Alignment of Nutri-Score with Mediterranean Diet Pyramid: A Food Level Analysis

Abstract

The Mediterranean diet (MD) has been incorporated as a healthy diet pattern in food-based dietary guidelines of countries all over Europe and the world. Testing the alignment of Nutri-Score with the MD Pyramid is a key step in ensuring that future food-level policies will not be conflicting with existing dietary guidelines. All foods available (n = 4002) in the HelTH database, were classified as eligible or not for inclusion in the MD and they were ranked in their respective tier in the food pyramid following two pyramid schemes, the 1995 traditional and 2020 sustainable MD pyramids. For all foods, Nutri-Score was calculated both as the continuous FSAm-NPS score and its categorical outcome—Nutri-Score grades—and their distribution across the MD pyramid tiers was used as a measure of alignment between the MD and the Nutri-Score algorithm. Only 25% of all foods were eligible under the traditional MD, while the sustainable MD covered ~58% of all foods. For both pyramids, Nutri-Score was successful in clearly separating the foods at the top and the bottom of the pyramids (Nutri-Score Mode “D” or “E” for the top tiers and “A” for the bottom tiers), thus suggesting a good alignment between the two. Good discriminatory capacity was also seen within each tier.

Ultra-Processed Foods in the Mediterranean Diet according to the NOVA Classification System; A Food Level Analysis of Branded Foods in Greece

“…When the nutritional quality of foods was expressed via the Nutri-Score Nutrient Profiling System, there was limited alignment between NOVA and nutritional quality. Even though NOVA1 foods had a lower FSAm-NPS score and, thus, a better nutritional quality than NOVA4, there was a significant percentage of NOVA4 foods graded from A to C. As shown in previous analyses, Nutri-Score tended to increase across the MDP, especially the sMDP, with foods at the bottom being graded mainly as A and D or E at the top [ 34 ]. That was irrespective of their degree of processing as shown in the current analysis.…”

“…Only 28.3% of the branded foods analyzed fitted in the tMDP, and only 55.3% fitted in the updated sMDP. Traditional Greek foods and dishes including cheese and spinach pies, moussaka, and pasticcio were excluded from both pyramids because they did not directly fit into a specific tier of either pyramid [ 9 , 13 , 34 ]. Overall, both MDPs showed a tendency to exclude UPFs and promote NOVA1 (minimally processed) foods.…”

“…Branded foods were screened for inclusion in either or both pyramids and then were assigned to their respective pyramid tier using the same methodology as previously published [ 34 ].…”

“…The Nutri-Score algorithm was calculated for each food based on its nutritional composition per 100 g/mL of food/beverage, as previously described [ 30 , 34 , 35 ]. Briefly, Nutri-Score studies energy (kJ), total sugars (g), saturated fatty acids (SFAs) (g), and sodium (mg) as “negative nutrients” and scores them in a scale from 0 to 10 for increasing content [ 36 ].…”

“…On the contrary, missing data for any “positive nutrients” was imputed with zero and FSAm-NPS score and Nutri-Score grade calculations were performed accordingly. Data imputation for “positive nutrients” took place for <10% of foods in food groups where such nutrients are relevant [ 34 ]. The main sources of missing nutrient values were lack of nutritional declaration or inability to obtain data due to the low quality of the available images.…”