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COMMENTARY
Year : 2018  |  Volume : 62  |  Issue : 4  |  Page : 305-307  

Report from a symposium on accelerating policy-driven action against excessive sugar consumption for the prevention of early childhood caries and noncommunicable diseases


1 Chief, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
2 Director, WHO Collaborating Centre for Nutrition and Oral Health, Newcastle University, Chandigarh, India
3 Assistant Professor, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
4 Senior Resident, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
5 Assistant Professor, PGIMER, Chandigarh, India
6 Former SRF, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication11-Dec-2018

Correspondence Address:
Dr. Om P Kharbanda
Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_314_17

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   Abstract 


Dental diseases and other noncommunicable diseases (NCDs) share common risks. Omnipresent and easily available sugars are a contributing risk factor for overweight, obesity, and diabetes. In addition, sugar consumption is known to cause dental caries in early childhood (early childhood caries) and in adults. It has been noticed that the prevalence of NCDs is increasing each year, leading to 70% of deaths. A symposium of diverse academicians was convened to identify the gaps in evidence, policy, and advocacy for action on sugars, emphasizing on its detrimental effects on oral health. Existence of policies on sugars, experiences of other countries, feasibility in India, and the role of public health dentists, public, and stakeholders were discussed. Policy priorities in India and advocacy to strengthen action against inappropriate sugar intake could help address the growing burden of sugar-related NCDs. Recommendations to this end were put forth by the panel of experts.

Keywords: Dental decay, early childhood caries, noncommunicable diseases, policy, public health, sugars


How to cite this article:
Kharbanda OP, Moynihan P, Priya H, Ivaturi A, Gupta A, Haldane D. Report from a symposium on accelerating policy-driven action against excessive sugar consumption for the prevention of early childhood caries and noncommunicable diseases. Indian J Public Health 2018;62:305-7

How to cite this URL:
Kharbanda OP, Moynihan P, Priya H, Ivaturi A, Gupta A, Haldane D. Report from a symposium on accelerating policy-driven action against excessive sugar consumption for the prevention of early childhood caries and noncommunicable diseases. Indian J Public Health [serial online] 2018 [cited 2019 Mar 19];62:305-7. Available from: http://www.ijph.in/text.asp?2018/62/4/305/247226




   Introduction Top


More than two-third of the total deaths due to NCDs in the South-East Asian Region (SEAR) of the WHO occur in India. Tobacco use, consumption of an unhealthy diet, physical inactivity, and harmful use of alcohol are the four behavioral risks responsible for a significant proportion of NCDs. In a span of 4 years, the age standardized incidence of obesity has increased by 22%. Nearly one out of every 10 persons aged 18 years and above in India has raised blood glucose which is an increase of 9% in the age standardized prevalence. More than two-third of the adolescents in the age group of 11–17 years are physically inactive, with the level of physical inactivity being 13%.[1]


   Sugar Consumption Top


The per capita consumption of sucrose refers to the raw sugar consumed per person in a given country in kg/year. The global average consumption of sugars is 23.7 kg. Calculated based on the statistical disappearance of sucrose, the production of sucrose in India stands at 27 million tons between 2012 and 2014, an increase of 15 million tons as compared to 2005. The per capita consumption of sugars lowered from 19.6 kg in 2005 to 18.9 kg in 2011.[2]

Although this decrease is only in the consumption of traditional sugars, there is a significant increase from other sources such as sugar sweetened beverages (SSBs). Consumption from SSB is 1.11 kg and from traditional sources such as jaggery and khandsari is 5 kg; all sources put together is 25.01 kg per person per year (five times the WHO recommended threshold for free sugar intake). SSB sales in India have increased by 13% per year since 1998, exceeding 11 l per capita/year.[1]

With a view toward identifying action and effective implementation of an agenda that can be scaled up to reduce burden of dental caries and other NCDs associated with sugars consumption, the Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, convened an International Symposium “Is Sugar The New Tobacco? – Oral Health Perspectives.” At this meeting held in New Delhi on November 11, 2016 [Figure 1], Global and Indian Experts deliberated on opportunities and challenges around the aspect of sugars consumption [Figure 2]. Here, a summary of the discussions is presented.
Figure 1: Participants of the International Symposium on sugar.

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Figure 2: Experts at the panel discussion during the International Symposium on sugar.

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Objectives

The objectives were threefold as follows:

  • To generate substantial evidence on role of dietary sugars and SSB consumption in the causation of dental caries and other NCDs
  • To understand addiction mechanisms, drawing parallels with tobacco
  • To decipher the best practices on regulation of sugars consumption and the plausible application of the same in the Indian context.


The following are the major themes:

  1. Strategic communication for the prevention of NCDs including dental caries, especially early childhood caries (ECC) caused by consumption of sugars and SSB
  2. Linkages for policy recommendations.



   Overview of Presentations Top


Trends in sugar consumption control

States such as Kerala in India also introduced Fat Tax, which follows the idea of increased pricing of foods containing high amounts of sugar and fat paving way for reduced consumption. Among the SEAR countries, Thailand has implemented a tax on specific SSBs, and revenue is earmarked for public health.

Trends globally indicate that the portion size has increased considerably and so has the frequency of eating.[2] The fact that 52% are affected by NCDs in India and there is a definite nexus between salt, oil, and sugar consumption sets the ground for action on sugar. A national-wide campaign on healthier eating and extensive research on calculation of portion size and amount of sugars consumed was suggested.[2]

Sugar consumption and caries risk including ECC, as described in a prospective study, are proportional. The number of life years with sugar consumption beyond the recommended threshold multiply the risk for caries.[3]

The need for a tool to measure the amounts of sugars consumed and to relate the same to the effect on oral health was emphasized. Datasets with this aspect are missing.[3] It was suggested that a re-focus on obtaining more valid data on the trends in sugar consumption is the needed to underpin intervention efforts.[4],[5],[6]

Food labeling and the role of regulatory bodies

Nutrition labeling, a significant aspect in educating the public on a mass level, was discussed by the experts. The contents of the label, with an explicit mention of added sugars, are needed to enable a simple way to identify dietary items that are high in sugars. It was also suggested that a health warning could be a necessity in the near future taking into account the fact that most of the foods sold as health drinks or energy boosters are full of free sugars.

Parallels on the addiction of sugars

Drawing parallels between sugar and tobacco was another gap finder in the symposium.

Similar to tobacco, once a high sugar substance is consumed, individuals are tempted to eat more following a synergistic effect of dopamine and insulin. Leptins are known to play a role as well.

Industrial marketing motives aim at neutralizing the outcomes of public health programs, and the advertising and magnetic marketing strategies where children often seem to be the soft target are likely to be responsible for the proclivity for these high sugar products.

These foods vivify hedonic desires for repeated consumption.

Sociological aspects of consumption

A study conducted in London, UK, to explore the cause effect relationship between free sugar consumption frequency, public health services, and caries showed that there is a dynamic relation between sugars and decay as well as socioeconomic status.[7]


   Strategic Communication Top


Identify approaches that can improve literacy on the aspect of sugars

Understanding the information needs of various segments of the population, effective health promotion messages need to be developed using communication channels. Social media platforms may be exploited. The drivers for behavior change need research.

Social and cultural aspects of sugar consumption

Research should focus on understanding and addressing the socioeconomic, cultural, and behavioral factors that play a role in food choices. The barriers to choosing healthier food over empty calories need to be identified.

Role of oral health providers

Following a life course approach, pregnant women to geriatric age groups – every individual needs to be empowered with skills to maintain good oral hygiene. These include brushing, mouth rinsing, and healthy eating.


   Concluding Remarks Top


In the quest to bring up an incremental paradigm, the symposium was concluded with a panel discussion. Several gaps in evidence and challenges in implementation were noted. Cues on how to mitigate any undesirable economic impacts were discussed.

The importance of engaging policymakers, civil society groups, and stakeholders for practical, cost-effective, and concerted collaborations was highlighted including the development of a taskforce and creation of knowledge hubs to monitor the progress on the recommendations.

Recommendations for advocacy efforts

  • A message that free sugar consumption is causative for NCDs should be comprehensively conveyed through health warning, communications of the ministry of health, and various other modes
  • Public awareness needs to be generated on the threshold levels of sugar consumption which associated with a healthy life (5% of total energy intake)[8]
  • Mothers need to be educated about the dangers of sugar consumption
  • Schoolchildren need to be the primary target group for activities aimed at reducing sugars intake, with programs that promote fruit intake and those which discourage sale of high sugars foods and drinks in the stores around schools and in school canteens.[9],[10]


Policy recommendations

  • The 28% additional cess on carbonated drinks, a part of the GST launched in 2017, should include specific taxation on high-sugar food products[9],[10]
  • Deliberations for nutrition labeling with explicit mention of the amount of free/added sugars as a health warning must be furthered
  • A comprehensive food industry, policy-making, and academia interaction need to be promoted
  • A policy on industrial marketing and reformulation of foods needs to be chalked out.


Acknowledgment

We humbly acknowledge the contribution of all the speakers of this event as well as the participants from various institutions across the country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organization. Global Status Report on Noncommunicable Diseases. World Health Organization; 2014.  Back to cited text no. 1
    
2.
Gulati S, Misra A. Sugar intake, obesity, and diabetes in India. Nutrients 2014;6:5955-74.  Back to cited text no. 2
    
3.
Peres MA, Sheiham A, Liu P, Demarco FF, Silva AE, Assunção MC, et al. Sugar consumption and changes in dental caries from childhood to adolescence. J Dent Res 2016;95:388-94.  Back to cited text no. 3
    
4.
Moynihan P. Sugars and dental caries: Evidence for setting a recommended threshold for intake. Adv Nutr 2016;7:149-56.  Back to cited text no. 4
    
5.
Paes Leme AF, Koo H, Bellato CM, Bedi G, Cury JA. The role of sucrose in cariogenic dental biofilm formation – New insight. J Dent Res 2006;85:878-87.  Back to cited text no. 5
    
6.
Moynihan PJ, Kelly SA. Effect on caries of restricting sugars intake: Systematic review to inform WHO guidelines. J Dent Res 2014;93:8-18.  Back to cited text no. 6
    
7.
Pine C, Adair P, Robinson L, Burnside G, Moynihan P, Wade W, et al. The BBaRTS healthy teeth behaviour change programme for preventing dental caries in primary school children: Study protocol for a cluster randomised controlled trial. Trials 2016;17:103.  Back to cited text no. 7
    
8.
Ministry of Health and Family Welfare. Operational Guidelines for Prevention, Screening and Control of Common NCDs – Hypertension, Diabetes and Common Cancers. Ministry of Health and Family Welfare; 2016.  Back to cited text no. 8
    
9.
Nakhimovsky SS, Feigl AB, Avila C, O'Sullivan G, Macgregor-Skinner E, Spranca M, et al. Taxes on sugar-sweetened beverages to reduce overweight and obesity in middle-income countries: A systematic review. PLoS One 2016;11:e0163358.  Back to cited text no. 9
    
10.
Schwendicke F, Thomson WM, Broadbent JM, Stolpe M. Effects of taxing sugar-sweetened beverages on caries and treatment costs. J Dent Res 2016;95:1327-32.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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