Use of Added Sugars Instead of Total Sugars May Improve the Capacity of the Health Star Rating System to Discriminate between Core and Discretionary Foods

Background The Australian Government has introduced a voluntary front-of-package labeling system that includes total sugar in the calculation. Objective Our aim was to determine the effect of substituting added sugars for total sugars when calculating Health Star Ratings (HSR) and identify whether use of added sugars improves the capacity to distinguish between core and discretionary food products. Design This study included packaged food and beverage products available in Australian supermarkets (n = 3,610). The product categories included in the analyses were breakfast cereals (n = 513), fruit (n = 571), milk (n = 309), non-alcoholic beverages (n = 1,040), vegetables (n = 787), and yogurt (n = 390). Added sugar values were estimated for each product using a validated method. HSRs were then estimated for every product according to the established method using total sugar, and then by substituting added sugar for total sugar. The scoring system was not modified when added sugar was used in place of total sugar in the HSR calculation. Products were classified as core or discretionary based on the Australian Dietary Guidelines. To investigate whether use of added sugar in the HSR algorithm improved the distinction between core and discretionary products as defined by the Australian Dietary Guidelines, the proportion of core products that received an HSR of >= 3.5 stars and the proportion of discretionary products that received an HSR of < 3.5 stars, for algorithms based upon total vs added sugars were determined. Results There were 2,263 core and 1,347 discretionary foods; 1,684 of 3,610 (47%) products contained added sugar (median 8.4 g/100 g, interquartile range = 5.0 to 12.2 g). When the HSR was calculated with added sugar instead of total sugar, an additional 166 (7.3%) core products received an HSR of >= 3.5 stars and 103 (7.6%) discretionary products received a rating of >= 3.5 stars. The odds of correctly identifying a product as core vs discretionary were increased by 61% (odds ratio 1.61, 95% CI 1.26 to 2.06; P< 0.001) when the algorithm was based on added compared to total sugars. Conclusions In the six product categories examined, substitution of added sugars for total sugars better aligned the HSR with the Australian Dietary Guidelines. Future work is required to investigate the impact in other product categories.