Citation: Vlassopoulos, A.; Katidi, A.; Savvidou, T.; Kapsokefalou, M. Alignment of Nutri-Score with Mediterranean Diet Pyramid: A Food Level Analysis. Nutrients 2022, 14, 5097. https://doi.org/10.3390/ nu14235097 Academic Editor: Laura Di Renzo Received: 31 October 2022 Accepted: 28 November 2022 Published: 1 December 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). nutrients Article Alignment of Nutri-Score with Mediterranean Diet Pyramid: A Food Level Analysis Antonis Vlassopoulos , Alexandra Katidi, Tereza Savvidou and Maria Kapsokefalou * Laboratory of Chemistry and Food Analysis, Department of Food Science and Human Nutrition, Agricultural University of Athens, 11855 Athens, Greece * Correspondence: kapsok@aua.gr Abstract: The Mediterranean diet (MD) has been incorporated as a healthy diet pattern in food-based dietary guidelines of countries all over Europe and the world. Testing the alignment of Nutri-Score with the MD Pyramid is a key step in ensuring that future food-level policies will not be conflicting with existing dietary guidelines. All foods available (n = 4002) in the HelTH database, were classified as eligible or not for inclusion in the MD and they were ranked in their respective tier in the food pyramid following two pyramid schemes, the 1995 traditional and 2020 sustainable MD pyramids. For all foods, Nutri-Score was calculated both as the continuous FSAm-NPS score and its categorical outcome—Nutri-Score grades—and their distribution across the MD pyramid tiers was used as a measure of alignment between the MD and the Nutri-Score algorithm. Only 25% of all foods were eligible under the traditional MD, while the sustainable MD covered ~58% of all foods. For both pyramids, Nutri-Score was successful in clearly separating the foods at the top and the bottom of the pyramids (Nutri-Score Mode “D” or “E” for the top tiers and “A” for the bottom tiers), thus suggesting a good alignment between the two. Good discriminatory capacity was also seen within each tier. Keywords: Mediterranean diet; Nutri-Score; front-of-pack labelling 1. Introduction The Mediterranean diet was firstly introduced for its health promoting benefits nearly three decades ago [1] and we recently celebrated a decade of it being recognized as an intangible world heritage monument [2]. In this period, the Mediterranean diet has been promoted across the globe as a healthy dietary pattern and incorporated into multiple policy actions in issues relating equally to health and agriculture/food promotion [3–7]. As research data continue to emerge confirming the role of Mediterranean diet adher- ence to longevity [8,9], new concepts and metrics are being developed in order to translate dietary guidelines into actionable food and nutrition policy interventions [10]. One such approach is the use of nutrient profiling to develop front-of-pack labeling (FOP) schemes that can effectively guide food choices in line with the existing dietary guidelines [10]. Nutri-Score is one such scheme that converts the nutritional content of foods into a five-tier score ranging from A to E (green to red) from healthier to less healthy choices within food groups [11]. The Nutri-Score scheme has been so far validated through research as a system that could successfully promote longevity and reduce mortality from non-communicable dis- eases [12,13]. However, more research is needed to understand how this system would operate in the food market and among consumers and, thus its maturity as a tool of public health policy [14]. A great volume of the research is focused on the consumer understanding of Nutri- Score [15] and its ability to discriminate foods successfully based on their nutritional composition [16–18]. However, an important element to be studied is whether Nutri-Score Nutrients 2022, 14, 5097. https://doi.org/10.3390/nu14235097 https://www.mdpi.com/journal/nutrients