A total of 3,374 incident cancer cases occured during follow-up (including 982 breast and 405 prostate cancers). Total TFAs was associated with higher prostate cancer risk (1.34[1.25;1.87] Ptrend=0.005). rTFAs were associated with increased overall cancer risk (HRfor quartile 4 versus 1: 1.21[1.06;1.39] Ptrend=0.03), in particular the conjugated linoleic acid isomer (CLA) (1.19[1.04;1.36] Ptrend=0.04). These associations were specifically observed for breast cancer, in particular before menopause (rTFAs: 1.78[1.11;2.87] Ptrend=0.006; CLA: 2.013[1.25;3.23] Ptrend=0.003). Several iTFAs were associated with overall (1.18[1.06;1.31] Ptrend=0.02 for transdocosenoic acid), breast (isomer 18:2t: 1.30[1.06;1.58] Ptrend=0.01; hexadecenoic acid: 1.28[1.05-1.56] Ptrend=0.02) and prostate (transdocosenoic acid: 1.52[1.09;2.12] Ptrend=0.07) cancer risks. In this large prospective study, several types of TFAs were associated with increased overall, breast and prostate cancer risks. Although further studies are needed to better understand underlying mechanisms, these results support the WHO's goal of achieving industrially produced TFAs elimination from food supplies.

Key messages

Higher intake of dietary trans fatty acids is associated with an increased risk of various cancers. Our findings support WHO’s global recommendation of eliminating industrially produced TFAs by 2023.

Nitrites and nitrates from food additives and cancer risk: results from the NutriNet-Santé cohort

 

Nitrates and nitrites occur naturally in water and soil and are commonly ingested from water and dietary sources. They are also frequently used as food additives mainly in processed meats. Experimental data consistently suggest their involvement in carcinogenesis but human data is still limited. The aim was to investigate the relationship between nitrate and nitrite intakes and the risk of cancer in a large prospective cohort with detailed and up-to-date dietary assessment. Overall, 101,056 adults from the French NutriNet-Santé cohort study (2009-ongoing) were included. Consumption of nitrites and nitrates was evaluated using repeated 24h dietary records, linked to a comprehensive food composition database which includes details of commercial names/brands of industrial products. Prospective associations between nitrite and nitrate exposures and the risk of cancer were assessed by multivariable Cox hazard models. During follow-up, 3311 first incident cancer cases were diagnosed. Compared with non-consumers, higher consumers of nitrates as food additives had higher risk of breast cancer (HR = 1.24 (1.03-1.48), P = 0.02); this was more specifically observed for potassium nitrate e252, P = 0.01). Higher consumers of nitrites as food additives, and specifically for sodium nitrite (e250), had a higher risk of prostate cancer (HR = 1.58 (1.14-2.18), P = 0.008 and HR = 1.62 (1.17-2.25), P = 0.004, respectively). No significant association was observed for nitrates and nitrites from natural sources. In this large prospective cohort, nitrates as food additives were positively associated with breast cancer risk and nitrites as food additives were positively associated with prostate cancer risk. While these results need confirmation in other large-scale prospective studies, they provide new insights in a context of lively debate around the ban of nitrite additives in food products.

Key messages

Nitrates as food additives were positively associated with breast cancer risk. Nitrites as food additives were positively associated with prostate cancer risk.

Influence of the urban context on the relationship between neighbourhood deprivation and obesity

BACKGROUND

In middle- and high-income countries, obesity is positively associated with neighbourhood deprivation. However, the moderating effect of the broader urban residential context on this relationship remains poorly understood.

METHODS

In this study, we have examined the nonlinear and geographically varying relationship between neighbourhood deprivation and the likelihood of being a person with overweight among participants of the French NutriNet-Santé adult cohort study (n = 68,698), adjusted for age, gender and educational level. Ten urban residential contexts (e.g., suburbs, peri-urban or rural areas) were defined. We used a multilevel generalised additive modelling framework for analyses.

RESULTS

We found that the relationship between neighbourhood deprivation and overweight differed according to urban context, in terms of both linearity and intensity. Overall, the deprivation-overweight relationship was strongly positive (with a higher prevalence of overweight in deprived neighbourhoods) in suburban areas of Paris and of other large French cities, while weak or null in small towns and rural areas, and intermediate in inner cities. In addition, we observed in suburbs of Paris and in peri-urban belts of large cities that beyond a certain level of neighbourhood deprivation, the relationship with overweight plateaued.

DISCUSSION

In a French population from a high-income country, suburbs, as well as moderately deprived neighbourhoods of peri-urban areas of large cities, are potential targets for public health and urban planning policies aiming at preventing obesity. Our results emphasize the value of local analyses to better capture the complexity and contextual variations of socioeconomic determinants of non-communicable diseases such as obesity.

The inflammatory potential of the diet is prospectively associated with subjective hearing impairment

Background

Age-related hearing loss is prevalent yet insufficiently addressed by public health research. Subjective hearing loss has been highlighted as a key determinant of reduced quality of life, while chronic low-grade inflammation is an established determinant of adverse age-related outcomes. To our knowledge, this study was the first to investigate the link between the inflammatory potential of the diet and hearing loss.

Methods

We prospectively studied 3,435 French adults enrolled in the SU.VI.MAX (1994-2002) and SU.VI.MAX 2 (2007-2009) cohorts. The inflammatory potential of the diet was estimated by the Dietary Inflammatory Index (DII) using established methodology and repeated, baseline 24-h dietary records. Subjective hearing impairment was assessed after a median of 12 years by 3 Yes/No items and by a composite score, dichotomized for analyses. We fit multivariable logistic regression models adjusted for pertinent covariates.

Results

Compared to men, women exhibited higher DII (more pro-inflammatory diet) and less hearing impairment (both p &lt; 0.0001). Given significant interaction results, sex-specific models were fit. Among men, a significant positive association between DII (continuous scale) and inability to follow a conversation in a noisy place was found (OR = 1.10; 95% CI: 1.02, 1.18), while the inverse association was seen among women (OR = 0.92; 95% CI: 0.87, 0.98). Regarding the need to turn up the volume on the television/radio, a significant positive association with DII (continuous scale) was found only among men (OR = 1.09; 95% CI: 1.01, 1.18). The only significant association with the composite score of subjective hearing loss was found among women, when modeling DII as quartiles (OR Q3 vs Q1=0.74; 95% CI: 0.57, 0.97).

Conclusions

The findings among men support the hypothesis that a pro-inflammatory diet could increase risk of age-related hearing loss, whereas the findings among women were unexpected and merit further investigation.

Key messages

Given rapid population aging worldwide, there is an urgent need for public health research on modifiable risk factors of hearing impairment. The role of diet in hearing impairment is complex and likely sex-specific; a pro-inflammatory diet might be a risk factor for hearing impairment, especially among men.

Food additives: distribution and co-occurrence in 126 000 food products of the French market

Background

More than 330 food additives (e.g. artificial sweeteners, emulsifiers, dyes) are authorized in Europe, with a great variability of use across food products. The objective of this study was to investigate the distribution and co-occurrence of food additives in a large-scale database of foods and beverages available on the French market.

Methods

The open access Open Food Facts database was used to retrieve the composition of food and beverage products commonly marketed on the French market (n = 126 556), based on the ingredients list. Clustering of food additive variables was used in order to determine groups of additives frequently co-occurring in food products. The clusters were confirmed by network analysis, using the eLasso method.

Results

53.8% of food products contained at least 1 food additive and 11.3% at least 5. Food categories most likely to contain food additives (in more than 85% of food items) were artificially sweetened beverages, ice creams, industrial sandwiches, biscuits and cakes. The most frequently used food additives were citric acid, lecithins and modified starches (&gt;10,000 products each). Some food additives with suspected health effects also pertained to the top 50: sodium nitrite, potassium nitrate, carrageenan, monosodium glutamate, sulfite ammonia caramel, acesulfame K, sucralose, (di/tri/poly) phosphates, mono- and diglycerides of fatty acids, potassium sorbate, cochineal, potassium metabisulphite, sodium alginate, and bixin (&gt;800 food products each). We identified 6 clusters of food additives frequently co-occurring in food products.

Conclusions

Food additives are widespread in industrial French products and some clusters of additives frequently co-occurring in food products were identified. These results pave the way to future etiological studies merging composition data to food consumption data to investigate their association with chronic disease risk, in particular potential 'cocktail effects'.

Key messages

Food additives are widespread in industrial French products and some clusters of additives frequently co-occurring in food products were identified. These results pave the way to future etiological studies to investigate their association with chronic disease risk, in particular potential ‘cocktail effects’.

Total and added sugar intakes, sugar types and cancer risk: results from the NutriNet-Santé cohort

Background

Excessive sugar is now recognized as a key risk factor for several cardiometabolic diseases. In contrast, the associations between sugars and cancer risk in cohort studies have been less investigated, and data is lacking regarding differential effect of sugar types and sources. Experimental data suggest that sugars could play a role in cancer etiology, through obesity but also through inflammatory and oxidative mechanisms and insulin resistance. Our objective was to study the associations between total and added sugar intake and cancer risk, accounting for sugar types and sources.

Methods

101,279 French adults from the NutriNet-Santé prospective cohort study (2009-2019) were included. Sugar intake was assessed using repeated 24h-dietary records, designed to register participants' usual consumption for more than 3,500 food and beverage items. Associations with cancer risk were assessed by multi-adjusted Cox proportional hazard models.

Results

Sugar intake was associated with increased cancer risk (2,503 cases, Hazard Ratio Quartile 4 vs 1=1.17, 95% Confidence Interval 1.00-2.37, P trend=0.02). This association was mainly driven by breast cancer (783 cases, HR Q4 vs Q1=1.51 (1.14-2.00); P trend=0.0007) and remained significant even when weight-gain during follow-up was accounted for. Associations were more specifically observed for added sugars (P trend=0.02), free sugars (P trend=0.007), sucrose (P trend=0.01), and sugars from milk-based desserts (P trend=0.02), from sugary drinks (P trend=0.002), and from dairy products (P trend=0.01).

Conclusions

These results suggest that sugar (especially added sugar), of which intake is increasing in Western countries, may represent a modifiable risk factor for cancer prevention, adding to its well-established effect on dental and cardiometabolic health. These findings provide important and novel insights to the current debate on the implementation of sugar taxation, marketing regulation, and other sugar-related policies.

Key messages

In this large-scale prospective cohort of French adults, sugar intake (especially added sugar) was associated with higher cancer risk. These results suggest that (added) sugar may represent a modifiable risk factor for cancer prevention, adding novel insights to current debates on implementing sugar-related public health policies.

Prospective associations of four nutrient profiles with weigh gain, overweight and obesity risk

Background

Nutrient Profiling Systems (NPSs), including the UK Food Standards Agency NPS and its variants are used to classify foods according to their nutritional composition for nutrition policies. The prospective validity of these NPSs requires however further investigation. The study investigates the associations of the original Food Standards Agency (FSA)-NPS and three variants - the Food Standards Australia New Zealand Nutrient Profiling Scoring Criterion (NPSC), the Health Star Rating (HSR) system NPS and the French NPS (HCSP-NPS) -, which are used as a basis for nutrition policies, with weight status.

Methods

Dietary indices based on each of the four investigated NPSs applied at the food level were computed at the individual level to characterize the diet quality of 71,178 French individuals from the NutriNet-Santé cohort. Associations of these Dietary Indices (DIs) (as tertiles) with weight gain were assessed using multivariable mixed models, and with overweight and obesity risks using multivariable Cox models.

Results

For the four NPSs, participants with a lower diet nutritional quality were more likely to have an increase in body mass index over time (median follow-up of 3.14 ± 2.76 years, beta coefficients positive, all p ≤ 0.0001), and an increased risk of overweight (HRT3vs.T1=1.27 [1.17-1.37] for the HCSP-DI, followed by the original FSA-DI with HRT3vs.T1=1.18 [1.09-1.28], the NPSC-DI with HRT3vs.T1=1.14 [1.06-1.24] and the HSR-DI, HRT3vs.T1=1.12 [1.04-1.21]). Whilst differences were small, the HCSP-DI appeared to show significantly greater association with risk of overweight compared to other NPS.

Conclusions

Less healthy diets defined using the Food Standards Agency-NPS and related systems were all associated with weight gain and overweight risk. Demonstrating this association with health outcomes is an important indicator of one validity dimension of NPSs and supports their use in public policies for the prevention of diet-related chronic diseases.

Key messages

Nutrient profile models of foods and beverages allow capturing the nutritional quality of diets and are prospectively associated with weight gain and obesity. The French NPS which underpins the front-of-pack Nutri-Score appeared to have a small but significant higher performance.

Ultra-processed/Ultra-formulated foods: association with chronic disease risk

During the past decades, diets have shifted towards an important increase in the degree of food processing and formulation. “Ultra-processed foods” (UPF) now represent more than 50% of energy intakes in several Western countries. In the very last years, an impressive accumulation of evidence from large-scale epidemiological studies linked regular UPF consumption to diverse adverse health outcomes. In this framework, our team of conducted pioneer studies within the prospective e-cohort NutriNet-Santé (n = 170 000) launched in 2009 in France. Dietary intakes were collected using repeated and validated 24-hour dietary records, covering &gt;3,500 food items, which have been categorized using the NOVA classification according to their degree of processing. These analyses highlighted robust significant associations between the consumption of UPF and increased risks of overall and breast cancers, cardiovascular, cerebrovascular, and coronary heart diseases, mortality, type 2-diabetes, overweight, obesity and weight gain, depressive symptoms, and gastro-intestinal disorders. Research perspectives now consist in elucidating the potential mechanisms that underlie these associations. Our team is launching an Europe-funded project built as a combination of epidemiological studies and in-vitro/in-vivo experiments, in order to shed light on individual exposure to food additive 'cocktails' in relation to human health. Meanwhile and even if further studies are needed to better understand the relative contributions of these factors, public health authorities in several countries have recently started to promote unprocessed or minimally processed foods and to recommend limiting the consumption of ultra-processed foods.

Adherence to the new WCRF cancer prevention recommendations associates with a decreased cancer risk

Background

Cancer remains one of the leading causes of death worldwide. In 2018, following its summary report, the World Cancer Research Fund (WCRF) issued its recommendations for cancer prevention based on the nutritional risk factors with a sufficient level of evidence. Our objective was to study whether adherence to these new recommendations leads to a reduced risk of cancer.

Methods

This study included 80,604 participants from the NutriNet-Santé population-based cohort study (2009-2019). Adherence to the 2018 WCRF recommendations was assessed using the operationalized score on a 7-point scale, proposed by Shams-White et al (Nutrients 2019), including: weight, physical activity, fruit and vegetables, dietary fibers, ultra-processed foods, red and processed meat, sugary drinks and alcohol. Usual dietary intakes were assessed using repeated 24h-dietary records and physical activity level using the IPAQ questionnaire. Multi-adjusted Cox proportional hazard models were used for the analyses.

Results

A total of 2,438 incident cancer cases were diagnosed during follow-up (median: 7.4 years). The median WCRF 2018 adherence score was 3.75 (IQR: 3.25-4.50). An increase of 1-point increment in the score was associated with a decreased risk of cancer overall (HR = 0.90; 95%CI 0.86-0.90; P&lt;.0001), and of obesity-related cancers (n = 1549 cases, HR = 0.89; 0.84-0.94; P&lt;.0001), aerodigestive cancers (n = 390, HR = 0.83; 0.74-0.93; P = 0.001), breast cancer (n = 749, HR = 0.92; 0.85-1.00; P = 0.04) and a non-significant trends for prostate (n = 332, HR = 0.89; 0.79-1.01; P = 0.07) and colorectal (n = 218, HR = 0.88; 0.76-1.03; P = 0.1) cancers.

Conclusions

Our results suggest that a higher adherence to the WCRF 2018 recommendations for cancer prevention is associated to a decreased risk of cancer. Given the consistency between overall food-based dietary guidelines and the WCRF cancer recommendations, our result support their general promotion to the general public and transposition as public health actions.

Key messages

Following the recommendations for cancer prevention issued by the WCRF in 2018 can contribute to decrease the burden of cancer. The WCRF cancer recommendations are consistent with overall food-based dietary guidelines and should be promoted to the general public and transposed as public health actions.

Sugary drinks, artificially sweetened beverages and cardiovascular disease in NutriNet-Santé cohort

Introduction

Sugary drinks consumption has increased worldwide in recent years and evidence demonstrating their detrimental impact on cardio-metabolic health is accumulating. Artificially sweetened beverages (ASB) are marketed as a healthier alternative, but their cardio-metabolic impact is being debated in the scientific community. This study aimed to investigate the relationships between the consumption of ASB, sugary drinks and the risk of first incident cardiovascular disease (CVD) in a large prospective cohort.

Methods

The French NutriNet-Santé cohort was launched in 2009. Every 6 months participants are asked to fill 3 validated web-based 24-hour dietary records. All major health events reported by participants were validated based on their medical records by a committee of physicians. Data were also linked to national health insurance system and to the French national cause of specific mortality registry. For each type of beverage, 3 categories were defined as follows: non-consumers, low consumers and high consumers (separated by sex-specific median among consumers). Multi-adjusted Cox proportional hazard models with age as the primary time scale were performed.

Results

A total of 104,761 participants were included. During follow-up (2009-2019), 1,379 first incident cases of CVD occurred. Compared to non-consumers, higher consumers of sugary drinks had a higher risk of overall CVD (HR = 1.21, 95% CI 1.04 to 1.40, Ptrend=0.009). Higher consumers of ASB had also a significantly higher risk of CVD (HR = 1.30, 95% CI 1.00 to 1.71, Ptrend =0.04).

Conclusions

Both sugary drinks and ASB were similarly associated with CVD risk. The health effects of non-nutritive sweeteners is currently being debated based on contrasted epidemiological results. Mechanistic data suggests metabolic effects through gut microbiota perturbation and body weight gain. To imply a causal link, they need replication in other large-scale prospective cohort as well as further mechanistic investigations.

Key messages

Higher consumption of sugary drinks and ASB was associated with higher risk of CVD, suggesting that ASB might not be a healthy substitute for sugary drinks when considering cardiovascular health. These data provide additional arguments to feed the current debate on taxes, labeling and regulation of sugary and artificially sweetened beverages.

CARPEM-LYNCH: a program linking hospital and NutriNet-Santé e-cohort data to test dynamic consent

Background

Technological innovations have contributed to rapid changes in translational research, allowing greater amounts of shared data on an unprecedented scale. However, methods for involving patients in research have not kept pace with changes in research capacity. Modern tools offering more flexibility in the management of patient consent are needed. The CARPEM-LYNCH program aims to explore the acceptance and feasibility of the concept of dynamic informed consent. It is a pilot program to test a research platform at the interface between hospital follow-up clinical data and data provided by patients through the NutriNet-Santé e-cohort platform.

Methods

Patients diagnosed with Lynch Syndrome followed at the European hospital Georges Pompidou (HEGP) are recruited and followed-up within the NutriNet-Santé online platform. In addition to generic NutriNet questionnaires (very detailed data on diet, physical activity, lifestyle, etc.), participants receive specific questionnaires related to their syndrome, perception of nutritional risk factors, and quality of life. Clinical data collected during standard hospital care will be linked to NutriNet data for participants who provide a dynamic consent. This dispositive will allow to investigate multiple dimensions of dietary behaviors and their health impact in these at-risk patients.

Results

The pilot phase has started. The first 20 patients have been included, showing good acceptance of the dynamic consent. Qualitative analysis of their responses is ongoing to optimize tools before large-scale deployment and extension to other hospital centers.

Conclusions

This experience of merging hospital and e-cohort data through dynamic consent to advance knowledge on health impact of diet and lifestyle in Lynch patients opens up a multitude of perspectives.

Key messages

Dynamic informed consent offers opportunities for data sharing between clinicians, researchers and patients with a promising impact on translational research. Dynamic informed consent can provide practical and sustainable solutions to the challenges of recruiting and retaining participants, managing consent and it can also be a source of economic efficiency.

Consumption of ultra-processed foods and the risk of overweight, obesity, and weight trajectories

Methods

Overall, 110260 participants aged at least 18 years from the French NutriNet-Santé cohort (2009-2019) were included. Dietary intakes were collected using repeated 24h dietary records, merged with a food composition database of 3300 different products, categorized according to their degree of processing by the NOVA classification. Associations between UPF intake and risks of overweight and obesity were assessed using Cox proportional hazard models. Associations between UPF intake and weight trajectories were assessed using linear mixed models for repeated measures with random slope and intercept.

Results

UPF intake was associated with a higher risk of overweight (n = 7063 incident cases; hazard ratio for an absolute increment of 10 in the percentage of ultra-processed foods in the diet = 1.11 (1.08-1.14); P &lt; 0.0001) and obesity (n = 3066 incident cases; HR = 1.09 (1.05-1.13); P &lt; 0.0001). Higher consumers of UPF (4th quartile) were more likely to present an increase in body mass index over time (β = 0.04, P &lt; 0.0001). These results remained statistically significant after adjustment for several markers of the nutritional quality of the diet (fruits and vegetables and sugary drinks consumption, intakes of saturated fatty acids, sodium, sugar, dietary fiber or Healthy/Western patterns) and after a large range of sensitivity analyses.

Conclusions

In this large observational prospective study, higher consumption of UPF was associated with a higher risk of overweight and obesity. Public health authorities in several countries recently started to recommend privileging unprocessed/minimally processed foods and limiting UPF consumption.

Key messages

The consumption of ultra-processed food is associated with an increased risk of overweight and obesity. As the French Public Helath agency recommends, their consumption should be limited. Nutritional composition, food additives, contact materials, or neoformed contaminants might play a role in these associations and further studies are needed to understand their relative contribution.

Ultra-processed food intake and cardiovascular disease risk in the NutriNet-Santé prospective cohort

Objective

To assess the prospective associations between consumption of ultra-processed foods (UPF) and the risk of cardiovascular diseases.

Methods

105159 participants aged at least 18 years (median age 41.5 years) from the French NutriNet-Santé cohort (2009-2018) were included. Dietary intakes were collected using repeated 24 hour dietary records, designed to register participants’ usual consumption for 3300 different food items, and categorized according to their degree of processing by the NOVA classification. Associations between UPF intake and risk of cardiovascular, coronary heart, and cerebrovascular diseases assessed by multivariable Cox proportional hazard models, adjusted for known risk factors.

Results

UPF intake was associated with higher cardiovascular disease risk (n = 1409 cases; HR for an absolute increment of 10 in the percentage of UPF = 1.12(1.05-1.20); P = 0.0008), coronary heart disease risk (n = 665 cases; HR = 1.13(1.02-1.24); P = 0.02), and cerebrovascular disease risk (n = 829 cases; HR = 1.11(1.01-1.22); P = 0.02). These results remained statistically significant after adjustment for several markers of the nutritional quality of the diet (saturated fatty acids, sodium and sugar intakes, dietary fiber or a Healthy pattern derived by principal component analysis) and after a large range of sensitivity analyses.

Conclusions

In this large observational prospective study, higher consumption of UPF was associated with higher risks of cardiovascular, coronary heart, and cerebrovascular diseases. These results need to be confirmed in other populations and settings, and causality remains to be established.

Key messages

The consumption of ultra-processed food is associated with an increased risk of cardiovascular diseases. As the French Public Helath agency recommends, their consumption should be limited. Nutritional composition, food additives, contact materials, or neoformed contaminants might play a role in these associations and further studies are needed to understand their relative contribution.

Sugary drink consumption and cancer risk: results from NutriNet-Santé prospective cohort

Background

The objective was to assess the associations between the consumption of sugary drinks (sugar sweetened beverages and 100% fruit juices), artificially sweetened beverages and cancer risk.

Methods

Overall, 101,257 participants aged ≥18y (mean age: 42.2) from the French NutriNet-Santé cohort (2009-2017) were included. Consumptions of sugary drinks and artificially sweetened beverages were assessed using repeated 24h-dietary records, designed to register participants’ usual consumption for 3,300 different food and beverage items. Associations between beverage consumption and the risk of overall, breast, prostate and colorectal cancer were assessed by multi-adjusted Fine&Gray Hazard models, accounting for competing risks.

Results

The consumption of sugary drinks was significantly associated with overall cancer risk (n = 2,193 cases, sHRfor a 100mL/d increase=1.18, 95% confidence interval 1.10 to 1.27, P&lt;.0001) and breast cancer risk (n = 693 cases, sHRfor a 100mL/d increase=1.22, 95% confidence interval 1.07 to 1.39, P = 0.004). The consumption of artificially sweetened beverages was not associated with cancer risk. In specific sub-analyses, the consumption of 100% fruit juice was significantly associated with overall cancer risk (n = 2,193 cases, sHRfor a 100mL/d increase =1.12, 95% confidence interval 1.03 to 1.23, P = 0.007).

Conclusions

In this large prospective study, the consumption of sugary drinks was positively associated with overall and breast cancer risks. Of note, 100% fruit juices were also positively associated with overall cancer risk. These results need replication in other large-scale prospective studies. They suggest that sugary drinks, which are massively consumed in Western countries, may potentially represent a modifiable risk factor for cancer prevention.

Key messages

In this large prospective study (n = 101,257), the consumption of sugary drinks (including 100% fruit juice) was associated with an increase in overall and breast cancer risk. In specific sub-analyses, 100% fruit juices were also associated with an increased risk of overall cancers. The consumption of artificially sweetened beverages was not associated with cancer risk.

Nutritional quality of food consumed (graded by the FSAm-NPS / Nutri-Score) and mortality in Europe

Background

Unhealthy diets are major contributors for non-communicable diseases (NCDs) and related deaths. To help consumers make healthier food choices, political authorities are considering implementing a simple label to reflect the nutritional quality of food products. The Nutri-Score, based on the nutrient profiling system of the Food Standards Agency (FSAm-NPS), was chosen by several countries in Europe (France, Belgium, Spain). Yet, its implementation is only voluntary per EU regulation. Scientific evidence is therefore needed regarding the relevance of the FSAm-NPS at the European level. Hence, our objective is to study how the nutritional quality of foods consumed graded by the FSAm-NPS relates to NCDs-related mortality in European populations.

Methods

Our prospective analyses included 501,594 adults from the EPIC cohort (1992-2015, median follow-up: 17.2y). Usual food intakes were assessed with standardized country-specific methods. The FSAm-NPS was calculated using the 100g content of each food in energy, sugar, saturated fatty acid, sodium, fibres, proteins, and fruits/vegetables/legumes/nuts. Multi-adjusted Cox proportional hazards models were computed.

Results

The consumption of foods with a higher FSAm-NPS score (lower nutritional quality) was associated with a higher risk of mortality overall (n = 50,743 events: HRQ5vs.Q1=1.06 [95%CI: 1.02-1.09], P-trend&lt;0.001) and by cancer (n = 21,971 events: HRQ5vs.Q1=1.06 [1.01-1.11], P-trend=0.003), respiratory diseases (n = 2,796 events: HRQ5vs.Q1=1.33 [1.16-1.52], P-trend&lt;0.001) and cardiovascular diseases, although more weakly (n = 12,407 events: HRQ5vs.Q1=1.05 [0.98,1.11], P-trend=0.04).

Conclusions

In this large multinational European cohort, consuming foods with a higher FSAm-NPS score was associated with higher mortality, supporting the relevance of the FSAm-NPS to grade the nutritional quality of food products for public health applications (e.g, Nutri-Score) to guide the consumers towards healthier food choices.

Key messages

The consumption of food products with a lower nutritional quality as graded by the FSAm-NPS score was associated with higher mortality in the large multinational European EPIC cohort. This adds support to the relevance of the FSAm-NPS to grade the nutritional quality of foodstuffs for public health applications (e.g. Nutri-Score label) to help consumers make healthier food choices.

Ultra-processed food intake and risk of type 2 diabetes in a French cohort of middle-aged adults

Objective

The consumption of ultra-processed foods has been increasing during the last decades, and has been previously associated with increased risks of mortality and several chronic diseases. The objective of this study is to assess for the first time the prospective associations between consumption of ultra-processed foods and the risk of type 2 diabetes (T2D).

Methods

104707 participants aged at least 18 years (median age 41.5 years) from the French NutriNet-Santé cohort (2009-2019). Dietary intakes were collected using repeated 24 hour dietary records, designed to register participants’ usual consumption for 3300 different food items, categorized according to their degree of processing by the NOVA classification. Associations between ultra-processed food intake and risk of T2D were assessed using multi-adjusted Cox proportional hazard models.

Results

Ultra-processed sugary products, fruits and vegetables, and beverages were the highest contributors of the ultra-processed category (respectively 27.9, 18.5 and 15.6%). Ultra-processed food intake was associated with a higher risk of T2D (n = 821 incident cases; hazard ratio for an absolute increment of 10 in the percentage of ultra-processed foods in the diet = 1.15 (1.06-1.25); P = 0.0009, 582252 person-years). These results remained statistically significant after adjustment for other metabolic comorbidities, for several markers of the nutritional quality of the diet (red meat and sugary drinks consumption, intakes of saturated fatty acids, sodium, sugar, dietary fiber or Healthy/Western patterns derived by principal component analysis) and after a large range of sensitivity analyses.

Conclusions

In this large observational prospective study, higher consumption of ultra-processed foods in the diet was associated with a higher risk of T2D. Public health authorities in several countries recently started to recommend privileging unprocessed/minimally processed foods and limiting ultra-processed food consumption.

Key messages

The consumption of ultra-processed food is associated with an increased risk of type 2 diabetes. As the French Public Helath agency recommends, their consumption should be limited. Nutritional composition, food additives, contact materials, or neoformed contaminants might play a role in these associations and further studies are needed to understand their relative contribution.