Globally, sugar consumption has tripled in the past 50 years. Although, arguable, fever and fever of us add visible sugar in our tea, and sprinkle less over our cereals and puddings, we are actually consuming far more invisible sugar due to an increased appetite for processed food. For example, the average can of regular cola contains seven teaspoons of sugar.
The consumption of sugar in its various forms has long been associated with the development of caries ( see Chapter 5 ). More recently, sugar has been identified as a major factor in the growing problem of obesity.
Some scientists have linked sugar consumption with a growth in certain disease ( such as cardiovascular disease, cancer and diabetes ), as well as contributing to childhood behavioural problems and detrimental health effects during weaning.
The coma panel on dietary sugars
In 1986, a committee was set up by the UK government to investigate all aspects of diet. The committee on medical Aspects of Food and Nutrition Policy ( COMA ) established the panel on dietary sugars to look at the role of sugar in the diet.
In 1989, the panel concluded that the role of sugars in the development of obesity was not clear, but there recommended that when a person in obese, the consumption of non-milk extrinsic sugars ( NMES ) should be restricted, combined with a reduction in fat intake of regular physical exercise.
The UK Health Education Authority ( later subsumed into NICE ) set out the Panel’s findings in abooklet called Sugar in the diet.
COMA classification of sugar
COMA distinguishes between sugar held within the cell structure of food ( natural sugar, known as intrinsic ), and those which have been released from the cell structure ( natural or add sugars, known as intrinsic ). Certain types of sugar ( such as fructose ) can be both extrinsic and intrinsic in nature depending on their state. Milk sugars are classified as extrinsic sugars.
Total sugars
Intrinsic sugars extrinsic sugar
Sugar molecules inside the cell, sugar molecules outside the cell
e.g. fresh fruit and vegetables milk sugar e.g. lactose in dairy products
non-milk extrinsic sugars ( NMES ) e.g. table
sugar, confectionary, honey, fruit juice
Intrinsic sugars
Intrinsic sugars are found in the cell walls of whole fruits and vegetables. They include fructose, glucose and sucrose, which do not begin to break down in the mouth, and are therefore generally less cariogenic than extrinsic sugars.
However, it is not guite as simple as that. Fructose in the skin of an apple ( which begins absorption in the stomach ) is less cariogenic than fructose in apple juice which is classified as an extrinsic sugars. Therefore, although fruit juice can be labeled as having no added sugar it is rendered cariogenic , as fructose is removed from the plant cell wall and is broken down by salivary amylase in the mouth.
Extrinsic sugars
Extrinsic sugars are also known as NMES ( think enemies ) and were found by the COMA Panel to be the sugars most responsible for dental caries.
NMES include:
- sucrose.
- fructose.
- glucose.
- dextrose.
- maltose.
NMES are found in processed foods such as confectionary, soft drinking, biscuit, cakes, as well as naturally in honey and fruit juice ( as we have seen ).
Although the sugars ( glucose and fructose ) in honey and natural like fruit juice, honey’s consistency facilitates its initial breakdown in the mouth, and it is therefore considered to be cariogenic. Honey is often marketed as a natural ‘ healthy ‘ food, which it is, but it should be remembered that it has the potential to cause caries when eaten frequently between meals, especially due to its sticky consistency ( see Chapter 5 ).
The same applies to dried fruits ( e.g. sultanas and raisins ). Which parent often give to children as a snack, thinking that the fruit content renders them safe for teeth, when in fact the drying process which they undergo during manufacture converts intrinsic sugars into more harmful NMES.
Of course, it goes without saying that syrup, raw sugar, brown sugar, muscovado and cane sugar all contain NMES.
Milk sugars
Milk sugars ( lactose and galactose ) are extrinsic sugars and occur naturally in milk and dairy products, such as yoghurt and cheese. They are regarded as less cariogenic than extrinsic sugars because they are accompanied by other essential nutrients( e.g. calcium ), which counteract potential damage to teeth.
COMA panel recommendations ( remember )
COMA’s recommendation are still regarded as an important guideline for those giving oral health advice in the united Kingdom today, and include the following:
- the average consumption of NMES should not exceed 60 g per person per day-10% of total dietary intake.
- fresh fruit juice and dried should only constitute one portion of the five a day.
- the frequency of sugary snacks and drinks should be minimized ( see Chapter 9 ). Foods and drinks that predispose to caries should be limited to main mealtimes. This is especially important for older dentate people, children and adolescents.
-schools should promote healthy eating patterns both by nutritional education and by providing and encouraging nutritionally sound food choices.
- sugars should not be added to bottle foods for infants and small children, which are in contact with teeth prolong periods, and dummies or comforters should not be dipped in sugar or sugary drinks.
- weaning foods should be free of ( or low in ) sugar, including sugars derived from fruit juices and fruit concentrates.
- bottle feeding after the age of 1 year should be discouraged, especially for those toddlers who regularly consume soya or infant formula, which contain extrinsic sugars.
- older people ( who have natural teeth ) should restrict the consumption of NMES because their teeth are more prone to decay due to root exposure and diminished salivary
- when medicine are needed ( particularly in the long term ), sugar-free formulations should be prescribed by doctors and selected by parents, respectively. In addition, food manufacturers should produce low sugar or sugar free alternatives to existing sugar-rich product, particularly those for children.
THE NACNE REPORT
Oral health education (OHEs) also need a basic knowledge of the National Advisory Committee on Nutritional Education (NACNE) report which was published in 1983 and, like COMA, is still relevant today.
This report outlined links between diet and a range of conditions and disease, including caries and coronary heart disease. It suggested, for the first time and six years ahead of COMA, quantitative dietary targets for the prevention of disease associated with affluence.
The target were short term (to be achieved by the end of the 1980s) and long term (to be achieved by the end of the twentieth century). It set guidelines for the population to reduce fats, salt and sugar, and to increase consumption of oily fish, fibre and fruit.
FREQUENCY OF SUGAR CONSUMPTION
The dental profession has been aware for over half a century that the frequency of sugar intake is far more significant in the development of caries than the amount consumed at any given time (see Chapter 5). Sugary foods are best taken during mealtimes, when salivary flow is good, while bedtime is a particularly bad time to consume sugar as the salivary flow rate slows during sleep.
Patients will often ask and be surprised by amounts of sugar in different foods and drinks. It is therefore helpful to be able to give an information sheet, setting out these amounts. When producing an exhibition or display, points about reducing sugar consumption can be emphasised by setting out a table of common snacks and putting sugar lumps or small bowls of sugar beside each to show the amount in each snacks or drink (see Chapter 17).
OHE advice to patients on sugar consumption
OHEs should be able to advice patients on the following topics in order to reduce their intake of sugar.
Reduce all snacks
Reduce all snacks particularly those containing sugar. It is important to give the same advice as other health professionals (such as dieticians and health visitors) who are concerned with other aspects of health, such as obesity.
Find healthy alternatives
In the past, the dental professional has suggested that plain crisps, peanuts and cheese are tooth-friendly alternatives to sweets, biscuits and confectionery. When reading labels,it can be seen that some nut snacks and flavored crisps contain hidden sugars, and this should be pointed out to patients.
OHEs must also be aware that patients may be told by other health professionals to avoid these foods for other health reasons. Advice must also be balanced by awareness that people (particularly schoolchildren and adolescents)require frequent intakes of carbohydrates to sustain energy. In such cases, it is a good idea to suggest healthy snacks such as wholegrain products, breadsticks, fruit and raw vegetables.
Identify 'hidden' sugars
Many people still associate sugar with white refined sucrose (table sugar), Although public awareness of hidden sugars is growing with the current trend toward healthy eating. It is important to be able to identify hidden sugars (e.g.glucose, fructose, dextrose, maltose, lactose and molasses), and advise patients to look for them on food labels.
Avoid adding sugar
This can be a hard habit to break for some, particularly when starred in childhood. OHEs should advise pregnant women and parents of young children in particular that adding sugar to food can contribute to obesity, caries and behavioral disorders.
Consider using sugar substitutes
See the text that follow.
Sugar substitutes
The use of artificial sweeteners is increasing as the public become more diet conscious, since their low calorific value means that they are virtually non-cariogenic and non-fattening. Sweeteners can be of synthetic or national origin such as xylitol(a non-cario