In these two prospective cohorts, consumption of foods with higher ratings based on the ONQI algorithm was associated with lower risk of chronic disease and total mortality over 20 years of follow-up. Higher ONQI-f scores were associated with a 9%–12% lower risk of chronic disease and a 10%–11% lower risk of all-cause mortality. These associations were driven by strong associations with risk of CVD and diabetes. The ONQI-f score was not significantly associated with risk of cancer. The ONQI score is one of many nutrient profiles and the NuVal™ Nutritional Scoring System is one of the many front-of-package labeling schemes currently used in the marketplace; to our knowledge this is the first system to be evaluated against health outcomes
The attention surrounding front-of–package labeling grew rapidly after the launch of the now defunct Smart Choices Program, which was developed by the Keystone Center and aimed to identify smarter choices within 19 specific product categories on the basis of nutrient profiles and food group content.28
The appearance of the Smart Choice symbol on food products such as sugar-sweetened cereals and high–saturated fat foods sparked a flurry of criticism from Congress,29
as well as the attorney general of Connecticut.30
This has prompted the FDA to address the issues and challenges of nutrition labeling, including plans to work with the food industry to develop a uniform and optimal approach to communicate nutrition-related information on food products.31, 32
The FDA recognizes the potential benefits of front-of-package labels33
, however, a large number of existing rating systems could overwhelm consumers, and minimize consumer confidence in any food product labels.
The FDA is currently conducting consumer research to evaluate the effectiveness of front-of-package labels.30
However, if the FDA opts to adopt or create a standardized front-of-package labeling system, it is imperative that the system is based on the best available scientific evidence. The goal of the front-of-package label is to communicate the healthfulness of the food, thus it is essential that the scoring system predicts lower risk of chronic disease. Second, the system should apply the same nutritional criteria to all food products, to allow for equal comparisons across all foods, rather than only selected foods that meet specified nutritional criteria or different food groups. Finally, the label should provide consumers with a quick and clear way to distinguish foods that are less healthy and should be consumed less frequently and foods that are healthy and should be consumed often.
Whether the FDA should develop or regulate front-of-package labels is controversial. Some critics argue that current labels are misleading, due to the lack of verification of the health claims and the selective presentation of healthy nutrients while ignoring harmful nutrients within the same food.34
However, if based on strong scientific evidence, a front-of-package label could provide consumers with a simple method to make point of purchase choices. Furthermore, a comprehensive front-of-package label would account for the levels of beneficial and unhealthful components of a food item.
Beyond consumer education, front-of-package labeling may also lead to overall improvement in the healthfulness of the food supply, as manufacturers may reformulate food products to earn higher scores.4, 13, 35
However, this may lead to the manipulation of the nutrient content of unhealthy food products, to increase a food’s rating score without meaningful improvement in nutritional quality.34
It may be useful to place a cap on the contribution of a micronutrient in any FOP scoring system, as done with the ONQI score, to avoid artificially inflated levels of nutrients from fortification or processing.
This analysis of the ONQI algorithm has several limitations. First, the food items on the FFQ do not distinguish between brand names and processing methods, such as canned, fresh and frozen forms of many produce items. These differences may be a large source of variation in nutrient composition in food products. For example, canned green beans have an ONQI score of 59, but canned without salt and fresh-frozen green beans have a score of 100. In the commercial application of the NuVal™ Nutritional Scoring System, the ONQI algorithm is used to generate a unique score for each branded product, matched to the unique product code (UPC). Second, in this analysis, the ONQI score of the diet was measured only once at baseline. A single measure of diet is prone to measurement error, and does not account for changes in diet, or in the food supply, over the course of follow-up. Additionally, self-reported diet assessed by the FFQ used in this cohort has had good validity when compared with weighed dietary records or biomarkers of intake19-21
, but is nevertheless imperfect. These sources of misclassification should be random with respect to disease risk and will usually lead to underestimation of associations.
Finally. the ONQI algorithm and NuVal™ Nutritional Scoring System were designed to measure nutritional quality at a food level, and not for an overall diet evaluation, which accounts for total energy balance, distribution of food intake and variety of foods. Even foods with a high ONQI score, relative to other foods, should not be consumed in unlimited amounts, thus quantity of total food must be accounted for. The ONQI-f score was adjusted for the total number of servings of food to account for this, and to evaluate the average ONQI score across the diet.
The ONQI score and several existing front-of-package labels portray a food’s overall nutritional value in the form of a single number, number of checkmarks or stars, or a single symbol, thus consumers must accept these scores and symbols at face value. Therefore, it is necessary to provide consumers with a rigorous validation of these labels to truly distinguish between healthful and less-healthful foods, which potentially could enhance consumer confidence of these labels. For this analysis, incidence of disease was considered as a measure of nutritional quality and healthfulness. In other words, a food that is identified as having a high “nutritional quality” should be associated with lower risk of disease and foods identified as “low quality” should be associated with higher risk of disease.
In conclusion, the ONQI algorithm which incorporates over 30 nutrients, food properties and magnitude of association with disease, was associated with lower risk of chronic disease and total mortality. Front-of-package labeling has the potential to help consumers select foods that contribute to a healthy diet and lower risk of disease. Future research on nutrient profiles and front-of-package labeling should use similar techniques to evaluate the ability of the scoring scheme to distinguish between more- and less-healthful foods as they relate to risk of future disease.