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AbstractObjectiveTo assess the prospective associations between consumption of ultra-processed foods and risk of cardiovascular diseases.DesignPopulation based cohort study.SettingNutriNet-Santé cohort, France 2009-18.Participants105 159 participants aged at least 18 years. Dietary intakes were collected using repeated 24 hour dietary records (5.7 for each participant on average), designed to register participants’ usual consumption of 3300 food items. These foods were categorised using the NOVA classification according to degree of processing.Main outcome measuresAssociations between intake of ultra-processed food and overall risk of cardiovascular, coronary heart, and cerebrovascular diseases assessed by multivariable Cox proportional hazard models adjusted for known risk factors.ResultsDuring a median follow-up of 5.2 years, intake of ultra-processed food was associated with a higher risk of overall cardiovascular disease (1409 cases; hazard ratio for an absolute increment of 10 in the percentage of ultra-processed foods in the diet 1.12 (95% confidence interval 1.05 to 1.20); P<0.001, 518 208 person years, incidence rates in high consumers of ultra-processed foods (fourth quarter) 277 per 100 000 person years, and in low consumers (first quarter) 242 per 100 000 person years), coronary heart disease risk (665 cases; hazard ratio 1.13 (1.02 to 1.24); P=0.02, 520 319 person years, incidence rates 124 and 109 per 100 000 person years, in the high and low consumers, respectively), and cerebrovascular disease risk (829 cases; hazard ratio 1.11 (1.01 to 1.21); P=0.02, 520 023 person years, incidence rates 163 and 144 per 100 000 person years, in high and low consumers, respectively). 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 fibre, or a healthy dietary pattern derived by principal component analysis) and after a large range of sensitivity analyses.ConclusionsIn this large observational prospective study, higher consumption of ultra-processed foods 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. Various factors in processing, such as nutritional composition of the final product, additives, contact materials, and neoformed contaminants might play a role in these associations, and further studies are needed to understand better the relative contributions. Meanwhile, 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.Study registrationClinicalTrials.gov NCT03335644.

AbstractObjectivesTo study the associations between artificial sweeteners from all dietary sources (beverages, but also table top sweeteners, dairy products, etc), overall and by molecule (aspartame, acesulfame potassium, and sucralose), and risk of cardiovascular diseases (overall, coronary heart disease, and cerebrovascular disease).DesignPopulation based prospective cohort study (2009-21).SettingFrance, primary prevention research.Participants103 388 participants of the web based NutriNet-Santé cohort (mean age 42.2±14.4, 79.8% female, 904 206 person years). Dietary intakes and consumption of artificial sweeteners were assessed by repeated 24 h dietary records, including brand names of industrial products.Main outcomes measuresAssociations between sweeteners (coded as a continuous variable, log10 transformed) and cardiovascular disease risk, assessed by multivariable adjusted Cox hazard models.ResultsTotal artificial sweetener intake was associated with increased risk of cardiovascular diseases (1502 events, hazard ratio 1.09, 95% confidence interval 1.01 to 1.18, P=0.03); absolute incidence rate in higher consumers (above the sex specific median) and non-consumers was 346 and 314 per 100 000 person years, respectively. Artificial sweeteners were more particularly associated with cerebrovascular disease risk (777 events, 1.18, 1.06 to 1.31, P=0.002; incidence rates 195 and 150 per 100 000 person years in higher and non-consumers, respectively). Aspartame intake was associated with increased risk of cerebrovascular events (1.17, 1.03 to 1.33, P=0.02; incidence rates 186 and 151 per 100 000 person years in higher and non-consumers, respectively), and acesulfame potassium and sucralose were associated with increased coronary heart disease risk (730 events; acesulfame potassium: 1.40, 1.06 to 1.84, P=0.02; incidence rates 167 and 164; sucralose: 1.31, 1.00 to 1.71, P=0.05; incidence rates 271 and 161).ConclusionsThe findings from this large scale prospective cohort study suggest a potential direct association between higher artificial sweetener consumption (especially aspartame, acesulfame potassium, and sucralose) and increased cardiovascular disease risk. Artificial sweeteners are present in thousands of food and beverage brands worldwide, however they remain a controversial topic and are currently being re-evaluated by the European Food Safety Authority, the World Health Organization, and other health agencies.Trial registrationClinicalTrials.gov NCT03335644

Background: Ultra-processed food (UPF) consumption has increased drastically worldwide and already represents 50%–60% of total daily energy intake in several high-income countries. In the meantime, the prevalence of overweight and obesity has risen continuously during the last century. The objective of this study was to investigate the associations between UPF consumption and the risk of overweight and obesity, as well as change in body mass index (BMI), in a large French cohort.Methods and findings: A total of 110,260 adult participants (≥18 years old, mean baseline age = 43.1 [SD 14.6] years; 78.2% women) from the French prospective population-based NutriNet-Santé cohort (2009–2019) were included. Dietary intakes were collected at baseline using repeated and validated 24-hour dietary records linked to a food composition database that included >3,500 different food items, each categorized according to their degree of processing by the NOVA classification. Associations between the proportion of UPF in the diet and BMI change during follow-up were assessed using linear mixed models. Associations with risk of overweight and obesity were assessed using Cox proportional hazard models. After adjusting for age, sex, educational level, marital status, physical activity, smoking status, alcohol intake, number of 24-hour dietary records, and energy intake, we observed a positive association between UPF intake and gain in BMI (β Time × UPF = 0.02 for an absolute increment of 10 in the percentage of UPF in the diet, P < 0.001). UPF intake was associated with a higher risk of overweight (n = 7,063 overweight participants; hazard ratio (HR) for an absolute increase of 10% of UPFs in the diet = 1.11, 95% CI: 1.08–1.14; P < 0.001) and obesity (n = 3,066 incident obese participants; HR10% = 1.09 (1.05–1.13); P < 0.001). These results remained statistically significant after adjustment for the nutritional quality of the diet and energy intake. Study limitations include possible selection bias, potential residual confounding due to the observational design, and a possible item misclassification according to the level of processing. Nonetheless, robustness was tested and verified using a large panel of sensitivity analyses.Conclusions: In this large observational prospective study, higher consumption of UPF was associated with gain in BMI and higher risks of overweight and obesity. Public health authorities in several countries recently started to recommend privileging unprocessed/minimally processed foods and limiting UPF consumption.

With the growing scientific appeal of e-epidemiology, concerns arise regarding validity and reliability of Web-based self-reported data. The objectives of the present study were to assess the validity of Web-based self-reported weight, height, and resulting body mass index (BMI) compared with standardized clinical measurements and to evaluate the concordance between Web-based self-reported anthropometrics and face-to-face declarations. A total of 2513 participants of the NutriNet-Santé study in France completed a Web-based anthropometric questionnaire 3 days before a clinical examination (validation sample) of whom 815 participants also responded to a face-to-face anthropometric interview (concordance sample). Several indicators were computed to compare data: paired t test of the difference, intraclass correlation coefficient (ICC), and Bland-Altman limits of agreement for weight, height, and BMI as continuous variables; and kappa statistics and percent agreement for validity, sensitivity, and specificity of BMI categories (normal, overweight, obese). Compared with clinical data, validity was high with ICC ranging from 0.94 for height to 0.99 for weight. BMI classification was correct in 93% of cases; kappa was 0.89. Of 2513 participants, 23.5% were classified overweight (BMI≥25) with Web-based self-report vs 25.7% with measured data, leading to a sensitivity of 88% and a specificity of 99%. For obesity, 9.1% vs 10.7% were classified obese (BMI≥30), respectively, leading to sensitivity and specificity of 83% and 100%. However, the Web-based self-report exhibited slight underreporting of weight and overreporting of height leading to significant underreporting of BMI (P<.05) for both men and women: -0.32 kg/m² (SD 0.66) and -0.34 kg/m² (SD 1.67), respectively. Mean BMI underreporting was -0.16, -0.36, and -0.63 kg/m² in the normal, overweight, and obese categories, respectively. Almost perfect agreement (ie, concordance) was observed between Web-based and face-to-face report (ICC ranged from 0.96 to 1.00, classification agreement was 98.5%, and kappa 0.97). Web-based self-reported weight and height data from the NutriNet-Santé study can be considered as valid enough to be used when studying associations of nutritional factors with anthropometrics and health outcomes. Although self-reported anthropometrics are inherently prone to biases, the magnitude of such biases can be considered comparable to face-to-face interview. Web-based self-reported data appear to be an accurate and useful tool to assess anthropometric data.

BACKGROUND:Ultra-processed food (UPF) consumption has increased over the last decades in Westernized countries. Our objective was to investigate for the first time the association between the proportion of UPF (%UPF) in the diet and incident depressive symptoms in the NutriNet-Santé cohort.METHODS:The sample included 20,380 women and 6350 men (aged 18-86 years) without depressive symptoms at the first Center for Epidemiologic Studies Depression Scale (CES-D) measurement, using validated cut-offs (CES-D score ≥ 17 for men and ≥ 23 for women). The proportion of UPF in the diet was computed for each subject using the NOVA classification applied to dietary intakes collected by repeated 24-h records (mean = 8; SD = 2.3). The association between UPF and depressive symptoms was evaluated using multivariable Cox proportional hazards models.RESULTS:Over a mean follow-up of 5.4 years, 2221 incident cases of depressive symptoms were identified. After accounting for a wide range of potential confounders, an increased risk of depressive symptoms was observed with an increased %UPF in the diet. In the main model adjusted for sociodemographic characteristics, body mass index, and lifestyle factors, the estimated hazard ratio for a 10% increase in UPF was 1.21 (95% confidence interval = 1.15-1.27). Considering %UPF in food groups, the association was significant only for beverages and sauces or added fats.CONCLUSION:Overall, UPF consumption was positively associated with the risk of incident depressive symptoms, suggesting that accounting for this non-nutritional aspect of the diet could be important for mental health promotion.

Background The effectiveness of Front-of-Pack nutrition Labels (FoPLs) may be influenced by national context. In light of the ongoing efforts to harmonize FoPLs across Europe, this study aimed to compare the effectiveness of five FoPLs (Health Star Rating system, Multiple Traffic Lights, Nutri-Score, Reference Intakes, Warning symbols) on consumer understanding and food choice in 12 European countries. Methods In 2018–2019, for three food categories, approximately 1000 participants per country were asked to select which food they would prefer to purchase between three products with distinct nutritional quality profiles, and then to rank the products by nutritional quality. Participants ( N  = 12,391 in total) completed these tasks first with no FoPL and then, after randomization to one of the five FoPLs, with a FoPL on the food packages. Associations between FoPLs and change in (i) nutritional quality of food choices and (ii) ability to correctly rank the products by nutritional quality were assessed with logistic regression models adjusted for sociodemographic and lifestyle characteristics of participants, conducted overall and by country. Findings Compared with the Reference Intakes, the Nutri-Score (OR = 3.23[2.75–3.81]; p  < 0.0001), followed by the Multiple Traffic Lights (OR = 1.68[1.42–1.98]; p  < 0.0001), was the most effective FoPL in helping consumers identify the foods’ nutritional quality, overall and in each of the 12 countries. Differences between FoPLs regarding food choice modifications were smaller, but the effect of the Nutri-Score seemed slightly higher in eliciting healthier food choices overall compared with the Reference Intakes, followed by the Warning symbols, the Multiple Traffic Lights and the Health Star Rating system. Interpretation In the context of FoPL harmonization in Europe, these findings from an online experiment provide insights into the Nutri-Score’s effectiveness on European consumers.

BACKGROUND: Nutrition-related chronic diseases such as cardiovascular diseases and cancer are of multiple origin, and may be due to genetic, biologic, behavioural and environmental factors. In order to detangle the specific role of nutritional factors, very large population sample cohort studies comprising precisely measured dietary intake and all necessary information for accurately assessing potential confounding factors are needed. Widespread use of internet is an opportunity to gradually collect huge amounts of data from a large sample of volunteers that can be automatically verified and processed. The objectives of the NutriNet-Santé study are: 1) to investigate the relationship between nutrition (nutrients, foods, dietary patterns, physical activity), mortality and health outcomes; and 2) to examine the determinants of dietary patterns and nutritional status (sociological, economic, cultural, biological, cognitive, perceptions, preferences, etc.), using a web-based approach. METHODS/DESIGN: Our web-based prospective cohort study is being conducted for a scheduled follow-up of 10 years. Using a dedicated web site, recruitment will be carried out for 5 years so as to register 500 000 volunteers aged >/= 18 years among whom 60% are expected to be included (having complete baseline data) and followed-up for at least 5 years for 240 000 participants. Questionnaires administered via internet at baseline and each year thereafter will assess socio-demographic and lifestyle characteristics, anthropometry, health status, physical activity and diet. Surveillance of health events will be implemented via questionnaires on hospitalisation and use of medication, and linkage with a national database on vital statistics. Biochemical samples and clinical examination will be collected in a subsample of volunteers. DISCUSSION: Self-administered data collection using internet as a complement to collection of biological data will enable identifying nutrition-related risks and protective factors, thereby more clearly elucidating determinants of nutritional status and their interactions. These are necessary steps for further refining nutritional recommendations aimed at improving the health status of populations.

Background The Nutri-Score summary graded front-of-pack nutrition label has been identified as an efficient tool to increase the nutritional quality of pre-packed food purchases. However, no study has been conducted to investigate the effect of the Nutri-Score on the shopping cart composition, considering the type of foods. The present paper aims to investigate the effect of the Nutri-Score on the type of food purchases, in terms of the relative contribution of unpacked and pre-packed foods, or the processing degree of foods. Methods Between September 2016 and April 2017, three consecutive randomized controlled trials were conducted in three specific populations – students ( N  = 1866), low-income individuals ( N  = 336) and subjects suffering from cardiometabolic diseases ( N  = 1180) – to investigate the effect of the Nutri-Score on purchasing intentions compared to the Reference Intakes and no label. Using these combined data, the proportion of unpacked products in the shopping carts, as well as the distribution of products across food categories taking into account the degree of processing (NOVA classification) were assessed by trials arm. Results The shopping carts of participants simulating purchases with the Nutri-Score affixed on pre-packed foods contained higher proportion of unpacked products – especially raw fruits and meats, i.e. with no FoPL –, compared to participants purchasing with no label (difference of 5.93 percentage points [3.88–7.99], p -value< 0.0001) or with the Reference Intakes (difference of 5.27[3.25–7.29], p-value< 0.0001). This higher proportion was partly explained by fewer purchases of pre-packed processed and ultra-processed products overall in the Nutri-Score group. Conclusions These findings provide new insights on the positive effect of the Nutri-Score, which appears to decrease purchases in processed products resulting in higher proportions of unprocessed and unpacked foods, in line with public health recommendations.

The objective of the present study was to conduct the first systematic review and meta-analysis of prospective studies investigating the associations between total cholesterol (TC), HDL-cholesterol (HDL-C) and LDL-cholesterol (LDL-C) levels and the risk of breast cancer. Relevant studies were identified in PubMed (up to January 2014). Inclusion criteria were original peer-reviewed publications with a prospective design. Random-effects models were used to estimate summary hazard ratios (HR) and 95 % CI. Distinction was made between studies that did or did not exclude cancer cases diagnosed during the first years of follow-up, thereby eliminating potential preclinical bias. Overall, the summary HR for the association between TC and breast cancer risk was 0·97 (95 % CI 0·94, 1·00; dose–response per 1 mmol/l increment, thirteen studies), and that between HDL-C and breast cancer risk was 0·86 (95 % CI 0·69, 1·09; dose–response per 1 mmol/l increment, six studies), with high heterogeneity (I 2= 67 and 47 %, respectively). For studies that eliminated preclinical bias, an inverse association was observed between the risk of breast cancer and TC (dose–response HR 0·94 (95 % CI 0·89, 0·99), seven studies, I 2= 78 %; highest v. lowest HR 0·82 (95 % CI 0·66, 1·02), nine studies, I 2= 81 %) and HDL-C (dose–response HR 0·81 (95 % CI 0·65, 1·02), five studies, I 2= 30 %; highest v. lowest HR 0·82 (95 % CI 0·69, 0·98), five studies, I 2= 0 %). There was no association observed between LDL-C and the risk of breast cancer (four studies). The present meta-analysis confirms the evidence of a modest but statistically significant inverse association between TC and more specifically HDL-C and the risk of breast cancer, supported by mechanistic plausibility from experimental studies. Further large prospective studies that adequately control for preclinical bias are needed to confirm the results on the role of cholesterol level and its fractions in the aetiology of breast cancer.

BACKGROUND:Switzerland, like other high-income countries, is facing a major public health challenge with the increasing burden of non-communicable diseases. Discussions are currently on-going in Switzerland regarding the implementation of a Front-of-Pack nutrition label (FoPL) as a public health measure to guide consumers towards healthier food choices, and the Nutri-Score represents an alternative supported by multiple actors. To date, no studies have investigated the performance of the Nutri-Score among Swiss consumers. This study aimed to compare the response of Swiss consumers to five FoPLs (Health Star Rating system, Multiple Traffic Lights, Nutri-Score, Reference Intakes and Warning symbol) in terms of perception and understanding of these labels and effects on food choices.METHODS:In 2019, 1,088 Swiss consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles and then classify the products within the sets according to their nutritional quality. Tasks were performed in situations without a label and then with one of the five FoPLs-depending on the group in which they were randomized-on the pack. Finally, participants were questioned on their perceptions regarding the label to which they were exposed.RESULTS:All FoPLs were favorably perceived, with marginal differences between FoPLs. The Nutri-Score demonstrated the highest percentage of improvement in food choices and the highest overall performance in helping consumers rank the products according to their nutritional quality.CONCLUSION:Overall, the Nutri-Score was the most efficient FoPL in informing Swiss consumers of the nutritional quality of food products, and as such could be a useful tool to improve food choices and reduce the burden of chronic diseases in Switzerland.