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So far in 2014 we have seen extensive media coverage on sugar in our diet, starting with a post-Christmas surge in stories about harm caused by sugar. In her annual report on the State of the Public's Health,1 Professor Dame Sally Davies, England's Chief Medical Officer, stated that average consumption of added sugar is higher than recommended among adults and children of all ages. Almost a third of the added sugar in the average diet of secondary school age children (aged 11–18) is from soft drinks, including carbonated drinks, smoothies, and fruit juices with added sugar. She suggested that if voluntary efforts do not reduce added sugar in our daily food, then we, as a society, may need to consider the public health benefits of regulation such as a ‘sugar tax’.
In January this year, the new campaign group ‘Action on Sugar’ was launched, comprising a group of medical, dental and public health specialists concerned with sugar and its effects on health.2 Added sugar in our diets is contributing to obesity, type II diabetes and tooth decay. It states that it will carry out a public health campaign to help the public avoid foods with hidden added sugars. It also identifies Children as a particularly vulnerable group. It urges the World Health Organization (WHO) to recommend reducing sugar intake to below 5% of daily calories.
In March 2014, WHO consulted on its draft guidance on recommended daily sugar intake before it publishes its latest advice.3 The current WHO guidelines, published based on best evidence available in 2002,4 state that sugars should make up less than 10% of total energy intake per day. The key concern is that an unhealthy diet results in weight gain and increased risk of noncommunicable diseases (NCDs). Dental caries is one of the most prevalent NCDs globally and, despite great improvements in its prevention and treatment in the past decades, it continues to cause pain, anxiety, functional limitation and social handicap through tooth loss for large numbers of people worldwide.
WHO commissioned two systematic reviews to inform its latest draft guidelines. One review looked at the effect of restricting sugar intake on dental caries. It found that incidence of caries is lower when intake of free-sugars is less than 10%, with some evidence that this is significant when the intake is less than 5%.5 So what are free sugars and what does 5% energy intake translate to?
We have a duty of care to help our patients better understand how frequent consumption of free sugars leads to dental caries as well as impacting their overall health, and provide clear advice on not just to reduce its intake but, more importantly, on where to find it and what to replace it with. The main culprit is free or refined sugar added to most processed foods, including savoury ones, from obvious sugary drinks, smoothies and yoghurts to soups and ready meals. Cariogenic bacteria being simple creatures thrive most on the readily available, refined simple sugars that have been extracted and ‘freed’, whereas whole fruits contain ‘natural’ sugar and also provide a wealth of other nutrients. Processed juice made from concentrate, even with no sugar added, has its natural sugar content extracted and made more readily available by the manufacturing process. Current food labelling informs on the amount of carbohydrate it contains, and what portion of it is sugar, but not on how much processed free sugar has actually been added.
An intake of 5% energy is equivalent to around 25 grams or six teaspoons of sugar a day for a healthy adult. The WHO's suggested limits apply to all sugars, including ‘hidden’ free sugars added to foods, as well as sugars naturally present in fruit juices and honey. Just one can of fizzy drink contains over 30 grams of sugar, already over the daily adult ration. How can we help parents? The Change4Life ‘Smart Swaps’ campaign advises that a healthier alternative to changing to sugar-free drinks is to swap to lower-fat milk or water.6 We need to advise on healthier choices as well as fewer hidden sugars.
Helping to bring about a change in dietary habits is complex. We need to understand factors that influence behaviour change and our role in supporting our patients. The 3rd edition of ‘Delivering Better Oral Health – An evidenced based toolkit for prevention’, due to be published soon, will have a new section on behaviour change. Additionally, there will be an updated healthy eating section including the ‘eat well plate’. These new and updated sections will help dental teams communicate appropriate dietary advice to all patients, to complement the role of fluoride and effective oral hygiene advice for optimum oral health.