It’s time we did something about sugar

sugar-caries

I saw this image in the paper:

Sheiham, A., & James, W. P. T. (2014). A reappraisal of the quantitative relationship between sugar intake and dental caries: the need for new criteria for developing goals for sugar intake. BMC Public Health, 14(1), 863.

It’s a very graphic illustration of the central role played by dietary sugar in tooth decay. Certianly makes one think about how to drastically reduce our dietary sugar intake.

There are a couple of “take home messages” in the paper:

“Sugar is the primary cause of dental caries”

Ths seems to have been debated in the past but is now widely accepted. Because acid attack arising from sugar metabolism is the only mechanism for inducing caries:

“the only confounding factors i.e. tooth brushing and the use of fluoride in drinking water or toothpaste serve to reduce the magnitude of the simple relationship between sugar intake changes and caries incidence.”

However fluoride is not a “silver bullet:”

“although fluoride reduces caries, unacceptably high levels of caries in adults persist in all countries, even in those with widespread water fluoridation and the use of fluoridated toothpastes [21].”

We shouldn’t neglect adult tooth decay

Perhaps we have been underestimating the problem because the apparent improvement in oral health comes from considering data for children:

“The sugar-caries relationship in adults has been largely ignored: all the conclusions on safe levels of sugar and the relationship between sugar and caries are based on children’s data. With fluoride and greater dental care caries has declined in children so some dental authorities have concluded that sugars are not a major determinant of caries provided fluoride toothpaste is use diligently with or without water fluoridation. However, it is now evident that the majority of caries occurs in adults, not in children, because the disease is cumulative and the rates of caries in individuals tracks from early childhood to adolescence and then into adulthood [21,26]. So the conclusion that sugar is not the major determinant of caries, is simply wrong.”

The impact of fluoride

Anti-fluoride propagandists are already quoting this research – using the central role of sugar to imply this proves fluoride is ineffective. But the authors say:

“Fluoride is associated with about 25% lower caries experience when sugar intakes are constant between 10-15%E [10-15% of energy itnake from sugar]  in 12 year-old children [20]. The widescale use of fluoride toothpaste is a reasonable explanation for the decline in children’s caries in many countries since the 1970s, yet what then becomes relatively evident is that caries becomes more prominent in adolescents and adults [4,21].

Ireland has had a mandatory national water fluoridation policy since 1964 but some areas have not implemented the fluoridation policy thereby allowing a comparison within a country where fluoride toothpaste is in widespread use but drinking water fluoride varies. Additional benefits accrued from having fluoride in water as well as toothpastes but 7.3% of even the youngest adults aged 16-24 years with lifelong fluoride exposure still had dental caries experience in 4.6 teeth as did 53% of the 35-44-year-olds assessed 35 years after the beginning of water fluoridation: the mean DMFT was 13.3 and 16.0 in those living in non-fluoridated areas [15]. Australia has water fluoridation in a number of cities, but despite fluoride use from both toothpastes and drinking water the mean DMFT and DF Surfaces for all adults increased; adults aged 65 years and older had ten times higher levels of caries than 15–24-year-olds [16]. Thus although fluoride reduces caries, unacceptably high levels of caries in adults persist in all countries, even in those with widespread water fluoridation and the use of fluoridated toothpastes [21].”

So research is showing a strong need to cut dietary sugar intake by both children and adults.  The authors say “for multiple reasons, including obesity and diabetes prevention, we need to adopt a new and radical policy of progressive sugar reduction.” They conclude:

“that public health goals need to set sugar intakes ideally <3%E with <5%E as a pragmatic goal, even when fluoride is widely used. Adult as well as children’s caries burdens should define the new criteria for developing goals for sugar intake.”

Obviously community water fluoridation (CWF) remains an important issue in New Zealand because political activists still work hard to remove it, or prevent it when health authorities attempt its introduction. It seems to me, though, that CWF, once achieved, plays its important role without having to continually educate and encourage the population to change their dietary habits. The battle over sugar will be so much harder because it will involve social pressure to change personal habits, as well as countering all the anti-science and freedom of choice arguments.

At least local body councils, and immature local body politics, will not play a key role.

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6 responses to “It’s time we did something about sugar

  1. This is a good book to read all about sugar,
    Pure white and deadly, John Yudkin
    sure it was written in 1972 but it is still a good read, and a free download
    http://darkj-fitness.tumblr.com/post/34915473766/pure-white-deadly-free-download-pdf-this

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  2. just opened my copy and this print is 1986 sorry

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  3. Having the prejudice that sugar was the critical factor in caries etiology, I was quite surprised to read the 2007 paper by the Iowa fluoride group which found poor correlation between sugar and cavities. Here is the Conclusion from the abstract:

    “Dental caries is a complex, multifactorial disease process dependent on the presence of oral bacteria, a fermentable carbohydrate substrate and host enamel. A simple NME-intrinsic/milk sugars categorization appears insufficient to capture the complex dietary component of the caries process.”

    Marshall et al, JADA January 2007 138, 39-46. Comparison of the intakes of sugars by young children with and without dental caries experience.

    The Iowa study was done at the individual level based on food diaries.

    It would be interesting to know what Dr. Levy thinks about the apparent conflict between his and Sheiham’s data. It seems likely that the disease is more complex than what the graph here presented implies.

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  4. Ken – you wrote on 15 Sept: people will crudely misrepresent the scientific literature in their efforts to pretend their particular political agenda is scientifically valid. The way they will dredge the scientific literature searching for studies they can quote and misrepresent seems an extreme form of cherry picking and confirmation bias. Surely those indulging in such crude literature dredging are fully aware of what they are doing.
    I suggest you have done this with the paper on sugar.
    What I take home from the paper is that water fluoridation does not prevent caries, it delays the impact of dietary sugars on tooth enamel.
    “Australia has water fluoridation in a number of cities, but despite fluoride use from both toothpastes and drinking water the mean DMFT and DF Surfaces for all adults increased; adults aged 65 years and older had ten times higher levels of caries than 15–24-year-olds [16]. Thus although fluoride reduces caries, unacceptably high levels of caries in adults persist in all countries, even in those with widespread water fluoridation and the use of fluoridated toothpastes [21].”
    What I take from the paper is that it is not community water fluoridation providing declining caries rates, it is the increase in an expanding range of topical applications and improved dental care. It is also obvious from reading the paper that the authors are concerned at the poor quality of studies an the lack of high end research into the issues around causation and treatment.
    Taking out the nutters and cranks on both sides of the fluoride issue there is no question in my mind that fluoride as used in topically treating decay has benefits, but increasingly the question as to those benefits being conferred through CWF is being asked and the answers are usually in the form of personal attack and derisive remarks. That Ken is not science it is BS.

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  5. Trevor, I suggest you reread the paper. In no way does it suggest that F does not have a beneficial role and it should not be interpreted that way. However, Fluoride Free groups are doing exactly that.

    You yourself admit F has a beneficial role but want to restrict that to only “topical application.” There is no doubt that topical applications are a useful way of getting benefits from fluoride but you have not understood the scientific literature if you think water fluoridation has no benefits. Quite apart from the research showing the expected long term benefits arising from incorporation into tooth enamel during tooth development, the surface reactions arising from the presence of F, Ca and PO4 in saliva and biofilms on existing teeth are well established. Fluoride in water is important for this. And this paper mentions this, together with regular tooth brushing, as being the only things reducing the harmful effects of sugar. Because it directly addresses the surface reaction caused by carbohydrate decomposition.

    Now you might interpret my suggestion you read the paper properly and my corrections of your misunderstanding of the literature as a “personal attack and derisive remark.” Well, tough. The problem is that you are putting your trust in the Connett clan and not the science. They are the ones who not only ask your false question but provide the false answer. The are also pretty handy with the personal attacks and derisive remarks, aren’t they?🙂

    >

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  6. Taking out the nutters and cranks on both sides of the fluoride issue there is no question in my mind that fluoride as used in topically treating decay has benefits

    Trev, CWF is topical application.

    nutters and cranks on both sides of the fluoride issue

    No.

    Firstly. there is the scientific research and the consensus of the world’s health communities.

    Secondly, there are those who accept the scientific consensus and those who refuse to accept the scientific consensus.

    Most rational observers have no difficulty making judgement on which of the two groups more closely earn the epithet, “nutters and cranks”.

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