Five-color Nutri-Score labeling and mortality risk in a nationwide, population-based cohort in Spain: the Study on Nutrition and Cardiovascular Risk in Spain (ENRICA).

Background: The 5-color Nutri-Score (5-CNS) front-of-package labeling system classifies products according to their nutritional quality, so healthier choices are easier when shopping.

Objectives: We examined the association between 5-CNS-based food consumption and long-term mortality in a Spanish, adult population.

Methods: We recruited 12,054 individuals, representative of the Spanish population aged ≥18 years, in 2008-10 and followed up with them to 2017. Habitual food consumption was collected at baseline with a validated computerized dietary history, conducted by trained interviewers. Based on nutritional quality, foods consumed were categorized into 5 labels [A/Green (best quality), B, C, D, and E/Red (worst quality)] using an established algorithm. For each individual, a 5-CNS dietary index (DI) was calculated by summing up the amount of g/day from the foods consumed by their corresponding nutritional quality rate (e.g., A rated 1 and E rated 5) and dividing it by kg of weight. The associations between baseline 5-CNS DI and mortality were analyzed using multivariate-adjusted Cox models.

Results: After a mean follow-up of 8.7 years, 514 deaths occurred (140 cardiovascular and 144 cancer deaths). The all-cause mortality HR for the highest versus the lowest quartile of baseline 5-CNS DI was 1.93 (95% CI, 1.34-2.79; P-trend, 0.001). The association was slightly higher for cardiovascular mortality and was similar for cancer. Those with the highest intake of foods labeled as D or E also had a higher all-cause mortality risk than those with the lowest intake (HR, 2.15; 95% CI, 1.56-2.97; P-trend < 0.001). Further, the isocaloric replacement of food products labeled as D or E with fresh foods decreases the risk of death.

Conclusions: The consumption of poor nutritional quality 5-CNS-labeled food products was associated with higher mortality in Spain. Pending further studies, these findings provide additional evidence to reinforce food policies on the use of this simple labeling tool at a country level.