Food additive emulsifiers and cancer risk: Results from the French prospective NutriNet-Santé cohort.

BACKGROUND: Emulsifiers are widely used food additives in industrially processed foods to improve texture and enhance shelf-life. Experimental research suggests deleterious effects of emulsifiers on the intestinal microbiota and the metabolome, leading to chronic inflammation and increasing susceptibility to carcinogenesis. However, human epidemiological evidence investigating their association with cancer is nonexistent. This study aimed to assess associations between food additive emulsifiers and cancer risk in a large population-based prospective cohort. METHODS AND FINDINGS: This study included 92,000 adults of the French NutriNet-Santé cohort without prevalent cancer at enrolment (44.5 y [SD: 14.5], 78.8% female, 2009 to 2021). They were followed for an average of 6.7 years [SD: 2.2]. Food additive emulsifier intakes were estimated for participants who provided at least 3 repeated 24-h dietary records linked to comprehensive, brand-specific food composition databases on food additives. Multivariable Cox regressions were conducted to estimate associations between emulsifiers and cancer incidence. Overall, 2,604 incident cancer cases were diagnosed during follow-up (including 750 breast, 322 prostate, and 207 colorectal cancers). Higher intakes of mono- and diglycerides of fatty acids (FAs) (E471) were associated with higher risks of overall cancer (HR high vs. low category = 1.15; 95% CI [1.04, 1.27], p-trend = 0.01), breast cancer (HR = 1.24; 95% CI [1.03, 1.51], p-trend = 0.04), and prostate cancer (HR = 1.46; 95% CI [1.09, 1.97], p-trend = 0.02). In addition, associations with breast cancer risk were observed for higher intakes of total carrageenans (E407 and E407a) (HR = 1.32; 95% CI [1.09, 1.60], p-trend = 0.009) and carrageenan (E407) (HR = 1.28; 95% CI [1.06, 1.56], p-trend = 0.01). No association was detected between any of the emulsifiers and colorectal cancer risk. Several associations with other emulsifiers were observed but were not robust throughout sensitivity analyses. Main limitations include possible exposure measurement errors in emulsifiers intake and potential residual confounding linked to the observational design. CONCLUSIONS: In this large prospective cohort, we observed associations between higher intakes of carrageenans and mono- and diglycerides of fatty acids with overall, breast and prostate cancer risk. These results need replication in other populations. They provide new epidemiological evidence on the role of emulsifiers in cancer risk. TRIAL REGISTRATION: ClinicalTrials.gov NCT03335644.

Consistency of the Initial and Updated Version of the Nutri-Score with Food-Based Dietary Guidelines: A French Perspective.

BACKGROUND: To help consumers to make healthier food choices, 7 European countries have implemented the front-of-pack nutrition label Nutri-Score. The algorithm was updated in 2022-2023 by the Nutri-Score European scientific committee, based on the current scientific knowledge. OBJECTIVES: The aim of this study was to investigate the consistency of the newly internationally developed algorithm with the French food-based dietary guidelines (FBDG) and compare the respective performances of the initial and updated algorithm. METHODS: Three complementary French food composition databases were used to access extensive coverage of the food supply in France (n = 46,752): the Oqali, OpenFoodFacts, and CIQUAL databases. Based on the French FBDG, a list of 41 criteria was defined by which the consistency between French FBDG and the Nutri-Score was assessed (eg, consumption of fresh vegetables is promoted in FBDG, thus the Nutri-Score should rate favorably such products). RESULTS: Of all criteria, the initial algorithm met 63% (26/41) of them, whereas the revised algorithm met 85% (35/41) of them. Improvements achieved by the updated version of the Nutri-Score in alignment with the FBDG were particularly observed for high-fat products (ie, fatty fish, nuts, and seeds), sweet products (ie, ice creams and sweet spreads), salty products (ie, savory snacks and salted nuts), dairy beverages, and beverages with artificial sweeteners. CONCLUSIONS: The Nutri-Score's updated nutrient profiling system appears to rate foods more consistently regarding the French dietary guidelines and improved the currently existing system. This work supports the implementation of the updated nutrient profiling system underlying Nutri-Score.

A randomized controlled trial to test the effects of displaying the Nutri-Score in food advertising on consumer perceptions and intentions to purchase and consume.

BACKGROUND: Some research shows that advertising for high-fat, sugar, or salt (HFSS) products is contributing to a shift in consumer preferences toward products of poor nutritional quality, leading to unhealthy nutritional intakes that increase the risk of obesity and chronic diseases. A strategy of displaying simple and understandable nutritional information (like the front-of-pack nutrition label Nutri-Score) in food messages could be an aid to help guide consumers' choice towards healthier products. METHODS: A randomized controlled experiment was conducted on 27,085 participants randomly assigned to two experimental conditions or a control condition. In both experimental conditions (independent variable: advertising messages with vs. without the Nutri-Score), participants were exposed to advertisements for diversified food products with contrasting nutritional quality and belonging to nine different food categories. Participants were then asked questions about their perception, affective evaluation, and intentions to purchase and consume the products. In the control condition, they were not exposed to the advertisements. RESULTS: Overall, interaction effects between the two variables (1) the messages with vs. without the Nutri-Score and (2) the nutritional quality of products, were significant for all dependent variables, with effect sizes between large and medium. Overall, the better the products' nutritional quality, the more positive their perceptions, affective evaluations, and intentions to buy and consume them. When the Nutri-score was displayed in advertising messages (vs. when it was not), perceptions, affective evaluation, and behavioral intentions: (1) became more positive for products of good nutritional quality (Nutri-score A and B), (2) became more negative for products of poor nutritional quality (Nutri-score D and E), (3) changed little or not at all for products of intermediate nutritional quality (Nutri-Score C). CONCLUSIONS: This research is the first in the literature to demonstrate that displaying the Nutri-Score in advertising messages assists consumers in directing their choices towards healthier foods. Regulations mandating the display of the Nutri-Score in food advertising could be an effective public health measure.

Improving student diet and food security in higher education using participatory and co-creation approaches: a systematic review.

BACKGROUND: Higher education students are an important target group for public health nutrition interventions. When designing tailored and contextually relevant interventions, participatory and co-creation approaches are increasingly recognized as promising but their use and effectiveness has not been assessed in this type of population. We systematically reviewed interventions aiming to improve dietary quality and/or food security in higher education settings with the aims 1) to identify and describe their participatory and co-creation approaches and 2) to compare the effectiveness of interventions using or not using participatory and co-creation approaches. METHODS: Our search in PubMed, Google Scholar, Web of Science, EMBASE was performed in January 2023 and yielded 3658 unique records, out of which 42 articles (66 interventions) were included. Effectiveness of interventions was assessed at the individual level (longitudinal evaluations) or at the group level (repeated cross-sectional evaluations). A five-level classification was used to describe a continuum of engagement from students and other partners in the intervention design and implementation: no participation (level one), consultation, co-production, co-design and co-creation (levels two to five). To synthetize effectiveness, comparisons were made between studies without participation (level one) or with participation (levels two-five). RESULTS: Ten (24%) out of 42 studies used a participatory and co-creation approach (levels two-five). Studies using a participatory and co-creation approach reported a positive finding on individual-level outcome (i.e. overall diet quality or food group intake or food security) in 5/13 (38%) intervention arms (vs 13/31 or 42% for those without participation). Studies using a participatory and co-creation approach reported a positive finding on group-level outcomes (i.e. food choices in campus food outlets) in 4/7 (57%) (vs 8/23 or 35% in those without participation). CONCLUSIONS: Participatory and co-creation approaches may improve the effectiveness of nutrition interventions in higher education settings but the level of evidence remains very limited. More research is warranted to identify best co-creation practices when designing, implementing and evaluating nutritional interventions in the higher education setting. TRIAL REGISTRATION: PROSPERO registration number CRD42023393004.

Complementarity between the updated version of the front-of-pack nutrition label Nutri-Score and the food-processing NOVA classification.

OBJECTIVE: To compare the initial and the updated versions of the front-of-pack label Nutri-Score (related to the nutritional content) with the NOVA classification (related to the degree of food processing) at the food level. DESIGN: Using the OpenFoodFacts database - 129,950 food products - we assessed the complementarity between the Nutri-Score (initial and updated) with the NOVA classification through a correspondence analysis. Contingency tables between the two classification systems were used. SETTINGS: The food offer in France. PARTICIPANTS: Not applicable. RESULTS: With both versions (i.e. initial and updated) of the Nutri-Score, the majority of ultra-processed products received medium to poor Nutri-Score ratings (between 77·9 % and 87·5 % of ultra-processed products depending on the version of the algorithm). Overall, the update of the Nutri-Score algorithm led to a reduction in the number of products rated A and B and an increase in the number of products rated D or E for all NOVA categories, with unprocessed foods being the least impacted (-3·8 percentage points (-5·2 %) rated A or B and +1·3 percentage points (+12·9 %) rated D or E) and ultra-processed foods the most impacted (-9·8 percentage points (-43·4 %) rated A or B and +7·8 percentage points (+14·1 %) rated D or E). Among ultra-processed foods rated favourably with the initial Nutri-Score, artificially sweetened beverages, sweetened plant-based drinks and bread products were the most penalised categories by the revision of Nutri-Score while low-sugar flavoured waters, fruit and legume preparations were the least affected. CONCLUSION: These results indicate that the update of the Nutri-Score reinforces its coherence with the NOVA classification, even though both systems measure two distinct health dimensions at the food level.

The association between consideration of future consequences and food intake is mediated by food choice motives in a French adult population.

OBJECTIVES: Consideration of future consequences (CFC) distinguishes individuals who adopt behaviours based on immediate needs and concerns from individuals who consider the future consequences of their behaviours. We aimed to assess the association between CFC and diet, and testing the mediating role of food choice motives on this relationship. DESIGN: Individuals (aged ≥ 18 years) completed the CFC-12 questionnaire in 2014, at least three 24-h dietary records, and a food choice motive questionnaire. A multiple mediator analysis allowed to assess the mediating effect of food choice motives on the cross-sectional association between CFC and diet, adjusted for socio-demographic factors. SETTING: Data from the NutriNet-Santé cohort study. PARTICIPANTS: 27 330 participants. RESULTS: CFC was associated with all food choice motives (P < 0·001), with the strongest positive associations for avoidance for environmental reasons, absence of contaminants and health motives and the strongest negative associations for innovation and convenience. Positive total effects were found between CFC and the consumption of healthy food groups (fruits and vegetables, whole-grain foods, legumes), and negative total effects for alcohol, meat and poultry and processed meat (P < 0·001). CFC was positively associated with diet quality (P < 0·001). Across food groups, major mediators of these relationships were higher health (8·4-32·6%), higher environmental (13·7-22·1 %) and lower innovation (7·3-25·1 %) concerns. CONCLUSIONS: CFC was associated with healthier dietary intake, essentially mediated by a greater motivation of future-oriented participants for self-centred and altruistic outcomes, including health and environment. Focusing on the awareness of future benefits in public health interventions might lead to healthier dietary behaviours.

Dietary exposure to nitrites and nitrates in association with type 2 diabetes risk: Results from the NutriNet-Santé population-based cohort study.

BACKGROUND: Nitrites and nitrates occur naturally in water and soil and are commonly ingested from drinking water and dietary sources. They are also used as food additives, mainly in processed meats, to increase shelf life and to avoid bacterial growth. Experimental studies suggested both benefits and harmful effects of nitrites and nitrates exposure on type 2 diabetes (T2D) onset, but epidemiological and clinical data are lacking. We aimed to study these associations in a large population-based prospective cohort study, distinguishing foods and water-originated nitrites/nitrates from those from food additives. METHODS AND FINDINGS: Overall, 104,168 adults from the French NutriNet-Santé cohort study (2009 to 2021, 79.1% female, mean age [SD] = 42.7 [14.5]) were included. Associations between self-reported exposure to nitrites and nitrates (evaluated using repeated 24-h dietary records, linked to a comprehensive food composition database and accounting for commercial names/brands details of industrial products) and risk of T2D were assessed using cause-specific multivariable Cox proportional hazard models adjusted for known risk factors (sociodemographic, anthropometric, lifestyle, medical history, and nutritional factors). During a median follow-up duration of 7.3 years (interquartile range: [3.2; 10.1] years), 969 incident T2D cases were ascertained. Total nitrites and foods and water-originated nitrites were both positively associated with a higher T2D risk (HRtertile 3 vs.1 = 1.27 (95% CI 1.04 to 1.54), Ptrend = 0.009 and 1.26 (95% CI 1.03 to 1.54), Ptrend = 0.02, respectively). Participants with higher exposure to additives-originated nitrites (i.e., above the sex-specific median) and specifically those having higher exposure to sodium nitrite (e250) had a higher T2D risk compared with those who were not exposed to additives-originated nitrites (HR higher consumers vs. non-consumers = 1.53 (95% CI 1.24 to 1.88), Ptrend < 0.001 and 1.54 (95% CI 1.26 to 1.90), Ptrend < 0.001, respectively). There was no evidence for an association between total, foods and water-originated, or additives-originated nitrates and T2D risk (all Ptrend = 0.7). No causal link can be established from this observational study. Main limitations include possible exposure measurement errors and the lack of validation versus specific nitrites/nitrates biomarkers; potential selection bias linked to the healthier behaviors of the cohort's participants compared to the general population; potential residual confounding linked to the observational design, as well as a self-reported, yet cross-checked, case ascertainment. CONCLUSIONS: The findings of this large prospective cohort did not support any potential benefits for dietary nitrites and nitrates. They suggested that a higher exposure to both foods and water-originated and additives-originated nitrites was associated with higher T2D risk in the NutriNet-Santé cohort. This study provides a new piece of evidence in the context of current debates about updating regulations to limit the use of nitrites as food additives. The results need to be replicated in other populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT03335644 (https://clinicaltrials.gov/ct2/show/NCT03335644).

Stages of Change toward Meat Reduction: Associations with Motives and Longitudinal Dietary Data on Animal-Based and Plant-Based Food Intakes in French Adults.

BACKGROUND: Reducing meat consumption is advocated for healthier and more sustainable diets. However, behavioral studies are needed to better understand the mechanisms underlying meat-reducing dietary changes. OBJECTIVES: The main aim of this study was to compare the motives associated with stages of change toward meat reduction in French adults, using the transtheoretical model (TTM). A second aim was to investigate the associations between stages of change and adherence to dietary patterns favoring a better balance of animal and plant food consumption over time. METHODS: This longitudinal study included 25,143 non-vegetarian participants of the web-based NutriNet-Santé cohort with a mean follow-up of 6.2 (SD = 2.6) y. Dietary data were obtained from 24-h dietary records over the period 2009-2019. The contribution of meat to total energy intake and scores measuring the contribution of healthy and unhealthy plant-based foods to the diet were computed. A questionnaire completed in 2018 allowed us to identify the TTM stages of change related to meat reduction (precontemplation, contemplation, preparation, action, and maintenance), and recorded motives related to meat consumption. We used multivariate linear mixed models for repeated data to assess associations between food intake changes and stages, and logistic regression for motives, presented as adjusted frequencies. RESULTS: Participants in later stages were characterized by a significantly higher decrease in meat intake over time, compared with the earliest stage (for example, ßmaintenance ∗ time = -0.08, P < 0.0001), and a higher increase in the healthy plant-based food consumption score over time (for example, ßmaintenance∗time = 0.11, P < 0.0001). Concerns about health, nutrition, and the environment were the most frequently cited motives for reducing meat consumption at all stages. CONCLUSIONS: Individuals who had already initiated meat reduction adhered to healthier and more sustainable diets than meat continuers. Characterizing motives according to readiness to reduce meat consumption could support tailored public health campaigns. TRIAL REGISTRATION NUMBER: The study protocol is registered at clinicaltrials.gov with Clinical Trial Registry number NCT03335644 available at https://clinicaltrials.gov/ct2/show/NCT03335644.

Sustainability analysis of the Mediterranean diet: results from the French NutriNet-Santé study.

The Mediterranean diet is often proposed as a sustainable diet model. This study aimed to evaluate the associations between adherence to the Mediterranean diet and sustainability domains in a cohort of French adults, using multiple criteria including nutritional quality, environmental pressures, monetary cost and dietary pesticide exposure. Food intakes of 29 210 NutriNet-Santé volunteers were assessed in 2014 using a semi-quantitative FFQ. Adherence to the Mediterranean diet was evaluated using the validated literature-based adherence score (MEDI-LITE). The associations between the MEDI-LITE and various sustainability indicators were examined using ANCOVA models, adjusted for sex, age and energy intake. Higher adherence to the MEDI-LITE was associated with higher nutritional quality scores, better overall nutrient profile as well as reduced environmental impact (land occupation: Q5 v. Q1: -35 %, greenhouse gas emissions: -40 % and cumulative energy demand: -17 %). In turn, monetary cost increased with increasing adherence to the Mediterranean diet (Q5 v. Q1: +15 %), while higher adherents to the Mediterranean diet had overall higher pesticide exposure due to their high plant-based food consumption. In this large cohort of French adults, greater adherence to the Mediterranean diet was associated with nutritional and environmental benefits, but also with higher monetary cost and greater exposure to pesticides, illustrating the necessity to develop large-scale strategies for healthy, safe (pesticide- and contaminant-free) and environmentally sustainable diets for all.

Plant-based meat substitutes are useful for healthier dietary patterns when adequately formulated - an optimization study in French adults (INCA3).

PURPOSE: We studied to what extent plant-based meat substitutes could improve the nutritional adequacy and healthiness of dietary patterns, depending on their nutrient composition. METHODS: From diets observed in French adults (INCA3, n = 1125), modeled diets were identified by allowing various dietary changes, between and within food categories, when two plant-based meat substitutes were made available: an average substitute (from 43 market substitutes) and a theoretical nutritionally designed substitute, fortified or not with zinc and iron at 30% or 50% of Nutrient Reference Values. Under each scenario, healthier but acceptable modeled diets were identified using multi-criteria optimization, by maximizing a health criteria related to Dietary Guidelines while minimizing deviation from the observed diets, under constraints for nutrient adequacy. RESULTS: Without fortification, the average substitute was hardly introduced into modeled diets, whereas the optimized substitute was preferentially introduced, in large amounts, yet together with a moderate reduction of red meat (- 20%). The comparative advantages of the optimized substitute were its higher contribution to vitamins B6 and C, fiber and α-linolenic acid (ALA) intakes, and its lower contribution to sodium intake. When fortified with iron and zinc, substitutes were introduced in larger amounts into modeled diets, with much higher red meat reductions (down to - 90%). The optimized substitute continued to be preferred, leading to healthier modeled diets that deviated less from the observed. CONCLUSION: Plant-based meat substitutes can be levers for healthy diets only when well nutritionally designed with enough zinc and iron for a substantial red meat reduction.

Respective contribution of ultra-processing and nutritional quality of foods to the overall diet quality: results from the NutriNet-Santé study.

BACKGROUND: Both the nutritional quality of the foods consumed (as nutrient composition) and their ultra-processed nature have been linked to health risks. However, the respective contribution of each of these correlated dimensions or their synergy to the overall diet quality has been rarely explored. OBJECTIVE: To identify the respective effects of the nutritional quality of the foods consumed, the ultra-processed nature of foods and their cross-effect contributing to the overall quality of the diet. DESIGN: Cross-sectional observational study. SETTING: Web-based French NutriNet-Santé cohort study. PARTICIPANTS: Participants in the NutriNet-Santé cohort study with at least three available 24 h records as baseline dietary data (N = 98 454 participants). MAIN OUTCOME MEASURES: The overall quality of the diet (qualified using the adherence to the 2017 French national nutrition and health dietary recommendations dietary score PNNS-GS2) was broken down into: (1) an effect of the nutritional quality of the foods consumed (qualified using the modified Foods Standards Agency nutrient profile model (underlying the Nutri-Score) dietary index FSAm-NPS DI); (2) an effect of the ultra-processed nature of the foods consumed (qualified using the proportion of ultra-processed foods consumed UPFp using the NOVA classification), and (3) a cross-effect of both dimensions. RESULTS: The overall effect from the 'nutritional quality of the foods consumed' (FSAm-NPS DI) was 1.10, corresponding to 26% of the total effect; the overall effect from ultra-processed foods consumption was 1.29, corresponding to 30% of the total effect; and cross-effect between nutritional quality of the foods consumed and ultra-processing was at 1.91, corresponding to 44% of total effects. CONCLUSIONS: Our study provides support to the postulate that nutritional quality and ultra-processing should be considered as two correlated but distinct and complementary dimensions of the diet.

Cross-sectional comparisons of dietary indexes underlying nutrition labels: nutri-score, Canadian 'high in' labels and Diabetes Canada Clinical Practices (DCCP).

PURPOSE: To assess the cross-sectional association between dietary indexes (DI) that underlie, respectively, the Nutri-score (NS), the proposed Canadian 'High In' Symbol (CHIL) and the Diabetes Canada Clinical Practice Guidelines (DCCP) with food consumption, nutrient intakes and metabolic markers. METHODS: 1836 adults (18-74 years) participating in the representative ESTEBAN study, conducted in mainland France in 2014-2016, were included in the analysis. Food consumption was assessed with three repeated 24 h dietary recalls. Anthropometric measurements and biomarkers of metabolic risk (cholesterol-total, LDL (Low Density Lipoprotein), HDL (High Density Lipoprotein)-triglycerides, glucose) were obtained through a clinical examination and fasting blood draw. The DI were assessed for their association with food consumption, dietary intakes and metabolic biomarkers as quintiles and continuous variables using multi-adjusted linear regression. Heathier diets were assigned to lower scores. RESULTS: Correlations between scores ranged from + 0.62 between CHIL-DI and NS-DI to + 0.75 between NS-DI and DCCP-DI. All DIs discriminated individuals according to the nutritional quality of their diets through food consumption and nutrient intakes (healthier diets were associated with lower intakes of energy, added sugars and saturated fat; and with higher intakes of fiber, vitamins and minerals). NS-DI was associated with blood glucose (adjusted mean in Q1 = 5 vs. Q5 = 5.46 mmol/dl, ptrend = 0.001) and DCCP-DI was associated with BMI (Q1 = 24.8 kg/m2 vs. Q5 = 25.8 kg/m2, ptrend = 0.025), while CHIL showed no significant association with any anthropometric measures or biomarkers. CONCLUSIONS: This study provides elements supporting the validity of the nutrient profiling systems underlying front-of-package nutrition labellings (FOPLs) to characterize the healthiness of diets.

Dietary pesticide exposure and non-communicable diseases and mortality: a systematic review of prospective studies among adults.

BACKGROUND: Research on the effect of pesticide exposure on health has been largely focused on occupational settings. Few reviews have synthesized the associations between dietary pesticide exposure and health outcomes in non-occupationally exposed adults. OBJECTIVE: We aim to summarize the evidence regarding dietary pesticide exposure and non-communicable diseases (NCD) in adults, using a systematic review of prospective studies. METHODS: Electronic and manual searches were performed until July 2023. The inclusion criteria were the following: 1) adults aged ≥ 18years, 2) (non)-randomized trials, prospective cohort studies, 3) dietary exposure to pesticides. A bias analysis was carried out using the Nutrition Evidence Systematic Review guidelines based on the Cochrane ROBINS-I. RESULTS: A total of 52 studies were retrieved and 6 studies that met the above criteria were included. Studies were conducted either in France or in the United States. The studies investigated the risk of cancer (n = 3), diabetes (n = 1), cardiovascular diseases (n = 1), and mortality (n = 1). The quality of the studies varied with overall grades derived from the bias analysis ranging from low to moderate bias. The level of evidence was estimated as low for the risk of cancer while the grading was not assignable for other outcomes, as only one study per outcome was available. CONCLUSIONS: Although further research is warranted to examine more in depth the relationships between low-dose chronic exposure to pesticides through diet and NCD outcomes in non-occupationally-exposed adults, studies suggest a possible role of exposure to dietary pesticide on health. Standardized methodological guidelines should also be proposed to allow for comparison across studies.

Behavioural risk patterns in adolescents with excess weight participating in the PRALIMAP-INÈS trial.

OBJECTIVE: To investigate clustering of risk behaviours in adolescents with excess weight. DESIGN: Cross-sectional analysis of baseline data from the PRALIMAP-INÈS trial. Information on food frequency consumption (fruit, vegetables, sugary products and beverages), physical activity, sedentary behaviour (week and weekend days), smoking and alcohol consumption (current frequency and intoxication episodes) and socio-demographic data was collected using self-reported questionnaires. Behavioural risk factors were entered as categorical variables in a two-step clustering procedure: multiple correspondence analysis followed by hierarchical clustering. Associations between cluster membership and socio-demographic variables were investigated using multivariable multinomial logistic regression. SETTING: French PRALIMAP-INÈS trial. PARTICIPANTS: Adolescents with excess weight. RESULTS: A total of 1391 participants (13-18 years old, 58·2 % female) were included in the analysis, which resulted in the identification of four groups of participants, including, respectively, 543 (39·0 %), 373 (26·8 %), 246 (17·7 %) and 229 (16·5 %) participants. Clusters 1 and 4 showed associations of rather healthy behaviours (high physical activity and low consumption of sugary products; high consumption of fruit and vegetables, respectively), while clusters 2 and 3 showed associations of rather unhealthy behaviours (high sedentary behaviour and low consumption of fruit and vegetables; smoking and alcohol consumption, respectively). Both social status and family structure were associated with cluster membership. CONCLUSIONS: Risk behaviour patterns in adolescents with excess weight were clustered in both healthier and less healthy ways, with a complex interplay with socio-demographic factors.

Associations between measures of socio-economic position and sustainable dietary patterns in the NutriNet-Santé study.

OBJECTIVE: We aimed to explore the relationship between socio-economic characteristics and sustainable dietary patterns. DESIGN: Dietary data were derived from a web-based FFQ. Diet sustainability was evaluated using a modified Sustainable Diet Index, comprising nutritional, environmental and cultural components (higher scores expressing higher sustainability). The socio-economic position markers were education, household income and occupation status. Multi-adjusted linear and Poisson regression models were used to assess the cross-sectional association of the markers of socio-economic status with a sustainable diet and sustainability subcomponents, respectively. SETTING: France. PARTICIPANTS: 29 119 NutriNet-Santé participants. RESULTS: Individuals with a more sustainable diet had slightly higher diet monetary cost, lower total energy intake and consumed less animal-based foods than their counterparts. Lower education level was associated with lower overall diet sustainability (ßprimary v. postgraduate = -0·62, 95 % CI (-0·72, -0·51)) and nutrition, socio-cultural and environmental subscores. Manual workers and employees had a lower modified Sustainable Diet Index than intermediate professionals (ßmanual workers v. intermediate professionals = -0·43, 95 % CI (-0·52, -0·33) and ßemployees v. intermediate professionals = -0·56, 95 % CI (-0·64, -0·48)). Participants with the lowest v. highest incomes had a higher environmental subscore but a lower socio-cultural subscore, whereas the results were less marked for occupational status. CONCLUSIONS: Overall, our results documented associations between socio-economic status and the level of diet sustainability, arguing for the implementation of appropriate food policies to promote sustainable diets at lower cost.

Comparative understanding and preference of Nutri-Score and NutrInform Battery in a sample of Spanish consumers.

BACKGROUND: Interpretive front-of-pack labels (FoPLs) are supported by World Health Organization as an important policy tool to promote healthy diets. At present, various FoPLs formats co-exist in the European Union (EU). However, as part of the Farm to Fork strategy published in 2020, the European Commission stated that it would propose a single mandatory FoPL. The aim of this study was to analyze Spanish consumers' preference and objective understanding of Nutri-Score and NutrInform, two FoPLs that are currently the subject of debate in the EU. METHODS: In a representative sample of 1026 Spanish adults (50% women, mean age ± SD = 46 ± 14 years), objective understanding was assessed by asking participants to identify the healthiest food products in three food categories (breakfast products, breakfast cereals and added fats). The preference dimensions were tested by asking participants about the perceived helpfulness of the FoPL in discriminating the nutritional quality of food products (subjective understanding) and their overall assessment of the FoPL's ease of use, informativeness, trust and liking (perception). RESULTS: In terms of objective understanding, Nutri-Score was significantly associated with an increase in consumers' ability to identify healthier food products across all food categories compared with NutrInform [OR (odds ratio) = 19.1 [14.2-25.7], P < 0.0001]. On the preference dimension, Nutri-Score was perceived as significantly easier to use and was more liked than NutrInform (standardized principal component analysis dimension, respectively, 0.32 ± 1.58 vs. -0.29 ± 1.66, P < 0.0001 and 0.080 ± 1.18 vs. -0.072 ± 1.17, P = 0.039). CONCLUSIONS: This study provides new evidence to support Nutri-Score in comparison with NutrInform in Spanish consumers, on both objective understanding and preference aspects.

Dairy product consumption and risk of cancer: A short report from the NutriNet-Santé prospective cohort study.

The impact of dairy product consumption for long-term health remains unclear, in particular regarding their involvement in cancer etiology for frequent locations like breast or prostate. Besides, little is known about potentially different effects of dairy product subtypes. Our objective was therefore to evaluate the associations between dairy product consumption (total and subtypes) and cancer risk. A total of 101 279 participants from the French NutriNet-Santé cohort study were included (78.7% women; mean [SD] age = 42.2 [14.5] years). Dairy product consumption was assessed using validated web-based 24-hour dietary records. Multiadjusted Cox models were computed. After a median [interquartile range] follow-up time of 5.9 [2.7-8.3] years, we documented 2503 incident cancer cases (783 breast, 323 prostate and 182 colorectal cancers). Total dairy product consumption was not significantly associated with cancer. However, the consumption of "fromage blanc" (a French type of quark/cottage cheese) was associated with an increased risk of cancer overall (HR for 1 serving increment [95% CI] = 1.11 [1.01-1.21]; P-trend = .03) and of colorectal cancer (HR = 1.39 [1.09-1.77]; P-trend < .01). Besides, sugary dairy dessert consumption was directly associated with colorectal cancer risk (HR for 1 serving increment = 1.58 [1.01-2.46]; P-trend = .046]. No association was observed between the consumption of dairy products or sugary dairy desserts and the risk of prostate and breast cancers. In our study, the consumption of dairy products was not associated with the risk of overall, colorectal, breast or prostate cancers. The consumption of "fromage blanc" and sugary dairy desserts were associated to an increased risk of colorectal cancer, but this warrants further investigations.

Artificial sweeteners and cancer risk: Results from the NutriNet-Santé population-based cohort study.

BACKGROUND: The food industry uses artificial sweeteners in a wide range of foods and beverages as alternatives to added sugars, for which deleterious effects on several chronic diseases are now well established. The safety of these food additives is debated, with conflicting findings regarding their role in the aetiology of various diseases. In particular, their carcinogenicity has been suggested by several experimental studies, but robust epidemiological evidence is lacking. Thus, our objective was to investigate the associations between artificial sweetener intakes (total from all dietary sources, and most frequently consumed ones: aspartame [E951], acesulfame-K [E950], and sucralose [E955]) and cancer risk (overall and by site). METHODS AND FINDINGS: Overall, 102,865 adults from the French population-based cohort NutriNet-Santé (2009-2021) were included (median follow-up time = 7.8 years). Dietary intakes and consumption of sweeteners were obtained by repeated 24-hour dietary records including brand names of industrial products. Associations between sweeteners and cancer incidence were assessed by Cox proportional hazards models, adjusted for age, sex, education, physical activity, smoking, body mass index, height, weight gain during follow-up, diabetes, family history of cancer, number of 24-hour dietary records, and baseline intakes of energy, alcohol, sodium, saturated fatty acids, fibre, sugar, fruit and vegetables, whole-grain foods, and dairy products. Compared to non-consumers, higher consumers of total artificial sweeteners (i.e., above the median exposure in consumers) had higher risk of overall cancer (n = 3,358 cases, hazard ratio [HR] = 1.13 [95% CI 1.03 to 1.25], P-trend = 0.002). In particular, aspartame (HR = 1.15 [95% CI 1.03 to 1.28], P = 0.002) and acesulfame-K (HR = 1.13 [95% CI 1.01 to 1.26], P = 0.007) were associated with increased cancer risk. Higher risks were also observed for breast cancer (n = 979 cases, HR = 1.22 [95% CI 1.01 to 1.48], P = 0.036, for aspartame) and obesity-related cancers (n = 2,023 cases, HR = 1.13 [95% CI 1.00 to 1.28], P = 0.036, for total artificial sweeteners, and HR = 1.15 [95% CI 1.01 to 1.32], P = 0.026, for aspartame). Limitations of this study include potential selection bias, residual confounding, and reverse causality, though sensitivity analyses were performed to address these concerns. CONCLUSIONS: In this large cohort study, artificial sweeteners (especially aspartame and acesulfame-K), which are used in many food and beverage brands worldwide, were associated with increased cancer risk. These findings provide important and novel insights for the ongoing re-evaluation of food additive sweeteners by the European Food Safety Authority and other health agencies globally. TRIAL REGISTRATION: ClinicalTrials.gov NCT03335644.

Ultra-processed foods and cancer risk: from global food systems to individual exposures and mechanisms.

Ultra-processed foods (UPFs) have become increasingly dominant globally, contributing to as much as 60% of total daily energy intake in some settings. Epidemiological evidence suggests this worldwide shift in food processing may partly be responsible for the global obesity epidemic and chronic disease burden. However, prospective studies examining the association between UPF consumption and cancer outcomes are limited. Available evidence suggests that UPFs may increase cancer risk via their obesogenic properties as well as through exposure to potentially carcinogenic compounds such as certain food additives and neoformed processing contaminants. We identify priority areas for future research and policy implications, including improved understanding of the potential dual harms of UPFs on the environment and cancer risk. The prevention of cancers related to the consumption of UPFs could be tackled using different strategies, including behaviour change interventions among consumers as well as bolder public health policies needed to improve food environments.

Associations between Resilience and Food Intake Are Mediated by Emotional Eating in the NutriNet-Santé Study.

BACKGROUND: Resilience, the ability to bounce back or recover from stress, has been associated with several health-related behaviors. However, data on food intake and emotional eating are lacking. OBJECTIVES: The objective of this cross-sectional study was to analyze the associations between resilience and diet quality and ultraprocessed food (UPF) and food group consumption, and to assess whether emotional eating was a mediator of these associations. METHODS: In 2017, 17,840 participants (73.5% female, mean age = 55.4 ± 14.0 y) of the NutriNet-Santé study completed the Brief Resilience Scale, the revised 21-item Three-Factor Eating Questionnaire, and ≥3 self-administered 24-h dietary records. Diet quality was assessed with the modified French National Nutrition and Health Program Guideline Score. Foods and beverages consumed were categorized according to their degree of processing by the NOVA classification. We assessed the association between resilience and emotional eating using linear regression models. We also assessed the mediating role of emotional eating in the associations between resilience and diet quality, energy intake, and UPF and food group consumption, controlling for sociodemographic characteristics. RESULTS: In our study, resilience was negatively associated with emotional eating (P < 0.0001). More resilient participants had greater overall diet quality, greater intakes of seafood, whole-grain foods, fats, unsalted oleaginous fruits, and alcoholic beverages, and lower intakes of UPFs, starchy foods, dairy desserts, sugary fatty products, and sugar and confectionery (all P < 0.05). Emotional eating was a mediator of the inverse associations between resilience and intake of energy, UPFs, dairy desserts, sugary fatty products, and of the positive associations between resilience and alcoholic beverages (all P < 0.05), with a 20-70% mediation. CONCLUSIONS: Our findings showed that resilience was associated with an overall better diet quality in the NutriNet-Santé population-based study. These associations were partially explained by emotional eating. These findings suggest that resilience should be considered in the promotion of healthy dietary habits.The study is registered at clinicaltrials.gov as #NCT03335644.