Front-of-pack labels can improve the ability of consumers to identify which foods are healthier, making them a useful public health tool. Nutri-Score is a front-of-pack labelling system adopted by several European countries. This system ranks foods according to their nutritional quality, but does not consider other dimensions such as the degree of food processing. The aim of this study is to compare the nutritional quality (as assessed by Nutri-Score) and the ultra-processing (as assessed by the NOVA classification) of foods in the Open Food Facts database. A simple correspondence analysis was carried out to study the relationship between the two systems. Ultra-processed foods (NOVA 4) were found in all Nutri-Score categories, ranging from 26.08% in nutritional category A, 51.48% in category B, 59.09% in category C, 67.39% in category D to up to 83.69% in nutritional category E. Given the negative effect that the consumption of ultra-processed foods has on different aspects of health, front-of-pack labelling with Nutri-Score should at least be accompanied by complementary labelling indicating the level of processing, such as the NOVA classification.

Objective: To determine the association between ultra-processed food intake and all-cause mortality in a representative sample of Spanish population. Design: Prospective cohort design in which follow-up lasted from baseline (1991) to mortality date or December 31st, 2017, whichever was first. Dietary information was collected using a validated frequency questionnaire and categorized following the NOVA classification according to the extent of food processing. The association between consumption of ultra-processed food and mortality was analysed using Cox models. Isocaloric substitution models were constructed to compare the health effects of the NOVA groups. Setting: Cohort from the DRECE study, representative of the Spanish population Participants: 4679 subjects between 5 and 59 years old Results: Average consumption of ultra-processed food was 370.8 grams/day (24.4% of energy intake). After a median follow-up of 27 years, 450 deaths occurred. Those who consumed the highest amount of ultra-processed foods had higher risk of mortality. For every 10% of the energy intake from ultra-processed foods consumption, an increase of 15% in the hazard of all-cause mortality was observed (HR, 1.15; 95%CI, 1.03-1.27; p-value= 0.012). Substitution of ultra-processed foods with minimally processed foods was significantly associated with a decreased risk of mortality. Conclusions: An increase in ultra-processed foods consumption was associated with higher risk of all-cause mortality in a representative sample of the Spanish population. Moreover, the theoretical substitution of ultra-processed food with unprocessed or minimally processed foods leads to a decrease in mortality. These results support the need to promote diets based on unprocessed or minimally processed foods.