This chapter covers the case study of Nutri-Score, a front-of-pack nutrition-labelling scheme available in several European countries. The case study includes an assessment of Nutri-Score against the five best practice criteria, policy options to enhance performance and an assessment of its transferability to other OECD and EU27 countries.
Healthy Eating and Active Lifestyles
Best Practices in Public Health
3. Nutri-Score
Abstract
Nutri-Score: Case study overview
Description: Nutri-Score is a nutrition logo introduced and promoted by the French Government (the French Ministry of Health and the French Public Health institute) as of 2017, based on academic work, which is placed at the front of pre‑packaged foods by companies that adhere on a voluntary basis. The overall objective of Nutri-Score is to improve consumer’s understanding of the nutritional content, increase healthier food choices in the population, and thus reduce obesity and its related diseases.
Best practice assessment:
Table 3.1. OECD Framework assessment of the Nutri-Score
|
Criteria |
Assessment |
|---|---|
|
Effectiveness |
Nutri-Score reduces the number of calories purchased, which is estimated to lead to 138 432 life years (LYs) and 204 851 disability-adjusted life years (DALYs) gained by 2050 in France |
|
Efficiency |
Nutri-Score is cost saving across France and all other OECD and EU27 countries |
|
Equity |
The design of Nutri-Score logo makes it accessible to different population groups, and these products are not relatively expensive |
|
Evidence‑base |
A randomised controlled trial in real-life grocery shopping settings was used in the present report to evaluate the impact of Nutri-Score, which is considered strong-quality evidence |
|
Extent of coverage |
Extent of coverage has grown significantly since Nutri-Score’s inception |
Enhancement options: to enhance equity, policy makers could consider options such as partnering with retail outlets to offer discounts/promotions on products carrying an A- or B-grade Nutri-Score as well as initiatives to boost health literacy, particularly amongst vulnerable populations. To enhance the evidence‑base, further studies using survey-based data on consumption would complement the evaluation on food purchases, and improve the evaluation of the equity dimension. To enhance extent of coverage, policy makers could explore opportunities to incentivise participation by international food and beverage companies, and enrol collective and commercial catering companies.
Transferability: Nutri-Score has been transferred from France to four European countries while two other countries announced their intention to adopt Nutri-Score, a further five OECD countries have an alternative front-of-pack traffic light system. These results suggest that Nutri-Score can be highly transferable, further, nutritional labels are likely to have political support given most countries have a national action to reduce levels of unhealthy eating.
Conclusion: Nutri-Score is a best practice and transferable intervention with the potential to significantly improve diet, reduce obesity and disease incidence when scaled-up across France and transferred to other OECD and non-OECD European countries.
Intervention description
Data from four OECD countries show that 50% of people have an unhealthy diet measured against national guidelines (OECD, 2019[1]). Poor diet is a key factor contributing to the obesity epidemic among OECD and non-OECD European countries. High rates of overweight and obesity are key risk factors for multiple chronic diseases, and are a heavy economic burden for societies and the economy.
Easy-to‑understand, simplified front-of-pack (FOP) food labelling schemes are among the recent emerging interventions used by OECD countries – on a mandatory or voluntary basis – to promote a healthier diet (OECD, 2017[2]). The FOP food labelling schemes are informative, simple and coloured logos that summarise the nutritional information and make it easy to understand for consumers. Evidence shows that FOP food labelling prompts better food choice and diet than simply listing nutrient profiles (Cecchini and Warin, 2015[3]).
OECD assessed that informative and easy-to‑understand FOP food labelling schemes have the potential to improve people’s diet; reduce obesity and its related diseases; lower expenditure on treatment of these chronic diseases; and increase labour market participation and productivity. When all these effects are combined, the economic return on investment (ROI) for an intuitive food labelling scheme is positive (ROI 2.1:1, meaning that for every EUR invested, the intervention returns EUR 2.1 in gross domestic product) (OECD, 2019[1]).
The French Nutri-Score is a FOP food logo reflecting the nutritional quality of a product. It is based on an easy-to‑understand scale of five colours (from dark green to dark orange), each of which are attached to a letter (from A to E, with A representing products with higher nutritional quality) (Figure 3.1). Following a recommendation from the French Ministry of Health, Nutri-Score was created by the French public health institute (Santé publique France), based on academic work listed in (Ministère des Solidarités et de la Santé, 2020[4]). Nutri-Score was first adopted in France in October 2017.
Figure 3.1. The Nutri-Score logo
The logo is attributed on the basis of a nutritional quality score taking into account nutrients that should be limited (e.g. calories, saturated fatty acid, salt, sugar) and nutrients that should be favoured (e.g. fibres, proteins, fruits and vegetable, olive oil). The nutritional quality score is derived from the British Food Standards Agency (FSA) nutrient profiling system (FSA score) combined with the Office of Communication (OfCom) cut-off values.
Nutri-Score is free of charge and works on a voluntary basis. Food companies that want to use Nutri-Score have to register with Santé publique France, and approve the terms and conditions for the use of the logo. Provided with a Nutri-Score calculator tool and instructions, they can then attribute and apply themselves the Nutri-score logo on their products. It was estimated that in 2020, over 400 food companies were engaged in the programme, representing about 50% of the market share in sales volume (Oqali, 2020[5]). By 2021, about 600 companies had adopted the Nutri-Score logo (Santé publique France, 2021[6]).
Nutri-score is a relatively new intervention that improves consumer knowledge on the nutritional quality of foods purchased. Two recent studies comparing the effect of various types of logo on food purchases, concluded the Nutri-Score was the “most effective” labelling scheme (Crosetto et al., 2019[7]; Dubois et al., 2020[8]). The study by Crosetto and colleagues is a laboratory field experiment with 691 adults aiming to compare the impact of five FOP labels on the FSA nutritional score of food baskets. Dubois and colleagues’ study is a real-life grocery shopping setting study, aiming to compare the impact of four FOP labels on FSA score of food purchases, including more than 1.6 million purchases in 60 supermarkets in France. Since its implementation in France, Nutri-Score has been transferred to four other countries (Belgium, Germany, Luxembourg, and Switzerland). In February 2021, these countries announced the establishment of a transnational co‑ordination mechanism to facilitate the use of Nutri-Score nutritional labelling, comprising a steering committee and a scientific committee (Santé publique France, 2021[9]).
OECD Best Practices Framework assessment
This section analyses Nutri-Score against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence‑base and Extent of coverage (see Box 3.1 for a high-level assessment of Nutri-Score). Further details on the OECD Framework are in Annex A.
Box 3.1. Best practice assessment overview: Nutri-Score
Effectiveness
Nutri-Score improves the nutritional quality of food purchased (in terms of the British Food Standards Agency nutrient profiling system) and decreases the number of calories purchased from labelled food products by 3%
According to OECD simulations, Nutri-Score would lead to 138 432 life years and 204 851 disability-adjusted life years (DALYs) gained by 2050 in France
Across all studied countries, Nutri-Score would have the largest gross impact on musculo-skeletal diseases with 4.5 million cases avoided by 2050, and cardiovascular diseases with 2 million cases avoided by 2050.
Efficiency
When expanded across the whole of France, it is estimated Nutri-Score will accumulate health expenditure savings of EUR 17.34 per person by 2050
When transferred to all OECD and EU27 countries, savings equivalent to 0.05% of total health expenditure per year are expected (until 2050)
For all OECD and EU27 countries, Nutri-Score is not only cost effective, but also cost saving
Equity
Different population groups can easily understand the Nutri-Score logo and therefore make healthier food choices
The average price of products with Nutri-Score and those without is similar indicating Nutri-Score does not exclude poorer population groups
Evidence‑base
A randomised-controlled trial (RCT) study in real-life conditions was used in the present report to evaluate the impact of the Nutri-Score, which is considered high-quality evidence
Extent of coverage
Extent of coverage has grown significantly since Nutri-Score’s inception with consumer awareness of the logo increasing from 58% in 2018 to 93% in 2020. Over the same period market share, based on sales volume, of food companies that adhere to Nutri-Score increased from 24% to 50%.
Effectiveness
Since the introduction of Nutri-Score, the quality of food purchased increased and the quantity of calories purchased decreased
In 2017, researchers assessed four different food labelling schemes using a real-life grocery shop setting (Allais et al., 2017[10]). As part of the study, researchers analysed differences in the content of food baskets purchased with a focus on four food products – breads, ready meals, fresh catering and pastries (see Box 3.2 for further details). The most successful food-labelling scheme, based on the study design, was Nutri-Score given it significantly increased the nutritional quality of food purchased, in particular among the low-income population (Allais et al., 2017[10]).
Box 3.2. Impact of Nutri-Score on food quality and calories purchased
The real-world study by Allais et al. (2017[10]) found Nutri-Score improved the nutritional quality of labelled food purchases by 2.5%, that is a reduction in the FSA score by 0.142 (t=‑1.66, p=0.097). Based on the same data, the researchers show that the total calories of purchased labelled food products decreased by ‑3.0% [‑4.64%; ‑1.36%]. In addition, the report notes that 54.6% of products purchased are labelled.
Furthermore, Nutri-Score encourages food companies to reformulate their products. For instance, previous evidence suggests that FOP labelling can motivate food manufacturers to reformulate products with lower levels of nutrients that contribute to obesity (Kloss et al., 2015[11]).
The remainder of this section presents the long-term impact of Nutri-Score in France as well as OECD and non-OECD European countries. The analysis relied on the OECD SPHeP-NCD model (Strategic Public Health Planning for non-communicable diseases) (see Annex A) using real-world inputs on the impact of Nutri-Score (i.e. Allais et al. (2017[10]) and Dubois et al. (2020[8])). In addition, the evaluation assumes that the effect observed on the four types of food products analysed in previous studies is generalisable to other types of labelled products. For a full list of assumptions, see Annex 3.A.
France
The implementation of Nutri-Score in France, as it is today, three years after implementation, is estimated to lead to 12 life years (LY) and 17 disability-adjusted life years (DALYs) gained per 100 000 people, on average, per year over the period 2021‑50. These figures translate into a cumulative gain of 138 432 LYs gained and 204 851 DALYs by 2050 (Figure 3.2).
Figure 3.2. Cumulative number of LYs and DALYs gained (2021‑50) – Nutri-Score, France
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
In gross terms, Nutri-Score is expected to have the greatest impact on musculoskeletal disorders (MSDs) and cardiovascular diseases (CVDs) (Figure 3.3). Between 2021 and 2050, the number of MSD and CVD cases is estimated to fall by 170 915 and 54 140 cases, respectively. Other diseases affected include diabetes, dementia and several cancers.
Figure 3.3. Cumulative number of disease cases avoided by 2050 – Nutri-Score, France
Note: MSDs = musculoskeletal disorders, CVDs = cardiovascular diseases. Related cancers include colorectal, breast, oesophageal and liver cancer. The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
OECD and non-OECD European countries
Transferring Nutri-Score to all OECD and EU27 countries is estimated to result in 15.2 and 18.4 LYs gained per 100 000 people, respectively, on average per year between 2021‑50 (ranging from 7.0 in Israel to 34.1 in Bulgaria) (Figure 3.4). For DALYs, gains are even higher at 19.4 for OECD and 22.4 for EU27 countries.
Figure 3.4. LYs and DALYs gained annually per 100 000 people, 2021‑50 – Nutri-Score, all countries
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2020.
In gross terms, Nutri-Score would have the greatest impact on MSDs with the intervention estimated to reduce the number of cases by 3.4 and 1.1 million among OECD and EU27 countries, respectively, between 2021 and 2050 (Figure 3.5). Across all countries, Nutri-Score would also reduce the number of CVD cases by 1.6 million cases, diabetes cases by over 0.5 million, dementia cases by 0.2 million, and cases of cancer related to nutrition by 0.13 million.
Figure 3.5. Total disease cases avoided, between 2021 and 2050 – Nutri-Score, OECD and EU27 countries
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Efficiency
Similar to “Effectiveness”, this section presents results for France followed by remaining OECD and non-OECD European countries.
France
By reducing rates of obesity, Nutri-Score can reduce health care costs. Over the modelled period of 2021‑50, the OECD-SPHeP NCD model estimates Nutri-Score would lead to cumulative health expenditure savings of EUR 17.34 per person by 2050 (Figure 3.6) or by EUR 0.88 per person, per year. Cost savings however are to an extent offset by intervention operating costs (see Table 3.2).
Figure 3.6. Cumulative health expenditure savings per person, EUR, 2021‑50 – Nutri-Score, France
Note: The black lines represent 95% confidence intervals. Savings are discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
OECD and non-OECD European countries
Average annual health expenditure (HE) savings as a proportion of total HE is 0.05% for both OECD and EU27 countries (Figure 3.7). On a per capita basis, this translates into average annual savings of EUR 01.05 and EUR 0.94 for OECD and EU27 countries, respectively.
Figure 3.7. Health expenditure (HE) savings as a percentage of total HE and per capita (EUR), average 2021‑50 – Nutri-Score, all countries
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Table 3.2 provides information on intervention costs, total health expenditure savings and the cost per DALY gained in local currency for OECD and non-OECD European countries. All countries recorded a negative cost per DALY gained indicating the intervention is not only cost effective, but also cost saving.
Table 3.2. Cost effectiveness figures in local currency – Nutri-Score, all countries
* Cost per DALY (disability-adjusted life year) gained is measured using total intervention costs less total health expenditure savings divided by total DALYs gained over the period 2021‑50. Costs and benefits have been discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
The reduction in chronic diseases resulting from Nutri-Score has, in turn, an impact on labour market participation and productivity. By reducing chronic disease incidence, Nutri-Score is expected to lead to an increase in employment and a reduction in absenteeism, presenteeism, and early retirement. Converting these labour market outputs into full-time equivalent (FTE) workers, it is estimated that OECD and EU27 countries will gain 11.1 FTE per 100 000 working age people per year between 2021 and 2050. In monetary terms, this translates into average per capita labour market production of EUR 3.5 for OECD and EUR 2.9 for EU27 countries (Figure 3.8).
Figure 3.8. Labour market impacts, average per year, 2021‑50 – Nutri-Score, all countries
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Equity
All population groups can easily interpret the Nutri-Score logo, and there is no association between labelled products and higher expenditure
Food labelling schemes may have regressive equity implications when the most educated and health-conscious respond more to labelling, for instance with informational labelling. Simplified labelling with colour coding are more appropriate to reach people from all socio‑economic groups (Lobstein, Neveux and Landon, 2020[12]). The Nutri-Score logo is a simplified, easy to understand, logo that associates a colour and a letter in a simple design to indicate the nutritional quality of the product (Figure 3.1) and is therefore easily interpretable by the wider population. At the stage of experimenting Nutri-Score, a laboratory study showed that the increase in nutritional quality observed in participants with lower income was nearly as large as that the one seen for the group as a whole (Crosetto et al., 2017[13]). One year after its national roll-out, Nutri-Score is well received and used by all socio‑economic groups, including subgroups who are more likely to have a lower-quality diet, according to a study based on online survey data (Sarda et al., 2020[14]). In their study, Sarda and colleagues showed that awareness of the logo did not vary with household income and education level.
Regarding the impact of the logo on purchasing behaviours, people with an intermediate‑income were more likely than those on a low-income to change their behaviours, while high-income groups did not differentiate from the low-income groups. People with a low-level of education were more likely than highly educated people to change their purchasing behaviours (Sarda et al., 2020[14]).
Prices of food products with the Nutri-Score label do not seem to be higher. A laboratory field experiment shows that nutritional gains associated with four food labelling schemes, including Nutri-Score, are not correlated with higher expenditure (Crosetto et al., 2019[7]). The French observatory of food quality (OQALI) confirmed these findings in a study, which showed the average price per kilogram of products with the Nutri-Score logo was similar to those without the logo (Oqali, 2020[5]).
Evidence‑base
Results for the effectiveness and efficiency of Nutri-Score is based on data from a randomised-controlled trial (RCT). The RCT measured the impact of four different types of food labelling schemes, including Nutri-Score, on food purchases. Evidence from the RCT was presented in a report (Allais et al., 2017[10]) and a journal article (Dubois et al., 2020[8]).
The RCT experiment was carried out in 60 stores across France, each of which belongs to three of the largest retail chains in the country. The study tested four different FOP labelling schemes on more than 1 200 products classified into four categories – breads, ready meals, fresh catering and pastries. Purchase data were provided by retailers for two time periods, before and after the experiment took place towards the end of 2016. The outcome measures in the study included the nutritional quality of purchased food using the Ofcom nutrient profiling score developed by the British FSA, and the number of calories contained in the basket of purchased products.
The Quality Assessment Tool for Quantitative Studies rates the quality of evidence as strong across several domains (see Table 3.3) (Effective Public Health Practice Project, 1998[15]).
Table 3.3. Evidence‑based assessment, Nutri-Score
Source: Effective Public Health Practice Project (1998[15]), “Quality assessment tool for quantitative studies”, https://www.nccmt.ca/knowledge-repositories/search/14; Allais et al. (2017[10]), “Évaluation Expérimentation Logos Nutritionnels, Rapport pour le FFAS”, https://solidarites-sante.gouv.fr/IMG/pdf/rapport_final_groupe_traitement_evaluation_logos.pdf; Dubois et al. (2020[8]), “Effects of front-of-pack labels on the nutritional quality of supermarket food purchases: evidence from a large‑scale randomised controlled trial”, https://doi.org/10.1007/s11747-020-00723-5.
Extent of coverage
Nutri-Score’s extent of coverage has expanded significantly since its inception
Key indicators reflecting the reach of the Nutri-Score to its target population are summarised below. Specifically, between 2018 and 2020:
Consumer awareness of the logo increased from around 58% to 93% (Sarda, Ducrot and Serry, 2020[16]).
The proportion of consumers who report changing their purchasing behaviours increased from 26.5% to 57.2% (Sarda, Ducrot and Serry, 2020[16]).
The number of food companies that adhere to the Nutri-Score increased from 73 to 415 (Oqali, 2020[5]).
The market share (in sales volume) of food companies that adhere to Nutri-Score increased from 24% to 50% (Oqali, 2020[5]).
Policy options to enhance performance
This section summarises policy options available to policy makers and administrators in settings where Nutri-Score is implemented (or being transferred) to further enhance the performance of this intervention.
Enhancing effectiveness
Optimise the algorithm behind the Nutri-Score. The algorithm behind Nutri-Score is based on the FSA score, and has been validated by scientific researches in France as well as in other European countries (Ministère des solidarités et de la santé, 2021[17]). The algorithm can be adapted to national public health recommendations. For instance, the initial FSA-based algorithm has been modified to reflect the public health recommendations that advocate favouring rapeseed, walnut and olive oils compared to other fats. More concretely, the percent of rapeseed, walnut and olive oils in the products is now included in the positive component “fruits, vegetables, pulses, and nuts” for the score calculation. Future developments of Nutri-Score could consider:
Adapting and optimising the algorithm to meet each country’s national dietary guidelines (e.g. regarding whole grain, oily fish).
Personalising nutritional scores using new technologies that take into account an individual’s preferences such as favouring food products low in salt for customers with heart conditions. For example, certain food retailers in France on their e‑commerce platforms use INNIT technology from the United States, which creates “personalised” health food labels.
Criticisms of Nutri-Score point to the limitations of using a single overall score to rate food products. Certain stakeholders argue that information by nutrient is preferable as it provides information that is more comprehensive. However, there are also issues with using comprehensive nutrient labelling – e.g. they are harder to interpret, which may reduce motivation to change consumption behaviour. At present, evidence shows that summary labels (such as Nutri-Score) are more effective than nutrient-specific ones, however, the discussion is ongoing (Ducrot et al., 2016[18]; Dubois et al., 2020[8]).
Improve health literacy levels. Research has shown that low rates of health literacy reduce understanding of nutrition-related information (Campos, Doxey and Hammond, 2011[19]). In 18 OECD countries, at least one‑third of the population shows poor health literacy levels, and in 12 of these countries, that proportion is above 50% (Moreira, 2018[20]). A study of health literacy in eight European countries revealed that approximately 47% of the population have either inadequate or problematic health literacy (Sørensen et al., 2015[21]). People with financial deprivation, low social status, low education or old age, are more likely to have higher rates of limited health literacy. To enhance the effectiveness of the Nutri-Score logo, efforts to enhance health literacy (with a focus on nutritional knowledge), particularly among vulnerable groups outlined above, are encouraged (OECD, 2019[22]). Example policies to boost health literacy are in Box 3.3.
Box 3.3. Boosting rates of health literacy
In 2018, OECD released the Health Working Paper “Health literacy for people‑centred care”. The paper outlined high-level policy options to boost population health literacy such as:
Counselling and training interventions in community settings and elsewhere (e.g. workplaces)
Encouraging health literacy in schools, for example by incorporating health literacy into the education curricula
Media campaigns and website that promote health literacy that are easy to access and navigate.
Source: Moreira (2018[20]), “Health literacy for people‑centred care: Where do OECD countries stand?”, https://doi.org/10.1787/d8494d3a-en.
Enhancing efficiency
Efficiency is calculated by obtaining information on effectiveness and expressing it in relation to inputs used. Therefore, policies to boost effectiveness without significant increases in costs will have a positive impact on efficiency.
Enhancing equity
Analyse price differences across the different Nutri-Score categories. To date, two studies suggest that the prices of food products with the Nutri-Score logo are no higher than similar products which do not use the logo (Crosetto et al., 2019[7]) (Oqali, 2020[5]) (see “Equity”). These studies compared the price of products with the Nutri-Score logo and those without. A step further would be to analyse the price difference between products with an A or B grade Nutri-Score logo (higher-quality products) and those with a C, D or E grade Nutri-Score logo (lower-quality products). Such analysis would provide important information on whether lower socio‑economic groups face barriers to purchasing high-quality food products.
Enhancing the evidence‑base
Enhance the evidence‑based supporting Nutri-Score using survey-based data. There are a number of experimental studies on FOP food labelling, but studies in real life settings are less common. While experimental studies, using for instance an experimental online supermarket, are indeed useful to study the effect of the logo itself net of other factors that may influence purchase behaviours, they are likely to overestimate the impact of food labelling, with effect sizes 17 times higher on average than those found in real-life condition studies (Dubois et al., 2020[8]).
Food purchases from retail stores are a reliable data source however they are not directly linked to consumption. Further, this type of data cannot be used to analyse the impact of FOP labelling schemes across population groups (for instance, by age, gender and education), except for data using registration to loyalty cards. Future studies using survey-based data on consumption may help enhance the evidence‑base supporting Nutri-score, although similar studies tend to suffer from recording errors.
Estimate whether Nutri-Score has an impact on food reformulation. Food manufacturers may respond to labelling schemes by voluntary reformulating their product so that it is more attractive to consumers (e.g. reduce salt or sugar content). Therefore, future studies could examine what, if any, impact Nutri-Score has had on food reformulation (e.g. using data collected by France’s observatory that monitors the quality of food (i.e. Observatoire de la Qualité de l’Alimientation – Oqali)).
Implement strategies to increase affordability. The rise of cheap foods low in nutritional value contributes to high rates of overweight and obesity in poorer populations (e.g. in France, 19.1% of the population are obese in the lowest income quintile compared to 10.3% in the highest income quintile) (Eurostat, 2014[23]). To improve access to high-quality foods, policy makers could partner with retail outlets (e.g. supermarkets) to offer discounts/offers/promotions on products with high grades on the Nutri-Score logo (A or B grades). This would improve equity by making nutritious foods more affordable as well as enhance the extent of coverage.
Enhancing the extent of coverage
Encourage food companies to use the Nutri-Score logo. In 2020, over 400 food companies were engaged in the programme, representing about 50% of the market share in sales volume (Oqali, 2020[5]). In 2021, the number of companies engaged in Nutri-Score increased to about 600 (Santé publique France, 2021[6]). A large majority of products displaying the Nutri-Score logo are own-brand products from major food retailers and national branded products (Oqali, 2020[5]). To increase the number of products with the logo, policy makers could use incentives or other techniques to encourage larger companies to use the logo. It is important to note here that at present there are ongoing discussions at the European level to introduce a streamlined mandatory FOP-labelling scheme.
Extend the Nutri-Score to collective and commercial catering. France is currently working on the roll-out of Nutri-Score to collective and commercial catering (Ministère des solidarités et de la santé, 2021[17]). For example, Nutri-Score has already been introduced in some school canteens in France (Elior Group, 2020[24]). The aim is not to choose products that are only classified A or B and to exclude D and E altogether (for instance cheese, a great source of calcium, is classified D or E), but rather to provide education on healthy eating.
A step further would be to use the scoring from Nutri-Score to limit the promotion of poor nutritional quality products for vulnerable populations. For instance, Santé publique France recommends banning advertising targeting children on TV and the internet for food products that are classified D or E (Santé publique France, 2020[25]).
Introduce policies that nudge consumers towards products with a healthier Nutri-Score. For example, after scanning a products barcode, it is possible to present consumers with a healthier alternative (e.g. product with a high Nutri-Score). For example, the NHS Food Scanner (United Kingdom) app allows consumers to scan product barcodes to identify if the item is a “Good choice”, if not, the app suggests alternative products with less saturated fat, sugar and salt, for example (NHS, 2022[26]).
Transferability
This section explores the transferability of Nutri-Score and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publically available data; and 3) additional considerations for policy makers interested in transferring Nutri-Score.
Previous transfers
Nutri-Score was adopted in France in October 2017. Four European countries also adopted Nutri-Score: Belgium in April 2018, Germany and Switzerland in September 2019, and Luxembourg in 2020. These countries are at different stages of implementation. Two countries announced their intention to adopt Nutri-Score – Spain in November 2018 (ongoing debate) and the Netherlands in November 2019 (European Food Agency News, 2021[27]).
Across OECD countries, there are a number of exiting food-labelling schemes. In Europe, the adoption of an EU-wide FOP labelling system is under discussion (European Commission, 2021[28]). Within the framework of the Farm-to-Fork initiative, the European Commission aims to propose a harmonised mandatory FOP food-labelling scheme by the end of 2022. While some countries are in support of the Nutri-Score, other countries, such as Italy, the Czech Republic and Greece, raise concerns about the ratings of certain national food products (e.g. cheese, olive oil) using Nutri-Score. Italy proposed an alternative FOP food-labelling scheme, Nutrinform, which uses battery symbols to indicate the percentage of energy, fats, sugars and salt in a recommended portion of food. Different preferences among European Member States highlights the challenges associated with international governance of a streamlined FOP-labelling scheme.
Transferability assessment
The following section outlines the methodological framework to assess transferability and results from the assessment.
Methodological framework
Details on the methodological framework to assess transferability are in Annex A.
Several indicators to assess the transferability of Nutri-Score were identified (Table 3.4). Indicators were drawn from international databases and surveys to maximise coverage across OECD and non-OECD European countries. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.
The transferability assessment for Nutri-Score is in particular limited given indicators related to the food retail market/consumer behaviour are collected by private research companies and are therefore not available for public use.
Nutri-Score, or similar FOP traffic light labelling schemes, are available in certain OECD/EU countries, therefore results from the transferability assessment can instead be used to identify areas to enhance the impact of the intervention.
Table 3.4. Indicators to assess the transferability of Nutri-Score
Source: OECD (2018[29]), “Preventative care spending as a proportion of current health expenditure”, https://data.oecd.org/healthres/health-spending.htm; WHO (2019[30]), “Existence of operational policy/strategy/action plan to reduce unhealthy diet related to NCDs (Noncommunicable diseases)”, https://apps.who.int/gho/data/node.imr.NCD_CCS_DietPlan?lang=en; OECD (2019[1]), The Heavy Burden of Obesity: The Economics of Prevention, https://dx.doi.org/10.1787/67450d67-en.
Results
At present, 26 OECD countries have FOP nutrition labelling schemes: seven countries with Nutri-Score, two countries with a Health Star Rating system (Australia and New Zealand), two countries with a traffic light system per nutrient (Portugal and the United Kingdom), while a further 15 countries use either a mixture of FOP schemes or a different scheme altogether, such as the Nordic Keyhole Logo in Norway, Sweden, Denmark and Iceland (see Table 3.5). These results indicate there are high levels of political support for nutrition food-labelling schemes. Further, the majority of countries have in place a national action plan to reduce levels of unhealthy eating (90%) and spend proportionally more on preventative care than France (1.8% versus 2.6% of current health expenditure) – similarly, these results reflect political support for interventions that encourage people to eat better.
Table 3.5. Transferability assessment by country, Nutri-Score (OECD and non-OECD European countries)
Darker shades indicate Nutri-Score is more transferable to that particular country
Note: † = operate Nutri-Score. *FOP = front-of-pack; **M = mandatory; V = voluntary. **CHE = current health expenditure. n/a = no available data. The shades of blue represent the distance each country is from the country in which the intervention currently operates, with a darker shade indicating greater transfer potential based on that particular indicator (see Annex A for further methodological details).
Source: OECD (2018[29]), “Preventative care spending as a proportion of current health expenditure”, https://data.oecd.org/healthres/health-spending.htm; WHO (2019[30]), “Existence of operational policy/strategy/action plan to reduce unhealthy diet related to NCDs (Noncommunicable diseases)”, https://apps.who.int/gho/data/node.imr.NCD_CCS_DietPlan?lang=en; OECD (2019[1]), The Heavy Burden of Obesity: The Economics of Prevention, https://dx.doi.org/10.1787/67450d67-en.
To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups, based on indicators reported in Table 3.4. Countries in clusters with more positive values have the greatest transfer potential. For further details on the methodological approach used, please refer to Annex A.
Key findings from each of the clusters are below with further details in Figure 3.9 and Table 3.6:
Countries in cluster one have sector specific, political and economic arrangements in place to transfer Nutri-Score and therefore have conditions in place to readily transfer Nutri-Score to their local context. This cluster includes France and countries with plans to transfer Nutri-Score to their local country.
Countries in cluster two, prior to transferring Nutri-Score, would benefit from assessing whether the sector is ready to implement such an intervention (e.g. determining whether front-of-pack labelling is allowed).
Countries in cluster three would similarly benefit from assessing the sector’s readiness to implement Nutri-Score, as well as ensuring that the intervention aligns with overarching political priorities and is affordable in the long-term, given relatively low levels of spending on health prevention.
Figure 3.9. Transferability assessment using clustering, Nutri-Score
Note: Bar charts show percentage difference between cluster mean and dataset mean, for each indicator.
Source: OECD (2018[29]), “Preventative care spending as a proportion of current health expenditure”, https://data.oecd.org/healthres/health-spending.htm; WHO (2019[30]), “Existence of operational policy/strategy/action plan to reduce unhealthy diet related to NCDs (Noncommunicable diseases)”, https://apps.who.int/gho/data/node.imr.NCD_CCS_DietPlan?lang=en; OECD (2019[1]), The Heavy Burden of Obesity: The Economics of Prevention, https://dx.doi.org/10.1787/67450d67-en.
Table 3.6. Countries by cluster, Nutri-Score
New indicators to assess transferability
Data from publically available datasets is not ideal to assess the transferability of public health interventions, in particular for food labelling schemes such as Nutri-Score given indicators on the food retail market and consumer behaviour are collected by private research companies (e.g. Euromonitor International). Box 3.4 outlines several new indicators policy makers could consider before transferring Nutri-Score.
Box 3.4. New indicators to assess transferability
In addition to the indicators from secondary sources of data outlined above, the following primary source indicators to measure transferability are recommended:
Population context
What is the level of health literacy in the population?
What proportion of food consumed is pre‑packaged?
Where do people purchase their food (e.g. supermarkets (online vs in-person), locally in fresh-food markets)?
What proportion of people report using nutrition food labels to guide food-purchasing decisions?
What is the impact of the food labelling scheme on different socio‑economic groups?
Intervention-specific context (retail food sector)
What is the effect of the food labelling scheme on the price of products?
What other, non-nutritional, quality labels already exist on products? (e.g. origin of food product, organic food label)
What is the level of support among food manufacturers for a food labelling scheme?
Does the legal and regulatory framework support nutrition food labels?
Political context
Has the intervention received political support from key decision-makers?
Has the intervention received commitment from key decision-makers?
What would be the effect of the intervention of traditional national products (e.g. olive oil and cheese)?
Economic context
What is the cost of implementing the intervention in the target setting?
What would be the economic impact on food producers and retailers particularly for certain national food products (such as cheese, olive oil)?
Conclusion and next steps
The Nutri-Score FOP labelling scheme is a best practice NCD intervention targeting unhealthy diets. Nutri-Score aligns with international evidence which states logos should be visible (e.g. large and front-of-package) and easily interpretable (WHO, 2019[31]). For this reason, a larger number of people can interpret the Nutri-Score logo, which may be reflected by growing consumer awareness. Evidence on the impact of Nutri-Score indicates it successfully reduces the number of calories people purchase, further, the impact was assessed using high-quality evidence (i.e. RCT).
Using OECD’s SPHeP-NCD model, it is estimated that Nutri-Score would lead to 12 LYs gained and 17 DALYs gained per 100 000 people per year over the period 2021‑50 in France. By reducing disease incidence, Nutri-Score is expected to lead to total health expenditure savings of EUR 17.34 per person by 2050, also in France. Across all OECD and EU27 countries, Nutri-Score would not only be cost effective, but also cost saving.
An assessment of Nutri-Score’s performance against the best practice criteria highlighted potential areas for improvement. These include, but are not limited to, enhancing levels of health literacy, analysing price differences across different Nutri-Score products, improving affordability of products with a high Nutri-Score.
Based on available information, Nutri-Score is considered broadly transferable – however, the difficulty associated with streamlining mandatory FOP-labelling across Europe is acknowledged. At present, six OECD European countries have adopted, or are in process to adopt, Nutri-Score, several other countries have a FOP label with a traffic light per nutrient, while others use health food logos or nutrient labelling schemes. An assessment of the Nutri-Score’s transferability potential was limited given relevant indicators (e.g. related to the food retail market) are collected by private research companies and not available for public use. Therefore, countries interested in transferring Nutri-Score should undertake their own assessment based on indicators outline in this document.
Box 3.5 outlines next steps for policy makers and funding agencies regarding PAP.
Box 3.5. Next steps for policy makers and funding agencies
Next steps for policy makers and funding agencies to enhance Nutri-Score are listed below:
Support policy efforts to enhance population health literacy to encourage people to make healthy choices (such as purchasing products with a high Nutri-Score)
Support and encourage food companies to use the Nutri-Score label, to improve coverage
Promote findings from the Nutri-Score case study to understand what countries are interested in transferring the intervention
Continue to invest in complementary prevention policies, such as procurement policies and regulation of food advertisement to children that help build healthier environments encouraging people to do physical activity and eat well.
References
[10] Allais, O. et al. (2017), Évaluation Expérimentation Logos Nutritionnels, Rapport pour le FFAS, https://solidarites-sante.gouv.fr/IMG/pdf/rapport_final_groupe_traitement_evaluation_logos.pdf.
[19] Campos, S., J. Doxey and D. Hammond (2011), “Nutrition labels on pre-packaged foods: a systematic review”, Public Health Nutrition, Vol. 14/8, pp. 1496-1506, https://doi.org/10.1017/s1368980010003290.
[3] Cecchini, M. and L. Warin (2015), “Impact of food labelling systems on food choices and eating behaviours: a systematic review and meta-analysis of randomized studies”, Obesity Reviews, Vol. 17/3, pp. 201-210, https://doi.org/10.1111/obr.12364.
[7] Crosetto, P. et al. (2019), “Nutritional and economic impact of five alternative front-of-pack nutritional labels: experimental evidence”, European Review of Agricultural Economics, Vol. 47/2, pp. 785-818, https://doi.org/10.1093/erae/jbz037.
[13] Crosetto, P. et al. (2017), “Modification des achats alimentaires en réponse à cinq logos nutritionnels”, Cahiers de Nutrition et de Dietetique, Vol. 52/3, pp. 129-133, https://doi.org/10.1016/J.CND.2017.04.002.
[8] Dubois, P. et al. (2020), “Effects of front-of-pack labels on the nutritional quality of supermarket food purchases: evidence from a large-scale randomized controlled trial”, Journal of the Academy of Marketing Science, Vol. 49/1, pp. 119-138, https://doi.org/10.1007/s11747-020-00723-5.
[18] Ducrot, P. et al. (2016), “Impact of Different Front-of-Pack Nutrition Labels on Consumer Purchasing Intentions”, American Journal of Preventive Medicine, Vol. 50/5, pp. 627-636, https://doi.org/10.1016/j.amepre.2015.10.020.
[15] Effective Public Health Practice Project (1998), Quality assessment tool for quantitative studies, https://www.nccmt.ca/knowledge-repositories/search/14.
[24] Elior Group (2020), Elior rolls out the Nutri-Score label in school canteens, a first in contract catering, https://www.eliorgroup.com/press/press-releases/elior-rolls-out-nutri-score-label-school-canteens-first-contract-catering (accessed on 30 June 2021).
[28] European Commission (2021), Nutrition labelling, https://ec.europa.eu/food/food/labelling-and-nutrition/food-information-consumers-legislation/nutrition-labelling_en (accessed on 1 July 2021).
[27] European Food Agency News (2021), Nutri-Score, the Spanish government splits up, https://www.efanews.eu/en/item/17737-nutri-score-the-spanish-government-splits-up.html (accessed on 1 July 2021).
[23] Eurostat (2014), Body mass index (BMI) by sex, age and income quintile.
[32] Hall, D. (2011), How Much Does a Good Wellness Program Cost?, https://blog.wellsource.com/much-good-wellness-program-cost (accessed on 1 July 2021).
[11] Kloss, L. et al. (2015), Sodium intake and its reduction by food reformulation in the European Union - A review, Elsevier GmbH, https://doi.org/10.1016/j.nfs.2015.03.001.
[12] Lobstein, T., M. Neveux and J. Landon (2020), “Costs, equity and acceptability of three policies to prevent obesity: A narrative review to support policy development”, Obesity Science & Practice, Vol. 6/5, pp. 562-583, https://doi.org/10.1002/OSP4.423.
[4] Ministère des Solidarités et de la Santé (2020), Etudes et rapports scientifiques, https://solidarites-sante.gouv.fr/prevention-en-sante/preserver-sa-sante/nutrition/nutri-score/etudes-et-rapports-scientifiques/ (accessed on 30 June 2021).
[17] Ministère des solidarités et de la santé (2021), NUTRI-SCORE ÉVALUATION À 3 ANS DU LOGO NUTRITIONNEL NUTRI-SCORE.
[20] Moreira, L. (2018), “Health literacy for people-centred care: Where do OECD countries stand?”, OECD Health Working Papers, No. 107, OECD Publishing, Paris, https://doi.org/10.1787/d8494d3a-en.
[26] NHS (2022), Better Health, healthier families, https://www.nhs.uk/healthier-families/food-facts/nhs-food-scanner-app/.
[22] OECD (2019), Health for Everyone?: Social Inequalities in Health and Health Systems, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/3c8385d0-en.
[1] OECD (2019), The Heavy Burden of Obesity: The Economics of Prevention, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/67450d67-en.
[29] OECD (2018), Preventative care spending as a proportion of current health expenditure, OECD, Paris.
[2] OECD (2017), Obesity Update 2017, OECD, Paris, http://www.oecd.org/health/obesity-update.htm (accessed on 24 May 2018).
[5] Oqali (2020), Suivi du NUTRI-SCORE par l’Oqali, Analyse à trois ans, Edition 2020.
[9] Santé publique France (2021), 7 pays européens se sont engagés à faciliter le déploiement du Nutri-Score, https://www.santepubliquefrance.fr/presse/2021/7-pays-europeens-se-sont-engages-a-faciliter-le-deploiement-du-nutri-score (accessed on 5 March 2021).
[33] Santé publique France (2021), Le Nutri-Score : un logo bien intégré dans le quotidien des Français, https://www.santepubliquefrance.fr/les-actualites/2021/le-nutri-score-un-logo-bien-integre-dans-le-quotidien-des-francais (accessed on 8 June 2021).
[6] Santé publique France (2021), Nutri-Score, https://www.santepubliquefrance.fr/determinants-de-sante/nutrition-et-activite-physique/articles/nutri-score (accessed on 30 June 2021).
[25] Santé publique France (2020), Comment limiter le marketing alimentaire, en particulier pour les produits gras, sucrés, salés en direction des enfants et des adolescents ?, https://www.santepubliquefrance.fr/les-actualites/2020/comment-limiter-le-marketing-alimentaire-en-particulier-pour-les-produits-gras-sucres-sales-en-direction-des-enfants-et-des-adolescents (accessed on 19 July 2021).
[16] Sarda, B., P. Ducrot and A. Serry (2020), Nutri-Score : Évolution de sa notoriété, sa perception et son impact sur les comportements d’achat déclarés entre 2018 et 2020, Santé Publique France, Saint-Maurice, https://www.santepubliquefrance.fr/determinants-de-sante/nutrition-et-activite-physique/documents/enquetes-etudes/nutri-score-evolution-de-sa-notoriete-sa-perception-et-son-impact-sur-les-comportements-d-achat-declares-entre-2018-et-2020 (accessed on 9 March 2021).
[14] Sarda, B. et al. (2020), “Appropriation of the front-of-pack nutrition label nutri-score across the french population: Evolution of awareness, support, and purchasing behaviors between 2018 and 2019”, Nutrients, Vol. 12/9, pp. 1-12, https://doi.org/10.3390/nu12092887.
[21] Sørensen, K. et al. (2015), “Health literacy in Europe: Comparative results of the European health literacy survey (HLS-EU)”, European Journal of Public Health, Vol. 25/6, pp. 1053-1058, https://doi.org/10.1093/eurpub/ckv043.
[30] WHO (2019), Existence of operational policy/strategy/action plan to reduce unhealthy diet related to NCDs (Noncommunicable diseases), https://apps.who.int/gho/data/node.imr.NCD_CCS_DietPlan?lang=en.
[31] WHO (2019), Guiding principles and framework manuel for front-of-pack labelling for promoting healthy diet, Department of Nutrition for Health and Development, https://www.who.int/nutrition/publications/policies/guidingprinciples-labelling-promoting-healthydiet.pdf?ua=1.