Is it possible to develop a global nutrient profile model?

Mike Rayner

British Heart Foundation Health Promotion Research Group

IUNS 20th International Conference of Nutrition, Granada, Spain, 15 -20 September 2013. Parallel Symposium on Nutrition Profiling

Presentation aims

• Explain why we need nutrient profiling at all

• Outline the general principles of nutrient profiling

• Consider what we mean by a global nutrient profile model – World-wide? Regional?

– For every conceivable/more than one application?

• Suggest a practical way forward: – Developing a common nutrient profile model for

marketing restrictions in Europe

A definition

• Nutrient profiling is:

’The science of classifying or ranking foods according to their nutritional composition for reasons related to preventing disease and promoting health’

Source: WHO, Guiding Principles and

Framework Manual for the development or adaptation of nutrient profile models. in press.

WHO Manual

• Definition and guiding principles

• Module 1: Planning

• Module 2: Development and adaptation

• Module 3: Validation

• Module 4: Implementation, monitoring and evaluation

FSA/Ofcom model

Points 0 1 2 … 10

Energy (kJ) ≤335 ≤670 ≤1005 … >3350

Sat fat (g) ≤1.0 ≤2.0 ≤3.0 … >10.0

Total sugar (g) ≤4.5 ≤9 ≤13.5 … >45.0

Sodium (mg) ≤90 ≤180 ≤270 … >900

5

Protein (g)* ≤1.6 >1.6 >3.2 … >8.0

Fibre (NSP) (g) ≤0.7 >0.7 >1.4 … >3.5

Fruit, Veg & Nuts

(g)

≤40 >40 >60 … >80

Healthy/Intermediate food = 3 or less

Healthy/Intermediate drink = 0 or less

Unhealthy food = 4 or more

Unhealthy drink = 1 or more

For both food and drinks: scores are

based on the content of nutrient

in 100g.

*If food scores 11 for protein, fibre and F&V then

scores 0 for protein except if scores 5

for FV&N

Can be advertised Cannot be advertised Wholemeal and white bread

Muesli and wheat biscuit cereal

with no added sugar

Fresh fruit

Most nuts

Takeaway salads with no dressing

or croutons

Most brands of baked beans

Some brands of baked oven chips

Some brands of chicken nuggets

Fish fingers

Chicken breast

Unsweetened fruit juice

Skimmed, semi-skimmed and

whole milk

Diet cola

Potato crisps

French fries

Most breakfast cereals

Raisins and sultanas

Cheddar cheese, half and full fat

Butter and margarine

Most sausages and burgers

Cookies

Confectionary

Peanut butter

Mayonnaise, reduced and full

calorie

Most pizzas

Sweetened milkshakes

Cola and other carbonated

sweetened drinks

The ‘4 Ps’

of marketing

theory

Voluntary public

health interventions

Public health

regulation

1. Product Product reformulation Compositional

standards

2. Promotion

(advertising)

Front-of-pack labelling

Advertising regulation

Health and nutrition

claims legislation

Advertising regulation

3. Place

(availability)

Place-based

promotions

Standards for public

provision (schools,

hospitals)

4. Price Price-based based

promotions

Agricultural subsidies

Health-related taxes

Specific applications of nutrient profiling

Module 3 of the manual: validating a nutrient profile model

• ‘Subjective’ judgements using a panel of nutritionists and a set of indicator foods

• Quantitative comparisons with views of expert nutritionists

• Comparison with currently achieved diets

• Comparison with theoretical diets

• Prediction of health outcomes

US ONQI model, Nurses’ Health Study

*Adjusted for age, energy intake,

smoking, aspirin, exercise, alcohol intake,

family history of MI, family history of

cancer, history of hypertension and

history of high cholesterol and BMI

Source: Chiuve SE, Sampson L, Willett WC.

The association between a nutritional quality

index and risk of chronic disease. Am J Prev

Med. 2011 May;40(5):505-13.

*

Alternatives to nutrient profiling

• Lists of healthy and unhealthy foods

• Classification systems based on level of processing

Whoa! Croissants, muffins, doughnuts, sweet rolls, crackers made with transfats, sweetened breakfast cereals

Missing from this list Crumpets, currant buns, crackers made without transfats, muesli.

Classifies foods into Ultra-processed Processed Ingredients Foods

Classifies foods into: Ultra-processed: Processed: Ingredients: Foods:

N= 382 Food (1) Ingredient (1) Processed (1) Ultra-processed (1)

Food

(2) 19%

Ingredient

(2) 10%

Processed

(2) 16%

Ultra-

processed

(2)

55%

Two researchers were asked to use the system to classify 382 Tesco foods

N= 382 Food (1) Ingredient (1) Processed (1) Ultra-processed (1)

Food

(2) 49 1 5 0

Ingredient

(2) 5 40 5 2

Processed

(2) 13 0 48 5

Ultra-

processed

(2)

5 0 15 192

Agreement 86%, expected agreement 36%, Kappa 0.78

Two researchers were asked to use the system to classify 382 Tesco foods

% of foods, ingredients, processed and ultra -processed that are unhealthy (according to FSA/Ofcom)

0102030405060708090

100

Unhealthy

Not unhealthy

WHO Manual • Definition and guiding principles

• Module 1: Planning

• Module 2: Development and adaptation

• Module 3: Validation

• Module 4: Implementation, monitoring and evaluation

Field testing workshops: South Africa, 14-15 April 2011 Canada, 7-9 June 2011 Thailand, 13-15 June 2011 Norway, 6-7 December 2011 Slovenia, 12-13 April 2012 United Arab Emirates, 8-10 May 2012

Lessons learnt from field testing the manual

• It’s easier to adapt an existing model than to develop a new model from scratch

Module 2b of the manual: adapting an existing nutrient profile model

• Choose an existing model

• Run that model against a sample of say 200 foods from your country

• Compare the model’s classifications against those of a few other models

• Modify model e.g. by creating exemptions, adding categories, changing thresholds/points awarded, etc.

FSA/Ofcom → FSANZ model

• Additional category – Beverages

– ‘Edible oils, edible oil spreads, butter and margarine, and cheese and processed cheese with a calcium level of more than 320 mg/100 g’

– All other foods

• Other minor changes e.g. – 0 points for < 5.0 g/100g of sugar rather than 4.5

– Fibre points for all foods but not drinks

Uses of the FSA/Ofcom model around the world

• Regulating tv advertising of foods to children (in UK, Ireland and New Zealand)

• Voluntary restrictions on the marketing of foods to children in general (McDonalds)

• Regulating health claims (in Australia/New Zealand and South Africa)

• Food labelling (in Australia/New Zealand)

• Monitoring food marketing spend (in US by Rudd Centre, Yale University), advertising exposure (in UK by Newcastle University)

• Setting targets for /scoring a food company’s product portfolio (in UK by Pepsico and by Access To Nutrition Index )

• Consumer education (in Australia (Food Switch ‘app’ for mobile phones))

Lessons learnt from field testing the manual

• It’s easier to adapt an existing model than to develop a new model from scratch

• A model developed for say the UK can be adapted for quite a different county say South Africa

• Some countries do not have the resources to develop their own models and need help

• Some countries want a model for a specific application and some want a model for lots of different applications.

• It is possible to develop regional (rather than country-specific) models

Outlining a process for developing a regional nutrient profile model for one

application

• Draft of 4th March 2013

• 119 models indentified,

54 met the inclusion

criteria

• 12: food labelling;

11: school food provision;

9: marketing restrictions

• Only 19 of the included

models have been

validated in any way

WHO Catalogue of Nutrient Profile Models

Models for regulating the marketing of food to children

Country Responsible agency Expressly for marketing restrictions

EJCN Paper

EHN report

Brazil National Health Surveillance Agency (ANVISA)

x x

Denmark Danish Food and Drink Federation

x x x

Korea Korea Food and Drug Institution x

UK Food Standards Agency (FSA) x x x

United States Center for Science in the Public Interest

x x

Multi-national Pepsico x x

Multi-national Disney x x

Europe EU Pledge Nutrition Criteria x x x

N&S America PAHO x

Sweden Swedish National Food Administration (Swedish keyhole)

x

Healthy Unhealthy

FSA/Ofcom model Nordic keyhole

Comparing nutrient profile model: strictness and agreement

50%

allowed

25%

allowed

Percentage

agreement :

3/4 = 75%

Kappa = 0.5

European Heart Network study to compare different nutrient profile models: methods

• Sample of 336 foods and drinks advertised to children in 2008 (weighted by number of advertisements)

• 14 commercial television channels most popular with children aged 4-16 years in the UK

• Television recordings of one week day and one weekend day every month (from 6am until 10pm) during the study period (January – December 2008).

• Original dataset 458 different food advertisements broadcast on a total of 18,888 occasions

• Individual foods, meals and brands treated specially • Nutritional data supplemented with data for equivalent

foods from the UK nutrient databank

European Heart Network study: models

• Models already used to regulate marketing of foods to children: FSA/Ofcom, Danish, EUPNC

• Models proposed for use in regulating marketing of foods to children: Keyhole, Choices International, Norwegian

• http://www.ehnheart.org/publications/publications/publication/705-ehn-research-on-nutrient-profile-model.html

Model

Kca

l/ k

J

Ad

de

d S

uga

r

Tota

l su

gar

Fat

Satu

rate

d F

at

Tran

s fa

t

Ch

ole

ste

rol

Sod

ium

/ Sa

lt

Pro

tein

Fib

re

Vit

amin

s/M

ine

rals

Tota

l Nu

trie

nts

Cat

ego

rie

s

Bas

e

EUPNC y y y y y y y y 8 8* Combination

UK y y y y y y 6 2 /100g

Keyhole y y y y y y y 7 25* Combination

Norwegian y y y y y 5 8 /100g

Danish y y 2 10 /100g

Choices International y y y y y y 6 9* Combination

Totals

5

2

5

4

5

1

0

5

2

3

1

European Heart Network study: characteristics of six models

* With subcategories

Model

Number of foods

Percentage

of foods approved

Number of foods,

weighted by ad frequency

Percentage of foods, weighted

by ad frequency

EU PNC 86 26 3758 32

UK 134 40 5571 47

Keyhole 16 5 642 5

Norwegian 151 45 4936 42

Danish 124 37 3828 33

Choices International 21 6 724 6

European Heart Network study: overall strictness

EHN Study: overall agreement between the six models

EUP

NC

UK

Keyh

ole

No

rweg

ian

Dan

ish

Ch

oic

es

Inte

rnat

ion

al

EUPNC 0.3949

*

0.0451 0.2657

*

0.2144

*

0.0287

UK 0.1206 0.3074

*

0.4933

**

0.0967

Keyhole 0.1479 0.2138

*

0.0070

Norwegian 0.5342

**

0.0385

Danish

0.0923

Choices International

P

e

r

c

e

n

t

a

g

e

Practical differences between models

• Subjective aspects to models:

– Categorising foods for models with many categories

• Information about the foods:

– Standard serving sizes

– Compositional information

Conclusions: Is a global model possible

Global Regional National

All applications

x x

(?)

One application

x

Spare slides

Links to original and modified versions of the

FSA/Ofcom model • FSA Ofcom model

• http://www.publichealth.ox.ac.uk/bhfhprg/publicationsandreports/acad-publications/bhfhprgpublished/nutrientprofilemodel

• Nutrient Profiling Calculator (FSANZ model) • http://www.foodstandards.gov.au/industry/claims/pages/nutrientp

rofilingcalculator/Default.aspx

• Proposed South African model for regulating health claims • http://www.doh.gov.za/docs/npc_nwu/NPC_NWU.html