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To our knowledge, our group was the first to investigate the associations between the FSA-NPS DI and health outcomes.

Using prospective designs, studies were conducted in the SU. MAX cohort (13 017 participants, 1994–2007) on the associations between the FSA-NPS DI and 13-year weight gain/obesity onset,19 metabolic syndrome,20 cardiovascular diseases21 and cancer.22 A higher FSA-NPS DI, reflecting a diet of lower nutritional quality, was associated with an increased risk for all the studied outcomes and, in particular, with an increased risk of cancer overall.22 No significant association with breast cancer risk was detected in this study,22 but the statistical power was limited for site-specific analyses (n=125 breast cancer cases).

The present study aimed at investigating the relationship between the FSA-NPS DI and breast cancer risk.

Primary outcome measure Associations between FSA-NPS DI and breast cancer risk (555 incident breast cancers diagnosed between 20) were characterised by multivariable-adjusted Cox proportional hazard models.=1.09 (1.01–1.18) and 1.05 (1.00–1.11), respectively).

At inclusion, participants fulfilled a set of five questionnaires on sociodemographic and lifestyle characteristics24 (eg, occupation, educational level, smoking status, alcohol consumption and number of children), anthropometrics25 26 (eg, height, weight), dietary intakes (see below), physical activity (validated IPAQ questionnaire)27 and health status (eg, personal and family history of diseases, medication use including hormonal treatment for menopause and oral contraception and menopausal status).

To assess its potential public health relevance, studies were conducted on the association between the nutritional quality of the diet, measured at the individual level by an energy-weighted mean of all FSA-NPS scores of foods usually consumed (FSA-NPS dietary index (FSA-NPS DI)), and the risk of chronic diseases.

This study was based on an observational cohort using self-reported dietary data, thus residual confounding cannot be entirely ruled out.

Finally, this holistic approach does not allow investigating which factors in the diet most specifically influence breast cancer risk.

This scoring system was initially developed and validated in the UK, where it is used for advertising regulation,8 9 11 12 and it has been adapted and validated in the French context.13–16 At the individual level, the nutritional quality of the diet can be characterised with a dietary index based on the FSA-NPS (FSA-NPS DI).

The FSA-NPS DI has been associated to food and nutrient intakes, nutritional status and adherence to the French nutritional recommendations.17 18To evaluate the relevance and potential public health impact of the 5-CNL adoption, it is important to assess whether there is a relationship between the nutritional quality of food choices at the individual level, as graded by the FSA-NPS DI, and the occurrence of nutrition-related chronic diseases.

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