Article open access publication

Nutritional quality of food as represented by the FSAm-NPS nutrient profiling system underlying the Nutri-Score label and cancer risk in Europe: Results from the EPIC prospective cohort study

PLoS Medicine, Public Library of Science (PLoS), ISSN 1549-1676

Volume 15, 9, 2018

DOI:10.1371/journal.pmed.1002651, Dimensions: pub.1107090832, PMC: PMC6143197, PMID: 30226842,



  1. (1) Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Centre (CRESS), Inserm U1153, Inra U1125, Cnam, COMUE Sorbonne Paris Cité, Paris 13 University, Bobigny, France
  2. (2) International Agency For Research On Cancer, grid.17703.32
  3. (3) Hôpital Avicenne, grid.413780.9
  4. (4) Imperial College London, grid.7445.2
  5. (5) Cancer Registry of Norway, grid.418941.1
  6. (6) Karolinska Institute, grid.4714.6
  7. (7) University of Helsinki, grid.7737.4
  8. (8) The Arctic University of Norway, grid.10919.30
  9. (9) Aarhus University, grid.7048.b, AU
  10. (10) Danish Cancer Society, grid.417390.8
  11. (11) Centre for research in epidemiology and population health, grid.463845.8
  12. (12) Institut Gustave Roussy, grid.14925.3b
  13. (13) German Cancer Research Center, grid.7497.d
  14. (14) German Institute of Human Nutrition, grid.418213.d
  15. (15) Hellenic Health Foundation, grid.424637.0
  16. (16) National and Kapodistrian University of Athens, grid.5216.0
  17. (17) Istituto per lo Studio e la Prevenzione Oncologica, grid.417623.5
  18. (18) Fondazione IRCCS Istituto Nazionale dei Tumori, grid.417893.0
  19. (19) University of Naples Federico II, grid.4691.a
  20. (20) Cancer registry and histopathology unit, "CIVIC-M.P. AREZZO" Hospital, ASP Ragusa, Italy
  21. (21) Unit of Cancer Epidemiology, Città della Salute e della Scienza University Hospital and Center for Cancer Prevention (CPO), Turin, Italy
  22. (22) National Institute for Public Health and the Environment, grid.31147.30
  23. (23) University Medical Center Utrecht, grid.7692.a
  24. (24) University of Malaya, grid.10347.31
  25. (25) Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
  26. (26) University of Oslo, grid.5510.1
  27. (27) Public Health Directorate, Asturias, Spain
  28. (28) Catalan Institute of Oncology, grid.418701.b
  29. (29) Ramon Llull University, grid.6162.3
  30. (30) Andalusian School of Public Health, grid.413740.5
  31. (31) Institute of Health Carlos III, grid.413448.e
  32. (32) Instituto Murciano de Investigación Biosanitaria, grid.452553.0
  33. (33) IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
  34. (34) Navarra Public Health Institute, Pamplona, Spain
  35. (35) Basque Government, grid.431260.2
  36. (36) Lund University, grid.4514.4
  37. (37) University of Gothenburg, grid.8761.8
  38. (38) Umeå University, grid.12650.30
  39. (39) University of Cambridge, grid.5335.0
  40. (40) Institute of Metabolic Science, grid.470900.a
  41. (41) University of Oxford, grid.4991.5
  42. (42) University of Ioannina, grid.9594.1


BACKGROUND: Helping consumers make healthier food choices is a key issue for the prevention of cancer and other diseases. In many countries, political authorities are considering the implementation of a simplified labelling system to reflect the nutritional quality of food products. The Nutri-Score, a five-colour nutrition label, is derived from the Nutrient Profiling System of the British Food Standards Agency (modified version) (FSAm-NPS). How the consumption of foods with high/low FSAm-NPS relates to cancer risk has been studied in national/regional cohorts but has not been characterized in diverse European populations. METHODS AND FINDINGS: This prospective analysis included 471,495 adults from the European Prospective Investigation into Cancer and Nutrition (EPIC, 1992-2014, median follow-up: 15.3 y), among whom there were 49,794 incident cancer cases (main locations: breast, n = 12,063; prostate, n = 6,745; colon-rectum, n = 5,806). Usual food intakes were assessed with standardized country-specific diet assessment methods. The FSAm-NPS was calculated for each food/beverage using their 100-g content in energy, sugar, saturated fatty acid, sodium, fibres, proteins, and fruits/vegetables/legumes/nuts. The FSAm-NPS scores of all food items usually consumed by a participant were averaged to obtain the individual FSAm-NPS Dietary Index (DI) scores. Multi-adjusted Cox proportional hazards models were computed. A higher FSAm-NPS DI score, reflecting a lower nutritional quality of the food consumed, was associated with a higher risk of total cancer (HRQ5 versus Q1 = 1.07; 95% CI 1.03-1.10, P-trend < 0.001). Absolute cancer rates in those with high and low (quintiles 5 and 1) FSAm-NPS DI scores were 81.4 and 69.5 cases/10,000 person-years, respectively. Higher FSAm-NPS DI scores were specifically associated with higher risks of cancers of the colon-rectum, upper aerodigestive tract and stomach, lung for men, and liver and postmenopausal breast for women (all P < 0.05). The main study limitation is that it was based on an observational cohort using self-reported dietary data obtained through a single baseline food frequency questionnaire; thus, exposure misclassification and residual confounding cannot be ruled out. CONCLUSIONS: In this large multinational European cohort, the consumption of food products with a higher FSAm-NPS score (lower nutritional quality) was associated with a higher risk of cancer. This supports the relevance of the FSAm-NPS as underlying nutrient profiling system for front-of-pack nutrition labels, as well as for other public health nutritional measures.


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