October 2016 Nonalcoholic Fatty Liver Disease Risk Soda Taxes Warning Labels JournaCALIFORNIA DENTAL ASSOCIATION

SUGAR IN THE SPOTLIGHT Cristin E. Kearns, DDS, MBA You are not a statistic.

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It’s been 35 years since a small group of dentists founded our company. And, while times may have changed, our promises remain the same: to only protect dentists, to protect them better than any other insurance company and to be there when they need us. At TDIC, we look forward to delivering on these promises as we innovate and grow.

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DEPARTMENTS

601 The Editor/When the Universe Gets Really Small

603 Impressions

643 RM Matters/Understanding the Role of the Better Business Bureau

647 Regulatory Compliance/Nitrous Oxide Safe Practices

651 Ethics/Timely Referrals — Our Ethical Obligations to Our Colleagues

654 Tech Trends 603

FEATURES

611 in the Spotlight An introduction to the issue. Cristin E. Kearns, DDS, MBA

613 and Nonalcoholic Fatty Liver Disease This article details how the increase in sugar consumption in the United States has led to a new disease, nonalcoholic fatty liver disease, which has become epidemic, even in children. Robert H. Lustig, MD, MSL

619 Understanding the Impact of Consumption on Risk for Type 2 Diabetes This review discusses the physiological mechanisms by which consumption of added may increase risk for type 2 diabetes, the research evidence that suggests it does and the reason why there is conflicting evidence to suggest that it does not. Candice Allister Price, PhD, and Kimber L. Stanhope, BS, MS, PhD

627 Advocating for Soda Taxes: How Oral Health Professionals Fit In This article provides strategies that oral health professionals can use to increase their visibility in the media to make the case for soda taxes. Alisha Somji, MPH; Laura Nixon, MPH; Leeza Arbatman, BA; Pamela Mejia, MS, MPH; Alysha Aziz, RN; Karen Sokal-Gutierrez, MD, MPH; and Lori Dorfman, DrPH, MPH

633 Sugar- Warning Labels: Lessons Learned From the Tobacco Industry This article shows how health warnings, such as those on tobacco products, could be an effective tool for educating consumers about the health risks of sugar-sweetened beverages. Lucy Popova, PhD

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Volume 44, Number 10 JournaCALIFORNIA DENTAL ASSOCIATION October 2016 CDA Classifieds.

Free postings. published by the Editorial Upcoming Topics Letters to the Editor California Kerry K. Carney, DDS, CDE November/ General Topics www.editorialmanager. EDITOR-IN-CHIEF Priceless results. Dental Association December/Regulatory Issues com/jcaldentassoc 1201 K St., 14th Floor [email protected] January/Women in Dentistry Sacramento, CA 95814 Ruchi K. Sahota, DDS, CDE Subscriptions 800.232.7645 EDITOR ASSOCIATE Advertising Subscriptions are available cda.org only to active members of Brian K. Shue, DDS, CDE Doug Brown the Association. The ADVERTISING SALES CDA Officers ASSOCIATE EDITOR subscription rate is $18 and [email protected] is included in membership Kenneth G. Wallis, DDS 916.554.7312 PRESIDENT Cristin E. Kearns, DDS, MBA dues. Nonmembers can EDITOR [email protected] GUEST view the publication online Permission and at cda.org/journal. Clelan G. Ehrler, DDS Andrea LaMattina Reprints PRESIDENT-ELECT SENIOR PUBLICATIONS Manage your subscription SPECIALIST Andrea LaMattina online: go to cda.org, log in [email protected] SENIOR PUBLICATIONS and update any changes to SPECIALIST Blake Ellington your mailing information. Natasha A. Lee, DDS [email protected] VICE PRESIDENT TECH TRENDS EDITOR Email questions or other 916.554.5950 [email protected] changes to membership@ Courtney Grant cda.org.

R. Del Brunner, DDS COMMUNICATIONS Manuscript SPECIALIST SECRETARY Submissions [email protected] Jack F. Conley, DDS www.editorialmanager. EMERITUS com/jcaldentassoc Kevin M. Keating, DDS, MS EDITOR TREASURER [email protected] Robert E. Horseman, DDS CDA clclassifiedsassifieds wworkork harderharder to HUMORIST EMERITUS Stay Connected cda.org/journal bbringring you results.results. SeSellinglling a practice Craig S. Yarborough, DDS, MBA Production or a piece ooff equipment? Now you SPEAKER OF THE HOUSE [email protected] Val B. Mina can include photos to help buyers SENIOR GRAPHIC DESIGNER Walter G. Weber, DDS Go Digital cda.org/apps see the potential. IMMEDIATE PAST PRESIDENT Randi Taylor GRAPHIC DESIGNER Look for this symbol, noting additional video [email protected] SENIOR content in the ePub version of the Journal. And if you’re hiring, candidates anywhere can apply right from Management Peter A. DuBois the site. Looking for a job? You can EXECUTIVE DIRECTOR Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the post that, too. And the best part— Jennifer George California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. it’s free to all CDA members. CHIEF MARKETING OFFICER Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. Carrie E. Gordon The California Dental Association holds the copyright for all articles and artwork published All of these features are designed to CHIEF STRATEGY OFFICER herein. The Journal of the California Dental Association is published under the supervision of help you get the results you need, CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for Alicia Malaby any expression of opinion or statement of fact, all of which are published solely on the authority COMMUNICATIONS faster than ever. Check it out for of the author whose name is indicated. The association reserves the right to illustrate, reduce, DIRECTOR revise or reject any manuscript submitted. Articles are considered for publication on condition yourself at cda.org/classifieds. that they are contributed solely to the Journal. Copyright 2016 by the California Dental Association. All rights reserved.

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When the Universe Gets Really Small Kerry K. Carney, DDS, CDE

rom my mother’s living room, you can see the Lick Observatory The birth of stars and their violent way off in the distance. It is a group of tiny white domes deaths in supernovae have little east of San Jose, settled on the relevance today. My observations Fpalomino ridge of the Diablo Range at are focused on my mother’s breathing. the summit of Mount Hamilton. It is an icon of the San Francisco Bay Area. The Lick Observatory saw its first light on Jan. 3, 1888. For nine years, bequest the modern-day equivalent center of my universe lies inches away it was the largest refracting telescope of $1.2 billion to the building of an on her hospital bed in her living room. in the world. It was a gift from James observatory on Mount Hamilton. The Lick Observatory is a distant Lick, piano maker, entrepreneur, The Lick Observatory has backdrop. The birth of stars and their chocolate speculator, landholder and figured prominently in astronomical violent deaths in supernovae have wealthiest man in California. Lick, like discoveries. The distance to the little relevance today. My observations many others, was drawn to California moon was precisely measured at the are focused on my mother’s breathing. by the Gold Rush. He brought with Lick Observatory by bouncing a Her comfort and security are my him a modest fortune from his piano laser off the moon in 1969. The Lick purpose as she nears the completion making company in South America revolutionized astronomy by replacing of her 97th revolution around the sun. and 600 pounds of Ghirardelli photographic plates with digital Astronomers speculate about chocolates from Peru. After successfully detectors in 1971. Its newest telescope wormholes, alternate universes and time converting the chocolate to cash, is the Automated Planet Finder travel. But I can sit here in my tiny he convinced his friend Domenico (APF). It is constantly searching universe containing just two people and Ghirardelli to come to San Francisco nearby stars for earth-sized planets. travel through time by reviewing the 10 to establish his chocolate company. The Lick’s list of contributions decades of my mother’s life. I can see Lick made his fortune not through to astronomy is long but the one her as a young girl in rough-and-tumble the mining of gold but through the that has the greatest visual impact Oklahoma when cars were beginning careful mining of the burgeoning is the deep-space photography that to replace horses as the common means golden economy of California. was perfected on Lick’s Crossley of transportation. I can see her as a He bought property throughout telescope in the 1900s. It revealed teenager living through the Dust Bowl California, including the island of the myriad galaxies beyond our Milky and Depression. I can see her witnessing Santa Catalina. He held large and Way. It was the forerunner of the her father destroying his bankbook important parcels of land in San Hubble Space Telescope’s beautiful because their savings were lost. Francisco and the Santa Clara Valley. eXtreme Deep Field photos that show I can see her as a newlywed when Lick opened a flour mill in San Jose innumerable galaxies, unimaginably she and my father listened to the radio and a grand hotel in San Francisco. far away. These photos prove the to learn that Pearl Harbor had been After accumulating his great universe is beautiful and vast. bombed. I can see her when our family wealth, he considered building statues Way up there at the Lick settled in Pennsylvania. I can see her and grand architectural tributes to Observatory, the researchers in those enjoying all the opportunities that himself and his accomplishments. tiny white domes are studying all the life and a happy family can present. However, after George Madeira wonders of the universe. But today, I can see her traveling the world and introduced him to the wonders of for me, that universe has become very enjoying great friendships. I can see astronomy with a guided telescopic small. It has shrunk to the distance all the lives she touched and enriched tour of the night sky, Lick decided to between my mother and me. The over her 28 years as a teacher. I can

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see her living out her happy retirement here in California surrounded by her family. I can time travel back and forth through her life in this tiny universe. She is my universal constant. No matter what your profession or Our archive is vocation, no matter how fast-paced your life seems, your whole universe can contract in an instant and time available 24/7. can slow to a standstill when a debt of devotion and love comes due. I am CDA’s archive is online for your research. Access every issue grateful for many, many things but I of the Journal from the past 17 years at cda.org/journal. am most grateful for having the good fortune to have had the mother I did. In loving memory, B.B. Carney 1919–2016. Q

The Journal welcomes letters We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/ jcaldentassoc. By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

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Friends in High Places and Others

David W. Chambers, EdM, MBA, PhD

Who do we want for patients, for friends, as allies for the organizations we invest our time in? Imagine a 2-by-2-foot table with “good/bad for me” on one dimension and “influential/benign” on the other. It should be obvious that we cultivate the powerful and friendly, avoid those who can potentially harm us, smile on nice little people and ignore the rest. What a joy to have a few friends who are in a position to do us some good. Those with little prospect of mattering receive little thought. We save a lot of time and energy that way. Those with small influence but presumed positive attitudes are our context. We “like” them on Facebook. We acknowledge their compliments and ignore their requests if inconvenient. They are frequently the objects of charity. We count on them, often in the aggregate. They are ideal patients. They have financial resources, time and availability, billable needs, networks of friends for referrals and capacity to show appreciation. In fact, that is the very definition of a patient: one who agrees to the conditions of treatment. We do not have a name for individuals who need dental care but have not agreed to the terms of treatment. These The nub: should be classified in the influential, but not very supporting quadrant. They include the patient who insists on care that the 1. We like those who have the dentist knows is less than optimal, insurance companies, those capacity and interest to do us good. who post negative ratings, young dentists who want to change what it means to be professional and owners of corporate 2. We ignore those who cannot chains that place commercial interests above professional ones. help us and defend against those This is the troubling cell — the one where interests who are capable of doing things that do not align with our own are advanced by people who matter. It says a lot about our character how we respond. The contrary to our interests. philosopher Isaiah Berlin suggested that there are two common 3. If we only walk with those patterns. The hedgehog curls up in a ball, leaving nothing but hard bristles to ward off attack. This defensive posture is who are there to help us, we will favored by those who perceive that they hold a better hand generally be behind or in front of than they are likely to get if the cards are shuffled and redealt. the crowd — but not “with it.” The fox, the other approach mentioned by Berlin, fusses around looking for a rational perspective on the matter. The great American advocate of pragmatism, William James, makes much the same distinctions, but he places the elements on a David W. Chambers, EdM, MBA, PhD, is professor time continuum. First, we ignore the powerful and unfriendly of dental education at the University of the Pacific, Arthur and then we push back. The third phase in this process is to A. Dugoni School of Dentistry, San Francisco, and editor Q of the Journal of the American College of Dentists. claim that the change was our idea in the first place.

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Children With Dental Sealants 80 Percent Less Prone to Caries Further evidence has been presented that shows dental sealants are more effective than other treatments in the fight against childhood caries. The American Dental Association and American Academy of Pediatric Dentistry (AAPD) have published two systematic reviews that evaluated the effectiveness of dental sealants. The literature breaks down the outcomes such as caries incidence, sealants retention and adverse side effects. The Patients With Two Prescription reports are titled “Sealants for Preventing and Arresting Pit-and-Fissure Occlusal Caries in Primary and Permanent Molars” and “Evidence-Based Drug Refills Likely to Become Clinical Practice Guideline for the Use of Pit-and-Fissure Sealants.” Long-Term Users Timothy Wright, DDS, MS, is the lead author. New research has pinpointed the “Sealants are a proven and effective therapy for preventing cavities in number of prescription refills it can children and teens. Oral disease can greatly impact one’s concentration and take to tip the scales and push a patient self-esteem and contributes to more than 51 million hours of missed school to become a long-term opioid user. A each year,” Wright said in a press release. “The joint report reaffirms that study done at the Oregon Health and sealants should be a routine part of cavity prevention, as children with sealants Science University found that patients are up to 80 percent less prone to cavities compared to those without them.” who received two refills were likely to The reports, which are accompanied with updated clinical practice become long-time users. The study was guidelines, were published in the August issue of the Journal of the American completed by using data from Oregon’s Dental Association, as well as the July/August issue of AAPD’s Pediatric prescription monitoring program as well Dentistry journal. as data from Oregon vital records and a hospital discharge registry. In total, “The new guideline gives clear direction for dentists to best use 3.6 million opioid prescriptions were sealants to improve the oral health of their patients,” Wright said. examined and it was found that “The To read the systematic review and odds ratio of becoming a long-term download the guideline, visit jada.ada.org. opioid user was 2.25 higher among For patient-friendly information to help patients who received two prescription your practice, download the JADA fills compared to one. It was also 2.96 patient page at jada.ada.org or visit higher for those initially receiving MouthHealthy.org and mychildrensteeth.org. between 400 and 799 cumulative morphine milligram equivalent dosages within 30 days, compared to patients on lower doses. Long- acting opioids were associated with a higher risk than short-acting drugs.” which clinicians have greater control,” dosage units of hydrocodone Richard Deyo is with the Oregon he said in a press release. “This in part combination products were Health and Science University reflects concern that we are dealing dispensed in the 2013–14 fiscal year. and was the lead researcher for the with risky drugs, not risky patients.” Opioid use and deaths attributed study, which was published in the Prescribers in the United States to abuse are sharply on the rise, Journal of General Internal Medicine. write nearly 100 percent of opioid sending government agencies and “Our data suggest the value of prescriptions worldwide, and in public health advocates looking attention to high-risk prescribing, over California alone more than 1 billion for tools to turn the tide.

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Undiagnosed Sleep Apnea Costing Billions The cost of undiagnosed sleep apnea economic burden of it going undiagnosed in the U.S. is in the billions, according to is around $149 billion. This amount is two new reports released by the American calculated by lost productivity, vehicle Academy of Sleep Medicine (AASM). accidents and workplace accidents. The reports, titled “Hidden health crisis “The high-quality, patient-centered care costing America billions” and “In an provided by board-certified sleep medicine age of constant activity, the solution to physicians can significantly reduce the improving the nation’s health may lie in health and economic burdens of sleep helping it sleep better,” includes results apnea,” said AASM President Ronald from of an online survey of obstructive Chervin, MD, MS, in a press release. sleep apnea patients. The reports conclude While dentists can play a key role in scope of the practice of dentistry. Proper that “diagnosing and treating every patient recognizing potential sleep-disordered SDB diagnosis requires monitoring of in the U.S. who has sleep apnea would breathing (SBD) and managing some the patient during sleep and evaluation produce an annual economic savings of aspects of treatment, SBD is a medical of the events during the sleep cycle by $100.1 billion.” The reports state that the condition and its diagnosis is outside the a qualified physician. Collaboration between the physician and the dentist in identifying and diagnosing patients who are suffering from SDB and determining the best mode of treatment ensures Gene Variant Found in Esophageal Cancer Study patients receive comprehensive and appropriate care. Additionally, as SDB A genetic mutation could be related to familial Barrett’s esophagus (FBE) and is progressive, continued monitoring esophageal cancer. New research published in the July issue of JAMA Oncology and managing of this chronic condition found “a rare mutation (S631G) in FBE in the uncharacterized gene VSIG10L is best handled through continued that segregated with disease in affected family members. Functional studies dentist-physician collaboration. revealed that this mutation disrupts maturation of the normal esophageal lining.” CDA’s policy on SBD (25RC- Amitabh Chak, MD, is with the University Hospitals Case Medical Center’s 2011-H) is the following: Seidman Cancer Center and Case Western Reserve University School of Medicine. Q It is appropriate for dentists to screen “Instances of esophageal cancer are on the rise, and the disease patients for signs and symptoms of has a poor five-year survival rate of less than 15 percent,” Chak said. SBD and to work with physicians “However, early detection through screening can prevent the development to diagnose and treat SBD. of esophageal cancer. Further research assessing this gene variant may Q CDA supports increased awareness reveal pathways important for the pathogenesis of BE and esophageal and the education of dental and medical professionals on appropriate adenocarcinoma, leading to earlier detection and better treatment options.” involvement in the screening, There have been little advancements in finding treatment and gaining diagnosis and treatment of SBD. an understanding of this disease and this study aims to Q CDA supports efforts at the federal change that. The discovery by the University Hospitals and state levels to ensure dentists Case Medical Center lays out the biology in disease are recognized members of the pathogenesis and could help enhance detection early health care team managing SBD with close monitoring of those with the variant. and to ensure that patients’ health “This is a step forward in combating this deadly care benefits are maintained disease as we discovered a new way to categorize those regardless of whether a dentist or at risk for esophageal adenocarcinoma,” Chak said. physician provides patient care. For more information, visit the Sleep Disordered Breathing Issue Summary resource at cda.org.

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Practice Support

Employment Practices

If you’re a practice owner in California, new Fair Labor Standards Act rules may have a big impact on how you classify your employees. First, review a duties test to determine if team members should be exempt. Then, either increase employees’ salaries to be compliant with the new regulations or reclassify them as hourly employees. The experts at CDA Practice Support are here to help you navigate the new overtime regulations and minimum salary thresholds so you can get your office ready by the Dec. 1 deadline. Explore online employment practices resources or ask an expert today.

800.232.7645 or cda.org/practicesupport OCT. 2016 IMPRESSIONS

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Dental Sealants Expose Children to Less BPA Than Many Household Items The amount of BPA in dental sealants is safe for young children, according to research recently published by the ADA Science Institute. Specifically, the research shows that dental sealants in a 6-year-old child has less BPA in Embryonic Mouth Formation them than food, drinks, sunscreen, shampoo, body wash and other cosmetics Explained and air and thermal paper. The report, published in the ADA Professional Product Review, lays out details on how the BPA released from dental Researchers at Whitehead Institute sealants is .09 nanograms — far lower than the limit for a 6-year-old child. have tested frogs to help explain mouth formation during embryonic David Sarrett, DDS, is the editor of the ADA Professional Product Review. development. Xenopus frogs were “This issue of the PPR provides a much-needed perspective on the amount studied over many years and it was of BPA in dental materials compared with other sources of exposure,” Sarrett discovered that the mouth starts said in a press release. “Dental sealants offer a tremendous oral health as a square with eight cells wide benefit to children and should continue to be a routine preventive service.” and eight cells high and then later Sealants are most effective in reducing cavities in children with newly becomes two cells wide and 20 cells formed permanent teeth. In fact, all children should have their molars high. Later in the development, evaluated for sealants soon after they erupt. For most children, this occurs the two rows of cells “unzip” to approximately at ages 6 and 12. Dentists can remind their patients that create the mouth as we know it. sealants can also be useful in cutting down formation of decay in adult Hazel Sive, is a professor of biology teeth, as well. An application of sealants is a at MIT and part of the Whitehead preventative measure to keep teeth healthy. research team that made the discovery. “Mouth formation involves It is an effective way to reduce the need for many steps that ensure the opening fillings and more expensive treatments that happens at the right time and at the may be required to repair the damage from right place — when the cells are cavities, so sealants can save patients money. connected with the correct junctions to be exposed to the outside and where the opening connects to a prepared region, in the case of the mouth to the digestive system. But I was so surprised when we found forming the premouth. Therefore, the earlier point to avoid years of surgery that this process is initiated in frogs study claims to have revealed a precise and orthodontics, we need to obtain several days before the mouth actually cellular mechanism that positions and a better handle on what’s going on. opens,” Sive said in a press release. contributes to the future mouth. Recognizing what is required to form The results of the research were Laura Jacox is another researcher a mouth and the face and how it’s published in the Aug. 2 issue of Cell on the project and said there is regulated is a step toward understanding Reports. The Whitehead research team still a lot of work to be done. how these processes can be disrupted.” propose that the premouth formation “There’s a lot of craniofacial The work of this study was occurs as “neural crest” cells come to lie development that we don’t understand,” supported by the National Institute on either side of the extreme anterior Jacox said. “If we hope to understand of Dental and Craniofacial Research domain (EAD) and that these cells why craniofacial anomalies happen in and Harvard University’s Herschel then signal to the EAD cells to begin humans and how to treat them at an Smith Graduate Fellowship.

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Virtual Dental Home Model of Care Proven to Be Effective The virtual dental home model The term “virtual dental home” of dental care has been proven to describes a dental care model in which a be effective at keeping people out of dentist utilizes teledentistry by connecting pain and kids in school, according to electronically to specially trained allied a recently released study. The results dental team members to deliver dental from a six-year study by the Pacific care to underserved populations. Center for Special Care, a program of Through the virtual dental home Image courtesy of University of the Pacific. the University of Pacific, Arthur A. model of dental care, specially trained Dugoni School of Dentistry, show that dental hygienists and assistants collect send that information electronically via a virtual dental homes “prevent suffering dental diagnostic records, including secure web-based system (called store- for millions of Californians who have X-rays and intraoral photos, from patients and-forward telehealth) to the supervising no access to a dentist” and, as a result, in community settings such as schools, dentist at a clinic or dental office. The reduces “school absenteeism.” Head Start sites and nursing homes. They dentist uses that information to establish a diagnosis and create a dental treatment plan for the hygienist or assistant to carry out. The hygienists and assistants provide basic care at the community site and refer Digital Dental Glossary of Terms Released patients to dental offices for procedures that require the skills of a dentist. Dentists looking for a complete list of dental terms will be pleased to The study, published in ScienceDaily, know that the American Academy of Implant Dentistry (AAID) has released followed more than 3,000 patients in the JOI Glossary of Terms, 2016 Edition. The glossary, published by the California since 2010. It found that Journal of Oral Implantology (JOI), features more than 1,500 terms, two-thirds of children and nearly half including words, phrases and definitions that are commonly found in general of the elderly with disabilities can dentistry, implantology and oral surgery. James Rutkowski, DMD, PhD, is the gain proper treatment through virtual editor-in-chief of the JOI. dental homes and the costs were “The goal of the JOI Glossary of Terms has always been to educate. lower per patient than Denti-Cal. Paul Glassman, DDS, MBA, is a Whether you are a first-year dental student or have been practicing dental professor of dental practice, director of implantology for 20 years, the Glossary is a wonderful professional resource community oral health and director of tool,” Rutkowski said in a press release. “It is our hope that the expanded the Pacific Center for Special Care at the 2016 edition of the Glossary reaches new audiences and continues to drive University of the Pacific, Arthur A. Dugoni professional growth for both AAID and the dental community.” School of Dentistry. Glassman developed This will be the first time the glossary has the virtual dental home approach. been published digitally. Previous editions were “Our six-year demonstration project

in print. The new digital flipbook format “was 2016 EDITION confirms that this is a safe, effective way developed with the goal of enhancing the to bring care to people who need it,” Glossary’s audience as well as improving content Glassman said in a press release. “Basing a dissemination and ease of use. The tools and virtual dental home in a school, a nursing features of the digital edition allow readers to home or other community setting allows dental hygienists to prevent or treat the more easily find the terms and definitions they need majority of oral health problems on site, in an online, searchable format.” and also brings prevention information The glossary can be accessed at joionline.org. to patients, families and caregivers. Finally, it connects on-site care in the community to dentists in dental offices.”

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Sugar in the Spotlight

Cristin E. Kearns, DDS, MBA

GUEST EDITOR

Cristin E. Kearns, DDS, ugar is having a public encourage dentists to consider their MBA, is a postdoctoral health moment. In 2015, the part in the latest movement to curb fellow at the University of World Health Organization nutrition-related chronic disease. California, San Francisco, and is affiliated with the (WHO) called on countries The federal government is off to Philip R. Lee Institute for to decrease added sugars an encouraging start. On the heels of Health Policy Studies and Sintake among adults and children to the WHO call, the 2015-2020 Dietary the department of oral reduce the risk of being overweight, Guidelines recommended that Americans and craniofacial sciences and dental caries.1 The WHO limit added sugars intake to less than in the School of Dentistry. 2 Her research examines recommended that added sugars intake 10 percent of daily calories, ending the influence of food be limited to less than 10 percent decades of vague recommendations to industry public relations of daily calories and that a further eat “less” sugar. The Food and Drug practices on the scientific reduction below 5 percent would Administration has already moved evidence informing public provide additional health benefits. to apply the new added sugars limit health policy. Seventy percent of Americans to food labeling. As of July 26, 2018, consume added sugars above the manufacturers with $10 million or more WHO’s recommended 10 percent in annual food sales will be required limit.2 As any dentist can attest, to disclose added sugars content and motivating individuals to reduce what percentage of the daily-added their added sugars intake will sugars limit it represents on packaged require an armamentarium of food nutrition labels.3 Consumers may interventions targeting a wide range reconsider their food choices when of socioecological influences. Health they learn that a 20-ounce bottle of care professionals can play an essential Coke contains 65 grams of sugars or role in supporting health behavior 130 percent of the daily limit (based change at the policy, community and on a 2,000 calorie diet). These new individual levels. This collection of requirements will end labeling practices articles in the Journal of the California that have allowed manufactures to Dental Association is designed to hide added sugars content behind more

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than 60 names for sugars, such as barley the metabolic effects of fructose. This time period in San Francisco, where , dextrose and . They will evidence suggests that the health a similar measure was defeated, also make clear the amount of sugars risks of added sugars consumption sugary beverage consumption in that are added to savory foods, such extend beyond overweight, obesity low-income neighborhoods increased as bread, pasta sauce and ketchup. and dental caries. These reviews are by 4 percent. These results are a At the state and local policy level, important for dentists to consider testament to what can be achieved a number of initiatives are focusing on when communicating with patients when we move beyond individual- reducing added sugars consumption or policymakers — might Americans’ level interventions to address the through economic incentives, health attitudes toward added sugars many layers of influence that intersect promotion programs and health risk consumption change if they perceived to shape a person’s food choice. Q disclosure.4 In 2014 Berkeley, Calif., the risks of consumption to be greater? REFERENCES became the first city in the nation , MD, who has been 1. World Health Organization. Guideline: Sugars intake for to adopt a tax on the distribution credited with launching the modern adults and children. Geneva: World Health Organization; 2015. of sugar-sweetened beverages and in antisugar movement, reviews research 2. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for 2015 the city of Philadelphia became linking fructose consumption with Americans, 8th ed. Washington, D.C.: U.S. Government Printing the first large American city to do so. a new disease: nonalcoholic fatty Office; 2016. Also notable in these efforts, though liver disease (NAFLD). NAFLD 3. U.S. Food and Drug Administration. Food Labeling: Revision of the Nutrition and Supplement Facts Labels. www.regulations. occurring too late for inclusion in has become another chronic disease gov/document?D=FDA-2012-N-1210-0875. 2016. Accessed this issue, are current initiatives on epidemic, with an alarming prevalence Aug. 24, 2016. the November 2016 ballot in the rate in children. Candice Allister 4. California Center for Public Health Advocacy. Kick the can, giving the boot to sugary drinks: SSB Campaign Map 2016. cities of Oakland and San Francisco, Price, PhD, and her colleague www.kickthecan.info/ssb-campaign-map-2016. 2016. Accessed which would enact one-cent per Kimber Stanhope, PhD, a leading Aug. 24, 2016. ounce taxes on the distribution researcher who conducts clinical 5. Falbe J, Thompson HR, Becker CM, Rojas N, McCulloch CE and Madsen KA. Impact of the Berkeley Excise Tax on of sugar-sweetened beverages. studies on the effects of diet on the Sugar-Sweetened Beverage Consumption. Am J Public Health A set of articles presents unique development of metabolic disease, 2016:e1-e7. perspectives on recent efforts to curb review research linking added sugars sugary beverage intake. Alisha Somji, consumption to type 2 diabetes risk. MPH, and colleagues present an Their review highlights conflicting analysis of media coverage of sugary evidence and new experimental beverage tax debates, which highlights techniques that hold promise for a shortfall of dental professional unraveling the true relationship of voices. Lucy Popova, PhD, reviews added sugars to type 2 diabetes. evidence supporting the effectiveness While dentists have long- of tobacco warning labels and discouraged added sugars consumption provides lessons that can be applied to improve dental health, sugar’s to sugary beverage warning labels moment in the spotlight offers renewed initiatives. She highlights industry opportunities for us to engage with efforts to counter warning labels and diverse stakeholders developing policy the important role dentists can play and community-level interventions. in policymaking by speaking to the An August 2016 study,5 which strength of evidence linking added evaluated Berkeley, Calif.’s, sugary sugars consumption to dental caries. beverage excise tax, passed in March On the subject of the strength 2015, found a 21 percent drop in of evidence linking added sugars to sugary beverage consumption in chronic disease, the second set of low-income neighborhoods after articles review emerging evidence of the tax took effect. During the same

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Fructose and Nonalcoholic Fatty Liver Disease

Robert H. Lustig, MD, MSL

AUTHOR

Robert H. Lustig, MD, n 1977, the first Dietary Goals for What Is NAFLD? MSL, is a professor of Americans were issued by the U.S. NAFLD is defined by the presence pediatrics in the division Senate, which targeted dietary of liver fat in absence of primary causes of endocrinology at the 9 University of California, saturated fat as the primary driver such as alcohol and hepatitis C. NAFLD 1 San Francisco, School of of heart disease. In response, the exists in three pathologic stages. Hepatic Medicine and the director Ifood industry reduced the fat content steatosis, or fatty liver, occurs when up of the Weight Assessment in processed food.2 However, to make to 5.5 percent of the liver parenchyma for Teen and Child Health it palatable, dietary sugar replaced is occupied by fat. Steatosis is now (WATCH) program at 10 UCSF. He is also affiliated the fat, so that by 2000, added sugar found in up to 33 percent of adults, 16 faculty at the Philip R. Lee had increased by 32 percent of total percent of all children and 38 percent of Institute for Health Policy calories.3 This dietary paradigm obese children.8 Of those with steatosis, Studies at UCSF. continues to this day. More than 55 approximately 5 percent will develop Conflict of Interest percent of all American adults consume nonalcoholic steatohepatitis (NASH), Disclosure: Dr. Lustig has never accepted money from more than 50 grams of added sugars per in which steatosis is accompanied by the food industry and has day, which is thought to be the cut- necroinflammation and fibrosis. Finally, no disclosures with respect off value for added risk of metabolic up to 25 percent of NASH patients to this article. However, he derangement and the new guideline for will progress to cirrhosis9 and cirrhosis has authored three popular added sugar from the USDA and more can further progress to hepatocellular books as a public health service. He is also the than the advised maximum according carcinoma. NASH is projected to become president of the nonprofit to the American Heart Association the leading cause of liver transplantation Institute for Responsible (25–37.5 gram/day).4 Furthermore, in the U.S. by 2020.11 Thirty to 40 percent Nutrition. U.S. adolescents average 94 grams per of NASH-cirrhotic patients succumb to day.5 Over the past 40 years, coincident a liver-related death within 10 years. with this change in dietary pattern, the diseases of Who Gets NAFLD? (type 2 diabetes, dyslipidemia, heart Considering NAFLD was first disease) have increased in prevalence.6 reported in adults in 198012 and in In addition, a brand new disease children in 1983,13 the secular trend — nonalcoholic fatty liver disease of NAFLD prevalence is staggering.14 (NAFLD) — has become epidemic, NAFLD is prevalent in 45 percent of even within the pediatric age group.7,8 Latino, 33 percent of Caucasian and 24

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percent of African-American adults.10 ȕ-oxidation to ketones, accelerating Q Genetics. The increased risk of fatty NAFLD is now the primary cause of liver hepatic lipid clearance for energy liver in some racial/ethnic groups transplantation in adults, outstripping usage by the rest of the body. may be partially explained by hepatitis C.15 NAFLD is strongly Q Increased de novo lipogenesis (DNL). sociocultural differences in dietary associated with insulin resistance16 and is DNL is driven by excessive dietary intake. However, genetic factors a primary predictor of type 2 diabetes.17 carbohydrates,28 increasing the may also play a role. Latinos are transcription of three enzymes, at highest risk, Caucasians have What Is the Pathogenesis of NAFLD? ATP citrate lyase, acetyl-CoA intermediate risk, while African- Prior to 1980, fatty liver disease meant carboxylase-1 and fatty acid Americans have lower-than- one thing: alcohol. But children don’t synthase, to convert carbohydrate expected prevalence for the degree drink alcohol. Therefore, understanding to fat, as in kwashiorkor. For of obesity and insulin resistance.34 the pathogenesis of NAFLD to support example, if carbohydrate intake Specific genetic polymorphisms prevention and control strategies is of exceeds energy expenditure, hepatic predispose to NAFLD, most utmost importance.18 Fatty liver occurs DNL is incremented tenfold.29 notably patatin-like phospholipase when the rate of the hepatic lipid influx 3 (PNPLA3), which may be pathways (either fatty acid import or de particularly important in Latinos.35 novo synthesis of fatty acids) exceeds the rate of hepatic lipid clearance (either fatty NAFLD is strongly What About Diet Drives NAFLD? acid catabolism or lipoprotein export).19,20 While each of the processes described Evidence suggests the following mechanisms associated with insulin above can be perturbed sufficiently in could promote the development of resistance and is a humans to increase liver fat, none of these fat accumulation in the liver: primary predictor of explains the rise of the current NAFLD Q Increased ingestion of dietary fat. epidemic, especially in children. There Unrestricted high-fat liquid feeding type 2 diabetes. are likely multiple factors driving NAFLD to rats generates hepatic steatosis,21 in any individual. Weight gain predicts whereas voluntary high-fat feeding incident NAFLD.36 Visceral adiposity and with chow does not.22 In humans, insulin resistance are major risk factors, although dietary fat ingestion Obese insulin-resistant subjects as these increase hepatic lipid processing. influences the accumulation of show markedly increased DNL.30 The increased risk in some racial/ethnic fat in the liver,23 only 15 percent Q Impaired hepatic fatty acid groups may be partially explained by of liver fat can be explained by ơ-oxidation. Abrupt and massive sociocultural differences in dietary intake. this mechanism.24 Furthermore, hepatic failure with steatosis However, as NAFLD has exploded with dietary fat makes up a smaller is noted in patients with Reye the export of the Western diet around percentage of total calories syndrome.31 However, lipid the world, specific macronutrient and/ due to the low-fat directive. ȕoxidation appears to exert only a or micronutrient component(s) of Q Increased free fatty acid (FFA) influx. minor influence in the development the diet have been implicated. There FFA from lipolysis of adipose tissue of NAFLD in humans.32 are four consumables that specifically from either the subcutaneous or Q Impaired triglyceride export. The promote the development of fatty liver visceral depot may contribute to fatty liver esterifies excess fatty acids disease unrelated to their calories.37 liver in type 2 diabetes.25,26 However, into triglycerides, which are then Q Trans fats. Trans fats can’t be other conditions of lipolysis do not exported out as very low-density completely metabolized by result in steatosis. For instance, lipoproteins (VLDL). Small numbers mitochondria due to the trans- patients with poorly controlled type of patients with the autosomal double bond and generate increased 1 diabetes manifest both lipolysis and recessive abetalipoproteinemia reactive oxygen species (ROS). insulin resistance, yet demonstrate demonstrate severe fatty liver, Trans fats have long been assumed low liver fat.27 This is presumably although their serum triglyceride to contribute to chronic metabolic due to enhanced fatty acid levels are markedly diminished.33 disease, especially atherosclerosis.

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Visceral adiposity Fructose Insulin resistance Adipose tissue lipolysis De novo Q Alcohol. Cross-sectional and lipogenesis prospective studies implicate a Beta-oxidation in dose-dependent effect of alcohol mitochondria in metabolic syndrome and FFA alcoholic steatohepatitis. Alcohol is Circulating Hepatic FFA metabolized to acetyl-CoA, which steatosis Triglycerides preferentially undergoes DNL, Lipotoxic FFA metabolites ApoB100 driving fatty liver disease. While Reactive oxygen species clearly a concern in adults, it is unlikely that alcohol contributes significantly to NAFLD in children. Dietary intake VLDL of fats Inflammation Q Fructose. On average, American Apoptosis NASH Fibrosis children consume 362 calories or the equivalent of 22 teaspoons of sugar daily.44 Fructose metabolism (FIGURE) generates lipogenic substrates (e.g., glyceraldehyde-3-phosphate and acetyl-CoA) in an unregulated FIGURE. This diagram illustrates nonalcoholic fatty liver disease development, highlighting the role of dietary fashion, which are delivered fructose and trans fats. In this model, free fatty acids (FFA) and their metabolites are thought to drive the steatosis, inflammation and fibrosis that are hallmarks of nonalcoholic steatohepatitis (NASH). Sequestering of fatty acids straight to the mitochondria, but in triglyceride droplets (hepatic steatosis) may actually protect against the inflammation and fibrosis that drive also simultaneously driving hepatic progressive NASH. NASH develops when lipid influx into the liver exceeds lipid clearance from the liver. This can DNL, which will either be exported occur through increased fat consumption, of which trans fat intake may be a particularly important component; as triglycerides or overwhelm the increased liver FFA availability from lipolysis of adipose tissue or intrahepatic triglyceride, which is exacerbated by liver’s lipid export capacity, leading insulin resistance; increased de novo lipogenesis, in which new FFA are synthesized using carbohydrates or amino to intrahepatic lipid deposition and acids as substrate; impaired hepatic beta-oxidation of FFA within mitochondria, which can lead to accumulation hepatic steatosis. In case-controlled of FFA; and impaired, very low-density lipoprotein (VLDL) secretion. VLDL secretion from the liver is the major mechanism for triglyceride export. From Perito ER, Rodriguez LA, Lustig RH. Dietary treatment of nonalcoholic studies, sugar-sweetened beverage steatohepatitis. Curr Opin Gastroenterol 2013;29: 170–176. (SSB) consumption is associated with hepatic steatosis, independent of the degree of obesity.45 In other case-controlled studies, total fructose The high trans fat content in fried percent of the amino acids in consumption was associated with and highly processed foods appear the typical Western diet. In the NAFLD.46,47 In adults on high- to specifically cause NAFLD.38,39 anabolic state, they build muscle. carbohydrate diets over 10 weeks, Conversely, monounsaturated lipids However, when provided in excess reduced fat oxidation and increased such as olive oil (oleic acid)40 and beyond anabolic requirements, DNL were seen in those randomized linoleic acid41 (the dietary ligands these classic ketogenic amino to high-fructose but not high- for hepatic PPAR-_) or t-3 fatty acids must be deaminated in diets.48 In adults, high-fructose diets acids42 decrease accumulation of fat the liver to be diverted toward exacerbate dyslipidemia and insulin in the liver. However, trans fats are energy utilization. This supplies resistance more than isocaloric now being removed from our diet too much acetyl-CoA to liver high-glucose diets — with effects because the FDA declared them not mitochondria, leading to liver most pronounced in adults who generally recognized as safe (GRAS). fat formation. BCAA serum already have metabolic syndrome.49 Q Branched-chain amino acids concentrations correlate with Trans fats, BCAAs, alcohol and fructose (BCAAs). Valine, leucine and metabolic syndrome.43 High all share four biochemical properties: isoleucine are essential amino BCAA concentrations are found Q They are metabolized for energy acids that account for > 20 in corn-fed beef, chicken and fish. primarily within the liver.

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Q They are not insulin regulated. protein and fiber content, and the same substitution of sugar for fat, the unleashing Q They do not have a “pop- amount of total carbohydrate. However, of a tsunami of metabolic syndrome and off” mechanism to form we reduced the percent of calories from the emergence of NAFLD as a primary glycogen for storage. dietary sugar from a mean of 28 percent to concern. Indeed, NAFLD is the hepatic Q They overwhelm mitochondrial 10 percent, while substituting isocalorically manifestation of metabolic syndrome57 `-oxidative capacity, leading to with starch. If their weight was declining, and fructose consumption drives each of excessive DNL, which drives we made them eat more. Then we studied the components of metabolic syndrome.58 hepatic insulin resistance them again 10 days later. Every aspect of While added sugar in the diet may not be and fatty liver disease.50 their metabolic health improved, with the sole perpetrator of chronic disease, it is essentially no change in weight. Blood the easiest to identify.59 By speaking with How Is NAFLD Treated? pressure reduced by 5 mmHg, triglycerides one voice, doctors and dentists can argue Treatment of the necroinflammation by 33 mg/dL, LDL by 10 mg/dL and lactate for public health measures to stem the tide associated with NASH can be achieved all improved markedly. Baseline glucose of noncommunicable disease nationwide. Q with pioglitazone,51 which increases the levels reduced by 5 mg/dL, glucose area peroxisomal capacity within hepatocytes, under the curve dropped by 8 percent, ACKNOWLEDGMENT The author acknowledges the assistance of Cristin Kearns, MBA, thus allowing for increased antioxidant fasting insulin dropped by 10 mU/L, DDS; Laura Schmidt, PhD, MSW, MPH; Stan Glantz, PhD; capacity. Other treatments that may hold insulin area under the curve dropped 25 Claire Brindis, DrPH; Jean-Marc Schwarz, PhD; and Kathleen promise include liraglutide and vitamin percent — all improved — on the same Mulligan, PhD, in discussions that made this article possible.

E, although long-term data are not number of calories and without weight REFERENCES available.52 However, these treatments loss, just by removing the added sugar — 1. U.S. Senate. Dietary Goals for the United States. In: do not reduce the hepatic steatosis. and in just 10 days. Furthermore, liver Congress t (ed). U.S. Government Printing Office: Washington, D.C., 1977. fat as measured by magnetic resonance 2. LaBerge AF. How the ideology of low fat conquered Can Fructose Restriction Specifically spectroscopy dropped by 22 percent despite America. J Hist Med Allied Sci 2008;63: 139–177. Reverse NAFLD? no changes in calories or weight, and the 3. Popkin BM, Nielsen SJ. The sweetening of the world’s diet. Obesity Res 2003;11: 1325–1332. Our group has demonstrated the effects reduction in liver fat correlated with the 4. Johnson RK, Appel LJ, Brands M, Howard BV, Lefevre M, of fructose on DNL and liver fat in two improvement in metabolic health.55 Lustig RH, et al. Dietary sugars intake and cardiovascular studies. First, in a crossover trial adults These data strongly argue that NAFLD health. A scientific statement from the American Heart Association. Circulation 2009;120: 1011–1020. consumed an isocaloric diet consisting is a potent, if not the primary driver 5. Rodriguez LA, Madsen KA, Cotterman C, Lustig RH. Added of either high-fructose or high-complex of metabolic dysfunction, especially in sugar intake and metabolic syndrome in U.S. adolescents: carbohydrates for two weeks each. children. These two studies argue that Cross-sectional analysis of NHANES 2005-2012. Public Health Nutr 2016;(in press). Compared to the complex carb diet, the fructose consumption drives development 6. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic high-fructose diet increased DNL and liver of NAFLD apart from its caloric content. syndrome among U.S. adults: Findings from the third National fat by 38 percent.53 Second, our recent Thus, the mechanisms of alcoholic and Health and Nutrition Examination Survey. JAMA 2002;287: 54 356–359. paper in the journal Obesity documents nonalcoholic fatty liver disease are quite 7. Welsh JA, Karpen S, Vos MB. Increasing prevalence the effects of isocaloric substitution similar, even if the substrate is different, of nonalcoholic fatty liver disease among United States of sugar with starch in 43 Latino and as fructose and ethanol are metabolized adolescents, 1988-1994 to 2007-2010. J Pediatr 2013;162: 56 496–500. African-American children with metabolic virtually identically in the liver. 8. Schwimmer JB, Deutsch R, Kahen T, Lavine JE, Stanley C, syndrome over a 10-day period. On Day 0, Behling C. Prevalence of fatty liver in children and adolescents. we assessed their metabolic health on their Conclusion Pediatrics 2006;118: 1388–1393. 9. Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt home diet using baseline lab tests, including Evolutionarily, sugar was a rare EM, Cusi K, et al. The diagnosis and management of lipids and lactate, oral glucose tolerance component of the human diet until the nonalcoholic fatty liver disease: Practice guideline by testing, dual-emission X-ray absorptiometry Industrial Revolution brought refined the American Association for the Study of Liver Diseases, American College of Gastroenterology and the American scanning for body composition and sugar to the masses, and with it, a host Gastroenterological Association. Gastroenterology magnetic resonance spectroscopy for liver, of chronic noncommunicable diseases, 2012;142: 1592–1609. visceral and subcutaneous fat. For the next including tooth decay. Furthermore, the 10. Browning JD, Szczepaniak LS, Dobbins R, Nuremberg P, Horton JD, Cohen JC, et al. Prevalence of hepatic steatosis in nine days, we catered their meals to provide ostensibly well-meaning dietary directive an urban population in the United States: Impact of ethnicity. the same caloric content, the same fat, of “low fat” led to the unregulated Hepatology 2004;40: 1387–1395.

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11. Wree A, Broderick L, Canbay A, Hoffman HM, Feldstein novo synthesis of fatty acids to total VLDL-triglyceride secretion Control, 2012. AE. From NAFLD to NASH to cirrhosis — new insights into during prolonged hyperglycemia/hyperinsulinemia in normal 45. Abid A, Taha O, Nseir W, Farah R, Grosovski M, Assy N. disease mechanisms. Nat Rev Gastroenterol Hepatol man. J Clin Invest 1996;98: 2008–2017. consumption is associated with fatty liver disease 2013;10: 627–636. 30. Schwarz JM, Linfoot P, Dare D, Aghajanian K. Hepatic de independent of metabolic syndrome J Hepatol 2009;51: 12. Ludwig J, Viggiano TR, McGill DB, Ott BJ. Nonalcoholic novo lipogenesis in normoinsulinemic and hyperinsulinemic 918–924. steatohepatitis: Mayo Clinic experience with a hitherto subjects consuming high-fat, low-carbohydrate and low-fat, 46. Ouyang X, Cirillo P, Sautin Y, McCall S, Bruchette unnamed disease. Mayo Clin Proc 1980;55: 434–438. high-carbohydrate isoenergetic diets. Am J Clin Nutr 2003;77: JL, Diehl AM, et al. Fructose consumption as a risk factor 13. Moran JR, Ghishan FK, Halter SA, Greene HL. 43–50. for nonalcoholic fatty liver disease. J Hepatol 2008;48: Steatohepatitis in obese children: A cause of chronic liver 31. Barr R, Glass IH, Chawla GS. Reye’s syndrome: Massive 993–999. dysfunction. Am J Gastroenterol 1983;78: 374–377. fatty metamorphosis of the liver with acute encephalopathy. 47. Thuy S, Ladurner R, Volynets V, Wagner S, Strahl S, 14. Adams LA, Lindor KD. Nonalcoholic fatty liver disease. Can Med Assoc J 1968;98: 1038–1044. Königsrainer A, et al. Nonalcoholic fatty liver disease in Ann Epidemiol 2007;17: 863–869. 32. Kotronen A, Seppälä-Lindroos A, Vehkavaara S, Bergholm humans is associated with increased plasma endotoxin and 15. Gitto S, Vukotic R, Vitale G, Pirillo M, Villa E, Andreone P. R, Frayn KN, Fielding BA, et al. Liver fat and lipid oxidation in plasminogen activator inhibitor 1 concentrations and with Nonalcoholic steatohepatitis and liver transplantation. Dig Liver humans. Liver Int 2009;29: 1439–1446. fructose intake. J Nutr 2008;138: 1452–1455. Dis 2016;48: 587–591. 33. Berriot-Varoqueaux N, Aggerbeck LP, Samson-Bouma M, 48. Stanhope KL, Schwarz JM, Keim NL, Griffen SC, Bremer 16. Fabbrini E, Magkos F, Mohammed BS, Pietka T, Abumrad Wetterau JR. The role of the microsomal triglygeride transfer AA, Graham JL, et al. Consuming fructose-sweetened, not NA, Patterson BW, et al. Intrahepatic fat, not visceral fat, is protein in abetalipoproteinemia. Annu Rev Nutr 2000;20: glucose-sweetened, beverages increases visceral adiposity and linked with metabolic complications of obesity. Proc Natl Acad 663–697. lipids and decreases insulin sensitivity in overweight/obese Sci 2009;106: 15430–15435. 34. Bambha K, Belt P, Abraham M, Wilson LA, Pabst M, humans. J Clin Invest 2009;119: 1322–1334. 17. Sung KC, Kim SH. Interrelationship between fatty liver and Ferrell L, et al. Ethnicity and nonalcoholic fatty liver disease. 49. Cox CL, Stanhope KL, Schwarz JM, Graham JL, Hatcher insulin resistance in the development of type 2 diabetes. J Clin Hepatology 2012;55: 769–780. B, Griffen SC, et al. Consumption of fructose-sweetened Endocrinol Metab 2011;96: 1093–1097. 35. Davis JN, Lê KA, Walker RW, Vikman S, Spruijt-Metz D, beverages for 10 weeks reduces net fat oxidation and energy 18. Weiss R, Bremer AA, Lustig RH. What is metabolic Weigensberg MJ, et al. Increased hepatic fat in overweight expenditure in overweight/obese men and women. Eur J Clin syndrome and why are children getting it? In: Braaten D (ed). Hispanic youth influenced by interaction between genetic Nutr 2012;66: 201–208. Year in Diabetes and Obesity, 2012. Ann NY Acad Sci: New variation in PNPLA3 and high dietary carbohydrate and sugar 50. Bremer AA, Mietus-Snyder ML, Lustig RH. Toward York, 2013. consumption. Am J Clin Nutr 2010;92: 1522–1527. a unifying hypothesis of metabolic syndrome. Pediatrics 19. Bradbury MW, Berk PD. Lipid metabolism in hepatic 36. Zelber-Sagi S, Lotan R, Shlomai A, Webb M, Harrari G, 2012;129: 557–570. steatosis. Clin Liver Dis 2004;8: 639–671. Buch A, et al. Predictors for incidence and remission of NAFLD 51. Cusi K, Orsak B, Bril F, Lomonaco R, Hecht J, Ortiz-Lopez 20. Koteish A, Diehl AM. Animal models of steatosis. Semin in the general population during a seven-year prospective C, et al. Long-Term Pioglitazone Treatment for Patients With Liver Dis 2001;21: 89–104. follow-up. J Hepatol 2012;56: 1145–1151. Nonalcoholic Steatohepatitis and Prediabetes or Type 2 21. Lieber CS, Leo MA, Mak KM, Xu Y, Cao Q, Ren C, et 37. Perito ER, Rodriguez LA, Lustig RH. Dietary treatment Diabetes Mellitus: A Randomized, Controlled Trial. Ann Int al. Model of nonalcoholic steatohepatitis. Am J Clin Nutr of nonalcoholic steatohepatitis. Curr Opin Gastroenterol Med 2016. 2004;79: 502–509. 2013;29: 170–176. 52. Barb D, Portillo-Sanchez P, Cusi K. Pharmacological 22. Romestaing C, Piquet MA, Bedu E, Rouleau V, Dautresme 38. Alkouri N, Dixon LJ, Feldstein AE. Lipotoxicity in management of nonalcoholic fatty liver disease. Metabolism M, Hourmand-Ollivier I, et al. Long-term highly saturated fat nonalcoholic fatty liver disease: Not all lipids are created 2016. diet does not induce NASH in Wistar rats. Nutr Metab (Lond) equal. Expert Rev Gastroenterol Hepatol 2009;3: 445–451. 53. Schwarz JM, Noworolski SM, Wen MJ, Dyachenko A, 2007;4: 4. 39. Tetri LH, Basaranoglu M, Brunt EM, Yerian LM, Prior JL, Weinberg ME, et al. Effect of a high-fructose weight- 23. Westerbacka J, Lammi K, Hakkinen AM, Rissanen A, Neuschwander-Tetri BA. Severe NAFLD with hepatic maintaining diet on lipogenesis and liver fat. J Clin Endocrinol Salminen I, Aro A, et al. Dietary fat content modifies liver fat necroinflammatory changes in mice fed trans fats and a high- Metab 2015;100: 2434–2442. in overweight nondiabetic subjects. J Clin Endocrinol Metab fructose corn equivalent. Am J Physiol Gastrointest Liver 54. Lustig RH, Mulligan K, Noworolski SM, Gugliucci A, Erkin- 2005;90: 2804–2809. Physiol 2008;295: G987–G995. Cakmak A, Wen MJ, et al. Isocaloric fructose restriction and 24. Donnelly KL, Smith CI, Schwarzenberg SJ, Jessurun J, Boldt 40. Nagao K, Inoue N, Wang YM, Shirouchi B, Yanagita T. metabolic improvement in children with obesity and metabolic MD, Parks EJ. Sources of fatty acids stored in liver and secreted Dietary conjugated linoleic acid alleviates nonalcoholic fatty syndrome. Obesity 2015;24: 453–460. via lipoproteins in patients with nonalcoholic fatty liver disease. liver disease in Zucker (fa/fa) rats. J Nutr 2005;135: 9–13. 55. Lustig RH, Wen M, Pan K, Tai V, Erkin-Cakmak A, Gugliucci J Clin Invest 2005;115: 1343–1351. 41. Assy N, Nassar F, Nasser G, Grosovski M. Olive oil A, et al. Reduction of fatty liver after short-term isocaloric 25. Anstee QM, Goldin RD. Mouse models in nonalcoholic consumption and nonalcoholic fatty liver disease. World J fructose restriction in children with metabolic syndrome fatty liver disease and steatohepatitis research. Int J Exp Pathol Gastroenterol 2009;15: 1809–1815. correlates with improvement in insulin dynamics. Obesity 2006;87: 1–16. 42. Cussons AJ, Watts GF, Mori TA, Stuckey BG. Omega-3 Society: Los Angeles, 2015. 26. Roden M. Mechanisms of disease: Hepatic steatosis in fatty acid supplementation decreases liver fat content in 56. Lustig RH. Fructose: It’s alcohol without the “buzz.” Adv type 2 diabetes-pathogenesis and clinical relevance. Nat Clin polycystic ovary syndrome: A randomized controlled trial Nutr 2013;4: 226–235. Pract Endo Metab 2006;2: 335–348. employing proton magnetic resonance spectroscopy. J Clin 57. Yki-Järvinen H. Nonalcoholic fatty liver disease as a cause 27. Perseghin G, Lattuada G, De Cobelli F, Esposito A, Endocrinol Metab 2009;94: 3842–3848. and a consequence of metabolic syndrome. Lancet Diabetes Costantino F, Canu T, et al. Reduced intrahepatic fat content 43. Newgard CB, An J, Bain JR MM, Stevens RD, Lien LF, Haqq Endocrinol 2014;2: 901–910. is associated with increased whole-body lipid oxidation AM, Shah SH, Arlotto M, Slentz CA, Rochon J, Gallup D, 58. Lim JS, Mietus-Snyder M, Valente A, Schwarz JM, Lustig in patients with type 1 diabetes. Diabetologia 2005;48: Ilkayeva O, Wenner BR, Yancy WS Jr., Eisenson H, Musante G, RH. The role of fructose in the pathogenesis of NAFLD and the 2615–2621. Surwit RS, Millington DS, Butler MD, Svetkey LP. A branched- metabolic syndrome. Nat Rev Gastroenterol Hepatol 2010;7: 28. Schwarz JM, Neese RA, Turner S, Dare D, Hellerstein chain amino acid-related metabolic signature that differentiates 251–264. MK. Short-term alterations in carbohydrate energy intake in obese and lean humans and contributes to insulin resistance. 59. Lustig RH, Schmidt LA, Brindis CD. The toxic truth about humans. Striking effects on hepatic glucose production, de Cell Metab 2009;9: 311–326. sugar. Nature 2012;487: 27–29. novo lipogenesis, lipolysis and whole-body fuel selection. J Clin 44. Ervin RB, Kit BK, Carroll MD, Ogden CL. Consumption Invest 1995;96: 2735–2743. of added sugar among U.S. children and adolescents, THE AUTHOR, Robert H. Lustig, MD, MSL, can be reached at 29. Aarsland A, Chinkes D, Wolfe RR. Contributions of de 2005–2008. In: Statistics NCfH (ed). Centers for Disease [email protected].

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® diabetes risk

CDA JOURNAL, VOL 44, Nº10

Understanding the Impact of Added Sugar Consumption on Risk for Type 2 Diabetes

Candice Allister Price, PhD, and Kimber L. Stanhope, BS, MS, PhD

ABSTRACT The association between dietary sugar and type 2 diabetes (T2D) is likely mediated by the unregulated hepatic metabolism of fructose, which promotes hepatic and whole-body insulin resistance. Experimental evidence from clinical studies that utilize sensitive methods to test the effects of added sugar on insulin sensitivity is required. Establishing a causal link between added sugar and insulin resistance will help to stimulate health policies that target the reduction of added sugar consumption and T2D prevention.

AUTHORS

Candice Allister Price, Kimber L. Stanhope, onsiderable epidemiological HFCS and are the most PhD, received her BS, MS, PhD, is an evidence over the past commonly consumed ‘added sugars’ doctorate in endocrinology associate research decade suggests that in the American diet. from the University of nutritional biologist at the California, Berkeley. As University of California, consumption of dietary The term “added sugar” refers to a scientist, she conducts Davis. She specializes in added sugars is linked to sugars that are not naturally occurring research to improve obesity well-controlled, clinical Cthe prevalence or risk for obesity, type in foods. Naturally occurring sugars, also and type 2 diabetes diet studies investigating 2 diabetes (T2D) and cardiovascular known as simple carbohydrates, come prevention efforts. the effects of sugar disease in adults and adolescents.1-9 in the form of (one Conflict of Interest consumption on the Disclosure: None reported. development of metabolic Clinical dietary intervention studies sugar) or (two sugars). disease. provide strong evidence to suggest that Monosaccharides include glucose, Conflict of Interest the link between added sugar intake and fructose and . Disaccharides Disclosure: None reported. risk is causal.10-15 include sucrose (glucose-fructose), However, direct experimental evidence maltose (glucose-glucose) and illustrating a causal relationship between (glucose-galactose). Examples of sources added sugar intake and risk for T2D of naturally occurring sugars include in humans is not as compelling. This , sugar beets, sugar cane, fruit review will discuss the physiological and milk. The two most commonly mechanisms by which consumption of consumed added sugars are sucrose and added sugars may increase risk for T2D, high-fructose (HFCS). Both the research evidence that suggests it does sugars contain fructose and glucose, but and the reason why there is conflicting differ as to chemical structure. Sucrose is a evidence to suggest that it does not. composed of one fructose and

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Sucrose High-fructose corn syrup Glucose Fructose CH OH 2 CH OH CH OH 2 O 2 O O O CH2OH

OH HO OH HO HO HO O CH OH 2 HO OH CH2OH OH OH OH OH

FIGURE. Chemical composition of sucrose versus high-fructose corn syrup.

one glucose as a single molecule, whereas to self-reported data from the National 1999 and 2010,33 coinciding with declines HFCS is composed of both fructose and Health and Nutrition Examination Survey in obesity.34 This is marked progress from glucose as separate monosaccharides (NHANES), U.S. adults consume an the increase of SSB consumption, 11.8 (FIGURE). Sucrose is extracted and average of approximately 15 percent of percent to 21 percent of daily energy purified from sugar cane and sugar beets. daily calories as added sugar.30 Results intake, which occurred between 1965 HFCS is derived from the hydrolysis of from this study30 also demonstrated and 2002.33 Nevertheless, fewer than cornstarch, which produces that added sugar consumption at this 1.5 percent of U.S. adults and children and then isomerization of glucose syrup level was associated with an increased meet the American Heart Association to produce syrup containing 42 percent risk for cardiovascular disease mortality (AHA) criteria for a healthy diet pattern fructose. The fructose in this syrup can of 18 percent over 15 years. for positive cardiovascular health.33 be extracted to produce syrup that is 90 Of the added sugars consumed in The criteria include a target that limits percent fructose. The proportion of the the U.S., approximately 42 percent are the consumption of sweets and bakery fructose to glucose in the final HFCS consumed as SSBs31 and the remainder as desserts to 2.5 50-gram servings/week product is variable depending on how solid food. Added sugars from beverages and SSBs to 4.5 8-ounce servings/week. much of the 90 percent fructose syrup is may affect metabolic function differently In 2013, the average consumption of added to the 42 percent fructose syrup. than added sugar from solid food due sweets and bakery desserts ranged from As described by the Code of Regulation,26 to their more rapid absorption from a low of 3.9 servings/week for Mexican the proportion of fructose in HFCS is the intestine. However, the only report American men to a high of 7.3 servings/ either approximately 42 percent or 55 comparing the chronic effects of solid week for white women. The average percent. However, when analyzed for versus liquid sugar focused mainly on consumption of SSBs ranged from a low fructose content, sodas sweetened with body weight.32 Adults gained significant of 6.8 servings/week for white women to HFCS contained 47 percent to 65 percent amounts of weight after four weeks of a high of 11.7 servings/week for Mexican fructose.27 Unfortunately, food and consuming sucrose in a beverage, but American men. Consumption of added beverage nutrition labels do not provide not after consuming sucrose in jelly sugar from as little as one SSB per day information stating the percentage of beans; the difference between diets was has been shown to be associated with an fructose in the HFCS that is contained in not significant.32 Studies comparing increased risk for T2D between 26 and the product, and thus consumers are not the effects of added sugars in solid 83 percent, with the highest risk seen able to determine how much fructose is foods versus beverages on risk factors amongst young and middle-aged women.35 present in the HFCS they are consuming. for type 2 diabetes and cardiovascular disease are currently lacking, so it Metabolic effects of fructose versus Sugar consumption in the U.S. cannot be assumed that consumption glucose: Is a calorie really just a calorie? exceeds dietary guidelines for of added sugars between these two Much speculation and press has been cardiovascular health. sources have similar metabolic effects. devoted to the adverse health effects The total amount of energy consumed Some improvement in added sugar of consuming HFCS versus sucrose. from naturally occurring sugars in fruit, intake has been observed over the last 13 However, both are fructose-containing vegetables and milk in the American years, mainly due to a large decrease in sugars and fructose is the principal diet is only about 5 percent of total daily SSB consumption.33 SSB consumption reason why added sugar consumption is energy intake.28,29 However, according was shown to have decreased between associated with metabolic disease. Studies

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comparing the consumption of fructose This enzyme is inhibited when hepatic to the ingestion of equal amounts of and glucose (mainly in beverages) in energy status is elevated and there glucose. The fatty acids are turned into humans have demonstrated that fructose is no need for more glucose. As a triglycerides (TG), which increases induces markedly greater metabolic result, the energy-replete liver will liver fat content and upregulates the dysregulation than glucose. Compared stop taking up glucose, and instead, packaging of TG into large, TG- with glucose, fructose has been shown to the glucose will bypass the liver to rich, very-low density lipoprotein-1 increase de novo lipogenesis (DNL) (the the peripheral circulation and be (VLDL-1) particles.47 The VLDL-1 synthesis of new fatty acids),36 inhibit distributed to other tissues. The is sent into the circulation leading to fat oxidation (the conversion of fat to metabolism of fructose in the liver, increased levels of postprandial TG, energy),37 increase liver fat content,38 on the other hand, is not regulated one of the first and most consistent increase blood lipids20,36,39,40 and uric because its rate-limiting enzyme, effects of fructose consumption.45,48,49 acid41 and decrease liver39 and whole- fructokinase, is not inhibited in With continued fructose consumption, body insulin sensitivity.36 However, all response to increased hepatic energy the increased TG production may of these studies utilized overfeeding status. Instead, fructokinase remains also lead to increased fat stores in the or ad libitum (unrestricted eating) liver.42 Increasing levels of hepatic dietary protocols, making it difficult lipids, particularly diacylglycerol to separate the effects of fructose from (DAG), prevents proper activation the effects of positive energy balance/ The uninhibited uptake of of the insulin receptor50 and may lead weight gain. Therefore, Schwarz and fructose causes a substrate to hepatic insulin resistance.39,42 42 colleagues recently investigated the overload that leads to increased Insulin resistance, a risk factor effects of fructose compared with starch for T2D, cardiovascular disease and using a crossover, energy-balanced DNL and inhibited fat oxidation metabolic syndrome, is the state when dietary protocol. They found, even in compared to the ingestion of insulin’s ability to do its many jobs is the absence of positive energy balance equal amounts of glucose. impaired. In the liver, one of these jobs and weight gain, subjects exhibited is to suppress hepatic glucose production, increased DNL, decreased fat oxidation, and thus, hepatic insulin resistance is increased liver fat and blood lipids measured by upregulation of hepatic and decreased hepatic (liver) insulin active at all times, regardless of the glucose production. Another role of sensitivity when consuming the fructose liver’s need for energy. As a result, the insulin in the liver is to suppress the diet. This study challenges the notion ingested fructose will be rapidly taken production and secretion of VLDL. that a calorie is a calorie and clearly up and metabolized almost exclusively Therefore, when fructose consumption demonstrates that the adverse metabolic by the liver43,44 and very little will leads to hepatic insulin resistance, hepatic effects of fructose overconsumption reach the peripheral circulation45 glucose production is upregulated,51 are not dependent on positive energy to be utilized by other tissues. and VLDL production and secretion, balance and body weight gain. which was already upregulated by the The uninhibited uptake of fructose increased liver fat content,47 is further Regulation of glucose and fructose by the liver leads to metabolic upregulated.52 DNL in the normal liver metabolism in the liver is not identical. dysregulation. is activated by insulin, but ironically, the Although fructose and glucose The rapid absorption and metabolism insulin-resistant liver remains sensitive are both monosaccharides and have of fructose within the liver triggers a to insulin’s stimulation of hepatic lipid identical chemical composition cascade of metabolic consequences. The production.53 This is called “selective

(C6H12O6), their metabolisms are liver can synthesize both glucose and insulin resistance.” Thus, when insulin not identical. Both sugars exit the fructose into fatty acids by the process binds to the receptor, the downstream intestine via the portal vein and are of DNL. However, the uninhibited signaling that inhibits glucose and VLDL delivered directly to the liver. Glucose uptake of fructose causes a substrate production in the liver is impaired, while metabolism in the liver is regulated by overload that leads to increased DNL46 the signaling that upregulates DNL an enzyme called phosphofructokinase. and inhibited fat oxidation37 compared remains intact. This continued activation

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of DNL in the insulin-resistant liver very colleagues have suggested that circulating in small dense LDL-C and LDL-C likely exacerbates the effects of sustained uric acid has a contributory causal role during consumption of fructose and fructose consumption, resulting in even in the development of T2D due to its sucrose that were higher than those higher increases of liver TG production, adverse effects on insulin sensitivity during consumption of glucose.20,39 liver fat accumulation, insulin resistance and on the pancreatic beta cell.67,68 Total cholesterol, fasting TG and liver and VLDL production.54,55 Increased fat content were increased in subjects and sustained VLDL production leads Sucrose and high-fructose corn syrup consuming sucrose-sweetened cola to dyslipidemia consisting of not just impair lipid metabolism. compared to subjects consuming diet higher levels of postprandial TG, but It is evident that glucose and fructose cola, water or isocaloric amounts of also increases in other risk factors for are metabolically different; however, low-fat milk for six months.22 Similarly, cardiovascular disease. These include these monosaccharides are not typically a recent study demonstrated dose- low-density lipoprotein cholesterol consumed as added sugars. Therefore, dependent elevations in body weight, (LDL-C), apolipoprotein B,56 small dense studies investigating the effects of plasma levels of postprandial TG, fasting LDL-C57 and apolipoprotein CIII.58 consuming sucrose and HFCS are more and postprandial LDL-C, apolipoprotein Continued exposure to high levels of B, apolipoprotein CIII and uric acid postprandial TG in the blood may lead following two weeks consumption of to lipid accumulation within the muscle beverages containing 0, 10, 17.5 and 25 22 25 cell. Intramyocellular lipid content is Recent evidence suggests that percent energy requirement as HFCS. negatively correlated with whole-body These studies suggest that consumption insulin sensitivity,59 possibly because, circulating uric acid is strongly of both sucrose and HFCS increase risk as in the liver, DAG prevents proper associated and predictive of factors for cardiovascular disease. activation of the insulin receptor.60,61 metabolic syndrome, fatty liver Results from studies in which men Reducing added sugar consumption consumed fructose-sweetened beverages and cardiovascular disease. improves metabolism health. for nine days42 and three weeks39 suggest Three recent dietary intervention that the development of hepatic insulin studies provide direct evidence that resistance precedes the development reducing consumption of added sugar of whole-body insulin resistance. relevant to understanding the metabolic results in beneficial health effects. and health consequences of added sugar Fasting glucose concentrations decreased Uric acid levels increase in response to consumption. There are old and recent in overweight/obese adults who were fructose. studies that provide strong evidence that provided with four servings of water/day as The association of fructose the consumption of sucrose or HFCS replacements for caloric beverages for six consumption with the development and increase risk factors for cardiovascular months.70 In healthy, overweight subjects, prevalence of T2D and cardiovascular disease. More than 30 years ago, Reiser replacing SSBs with artificially sweetened disease may also be related to the effect and colleagues provided insulin-resistant beverages for 12 weeks reduced hepatic of fructose to increase circulating uric subjects standardized, energy-balanced fat content by 74 percent.71 Another acid levels.25,41,62 The rapid absorption diets containing 5, 18 or 33 percent of study in Hispanic and African-American and unregulated metabolism of fructose energy as sucrose, each for six weeks. adolescents with metabolic syndrome leads to upregulation of the purine Compared with the 5 percent sucrose demonstrated beneficial results in just nine degradation pathway,44 of which uric diet, total, VLDL- and LDL-cholesterol days. Reducing added sugar intake from acid is an end product. While uric acid’s plasma concentrations increased by 17 27 percent to 12 percent of daily calories, role in gout has been established for percent on the 18 percent sucrose diet with starch replacing the removed added years, more recent evidence suggests and by 22 percent on the 33 percent sugar, lowered blood pressure, body weight, that circulating uric acid is strongly sucrose diet.69 In more recent crossover total triglycerides (TG), low-density and associated and predictive of metabolic studies comparing glucose-, sucrose- and small-density lipoprotein (sdLDL-C and syndrome, fatty liver and cardiovascular fructose-sweetened beverages, Aeberli LDL-C), apolipoprotein B and CIII, small disease.63-66 Furthermore, Johnson and and colleagues observed similar increases and improved glucose tolerance.72,73

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More evidence is needed to determine fasting insulin and glucose levels. Its main hepatic insulin resistance in either study. the direct effect of added sugar advantage is its utility for large population In the study by Aeberli and colleagues, consumption on insulin resistance. studies,78 however, it is frequently used in body weight and BMI were significantly Evidence to support a causal intervention studies with limited samples higher after the glucose intervention relationship between consumption of sizes. Several diet intervention studies that compared to the fructose intervention,39 added sugar and insulin resistance, also have utilized HOMA-IR to index insulin and in the Schwarz study, diet was called reduced insulin sensitivity, is sensitivity have failed to detect effects of specifically designed to maintain energy not as strong as that for consumption dietary sugar manipulations.22,24,71,79,80 balance and body weight throughout both of added sugar and lipid risk factors of Only a few studies have used the interventions.42 As already stated, these cardiovascular disease. Insulin resistance hyperinsulinemic euglycemic clamp two studies support the idea that hepatic is a major risk factor for T2D and is to determine the effects of fructose insulin resistance precedes whole-body defined as a reduction in tissue insulin consumption on insulin sensitivity. In insulin resistance. They also demonstrate response and signaling.74 This results in 2013, researchers in Switzerland reported that HOMA-IR, based on the changes impaired insulin function, which in the significantly reduced hepatic insulin of fasting glucose and insulin, does not liver, as already stated, leads to increased have the sensitivity to detect changes in hepatic glucose production and VLDL hepatic insulin sensitivity. Furthermore, production/secretion. With whole-body Shaibi and colleagues have reported that insulin resistance, the major impairments These two studies HOMA-IR lacked the sensitivity to detect in insulin function lead to reduced changes of whole-body insulin sensitivity uptake of glucose from the blood by support the idea that that were detected by more laborious muscle and other tissue cells and reduced hepatic insulin resistance methods.81 More sensitive measures than removal of lipids from the circulation. precedes whole-body HOMA-IR are necessary to directly assess the impact of consuming sugar on Use of the ‘gold standard’ method insulin resistance. the development of insulin resistance. directly assesses the effects of added A few studies that have used oral glucose sugar on insulin resistance. tolerance tests (OGTT),72,82 or variations Population data show strong of,46,83,84 have detected effects of dietary associations between added sugar sensitivity, indexed by liver glucose sugar manipulations on glucose tolerance. consumption and insulin resistance production, in subjects consuming 80 g of OGTTs are easier and less expensive and T2D.4-8,75,76 In contrast, direct fructose per day for three weeks compared to conduct than the hyperinsulinemic experimental evidence demonstrating to when they consumed 80 g of glucose/ euglycemic clamp. Impaired glucose that added sugar consumption leads day.39 They did not, however, observe tolerance, indexed as a two-hour glucose to a reduction in insulin sensitivity in any differences in whole-body insulin concentration between 140–199 mg/dl humans is sparse. This is partly due to the sensitivity, fasting glucose, fasting insulin during OGTT, is indicative of whole-body variable validity and sensitivity of current and, presumably, HOMA-IR. Schwarz insulin resistance and is a strong predictor methods for assessing insulin sensitivity. and colleagues reported similar results for of future T2D.85 Several investigators The hyperinsulinemic euglycemic clamp their nine-day crossover study comparing have proposed methods for utilizing is considered to be the gold standard for a fructose diet to a complex carbohydrate OGTT outcomes to calculate an index for determining both whole-body insulin diet.42 Again, even though changes in whole-body insulin sensitivity,86-89 and a sensitivity, via insulin-mediated glucose fasting glucose, fasting insulin, HOMA-IR couple of these have been utilized to show disposal and hepatic insulin sensitivity, and whole-body insulin sensitivity were detrimental effects of fructose24,88 or fructose via liver glucose production.77 It is also not detected following either diet, liver and glucose82,86 consumption on whole-body the most difficult and expensive of the glucose production was less suppressed insulin sensitivity. The sensitivity of these methods to conduct. The least expensive when the subjects consumed the fructose methods compared to hyperinsulinemic and easiest method is homeostatic compared with the complex carbohydrate euglycemic clamp in detecting a change in model assessment of insulin resistance diet. Importantly, body weight gain was whole-body insulin sensitivity following a (HOMA-IR), which is calculated from clearly not the mediator for the increase in dietary is unknown.

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Fructose induces metabolic dysfunction is reduced. However, stronger direct 4. Yoshida M, McKeown NM, Rogers G, et al. Surrogate by two pathways. experimental evidence from studies that markers of insulin resistance are associated with consumption of sugar-sweetened drinks and fruit juice in middle and older- Obesity is one of the major risk utilize methods more sensitive than aged adults. J Nutr 2007;137(9):2121–7. factors for insulin resistance, T2D HOMA-IR to test the effects of sucrose 5. Bhupathiraju SN, Pan A, Malik VS, et al. Caffeinated and and cardiovascular disease,90 and and HFCS to promote insulin resistance caffeine-free beverages and risk of type 2 diabetes. Am J 91-95 Clin Nutr 2013;97(1):155–66. both population studies and direct is required to establish a causal link 6. de Koning L, Malik VS, Rimm EB, Willett WC, Hu FB. 25,36,96-98 experimental evidence suggest between added sugar intake and insulin Sugar-sweetened and artificially sweetened beverage that sugar consumption induces weight resistance. Establishing this link will consumption and risk of type 2 diabetes in men. Am J Clin Nutr 2011;93(6):1321–7. gain. This evidence, along with the help to stimulate the implementation 7. Montonen J, Jarvinen R, Knekt P, Heliovaara M, Reunanen evidence that sugar consumption of policy changes targeting T2D and A. Consumption of sweetened beverages and intakes of increases risk factors even in the absence obesity prevention. Policies that help to fructose and glucose predict type 2 diabetes occurrence. J of weight gain,21,42,69,83,84,99 suggests that change the food environment into one Nutr 2007;137(6):1447–54. 8. Palmer JR, Boggs DA, Krishnan S, et al. Sugar- added sugar consumption promotes the that does not promote the development sweetened beverages and incidence of type 2 diabetes development of metabolic disease by of obesity and metabolic disease may lead mellitus in African-American women. Arch Intern Med promoting weight gain and through to behavioral changes in a population 2008;168(14):1487–92. 9. Bremer AA, Auinger P, Byrd RS. Sugar-Sweetened the direct adverse effects of fructose. that is not meeting dietary guidelines. Beverage Intake Trends in U.S. Adolescents and Their Furthermore, it is possible that when Similarly, clinical interventions Association With Insulin Resistance-Related Parameters. J added sugar consumption promotes investigating the effects of dental caries Nutr Metab 2010;Epub 2009 Sep 6. 10. Bernabe E, Vehkalahti MM, Sheiham A, Aromaa A, weight gain, the direct adverse effects and periodontitis on metabolic disease Suominen AL. Sugar-sweetened beverages and dental of fructose (i.e., increased DNL, risk are needed to establish potential caries in adults: A four-year prospective study. J Dent hepatic fat content and hepatic insulin mechanisms of contribution and direct 2014;42(8):952–8. 11. Wilder JR, Kaste LM, Handler A, Chapple-McGruder resistance) are exacerbated. This is causation. Such evidence may lead T, Rankin KM. The association between sugar-sweetened an important possibility to consider to improved dental care and reduced beverages and dental caries among third-grade students in given that the average American diet incidence of periodontal disease. The Georgia. J Public Health Dent 2016;76(1):76–84. 12. Bahekar AA, Singh S, Saha S, Molnar J, Arora R. The 30 contains 50 percent more added sugar health community, including physicians prevalence and incidence of coronary heart disease is than that recommended by the newly and dentists, can have a significant role significantly increased in periodontitis: A meta-analysis. Am revised 2015-2020 Dietary Guideline in attenuating the obesity and T2D crisis Heart J 2007;154(5):830–7. 13. Demmer RT, Jacobs DR Jr., Desvarieux M. Periodontal 100 for Americans and has resulted in by educating their patients about clinical disease and incident type 2 diabetes: Results from the weight gain and obesity in two-thirds research findings and dietary guidelines First National Health and Nutrition Examination Survey of the U.S. adult population.101 that limit add sugar consumption. and its epidemiologic follow-up study. Diabetes Care 2008;31(7):1373–9. 14. DeStefano F, Anda RF, Kahn HS, Williamson DF, Russell Conclusion ACKNOWLEDGMENT CM. Dental disease and risk of coronary heart disease and Substantial evidence from Research conducted by Kimber L. Stanhope, BS, MS, PhD, mortality. BMJ 1993;306(6879):688–91. et al. is funded from NIH grants R01 HL-075675, 1R01 HL- 15. Kjellstrom B, Ryden L, Klinge B, Norhammar epidemiological studies supports a 091333, 1R01 HL-107256 and a University of California, A. Periodontal disease — important to consider in positive association between the Davis, multicampus award. Dr. Stanhope is supported by an cardiovascular disease prevention. Expert Rev Cardiovasc consumption of added sugars and NIH K12 HD051958. Ther 2016;14(9):987–9. 16. Meurman JH, Sanz M, Janket SJ. Oral health, metabolic dysfunction that increases REFERENCES atherosclerosis and cardiovascular disease. Crit Rev Oral risks for T2D and cardiovascular 1. Brown IJ, Stamler J, Van Horn L, et al. Sugar-sweetened Biol Med 2004;15(6):403–13. disease. The evidence from clinical beverage, sugar intake of individuals and their blood 17. Preshaw PM, Alba AL, Herrera D, et al. Periodontitis pressure: International study of macro/micronutrients and and diabetes: A two-way relationship. Diabetologia diet intervention studies testing the blood pressure. 2011;57(4):695–701. 2012;55(1):21–31. effects of sucrose or HFCS on risk 2. Duffey KJ, Gordon-Larsen P, Steffen LM, Jacobs DR Jr., 18. Cotti E, Mercuro G. Apical periodontitis and factors for cardiovascular disease suggest Popkin BM. Drinking caloric beverages increases the risk of cardiovascular diseases: Previous findings and ongoing adverse cardiometabolic outcomes in the Coronary Artery research. Int Endod J 2015;48(10):926–32. that sugar consumption can increase Risk Development in Young Adults (CARDIA) Study. Am J 19. Genco R, Offenbacher S, Beck J. Periodontal disease risk for cardiovascular disease. Recent Clin Nutr 2010;92(4):954–9. and cardiovascular disease: Epidemiology and possible dietary intervention studies also show 3. Welsh JA, Sharma A, Cunningham SA, Vos MB. mechanisms. J Am Dent Assoc 2002;133 Suppl:14S–22S. Consumption of added sugars and indicators of 20. Aeberli I, Gerber PA, Hochuli M, et al. Low to moderate improvement in risk factors for metabolic cardiovascular disease risk among U.S. adolescents. sugar-sweetened beverage consumption impairs glucose disease when intake of added sugar Circulation 2011;123(3):249–57. and lipid metabolism and promotes inflammation in healthy

624 OCTOBER 2016 CDA JOURNAL, VOL 44, Nº10

young men: A randomized controlled trial. Am J Clin Nutr 34. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of high-fructose corn syrup-, sucrose-, fructose- and 2011;94(2):479–85. of obesity and trends in body mass index among glucose-sweetened beverages with meals. Am J Clin Nutr 21. Black RN, Spence M, McMahon RO, et al. U.S. children and adolescents, 1999–2010. JAMA 2008;87(5):1194–203. Effect of eucaloric high- and low-sucrose diets with 2012;307(5):483–90. 49. Teff KL, Elliott SS, Tschop M, et al. Dietary fructose identical macronutrient profile on insulin resistance and 35. Hu FB, Malik VS. Sugar-sweetened beverages and risk reduces circulating insulin and leptin, attenuates vascular risk: A randomized controlled trial. Diabetes of obesity and type 2 diabetes: Epidemiologic evidence. postprandial suppression of ghrelin and increases 2006;55(12):3566–72. Physiol Behav 2010;100(1):47–54. triglycerides in women. J Clin Endocrinol Metab 22. Maersk M, Belza A, Stodkilde-Jorgensen H, et al. 36. Stanhope KL, Schwarz JM, Keim NL, et al. Consuming 2004;89(6):2963–72. Sucrose-sweetened beverages increase fat storage in the fructose-sweetened, not glucose-sweetened, beverages 50. Yu C, Chen Y, Cline GW, et al. Mechanism by which liver, muscle and visceral fat depot: A six-month randomized increases visceral adiposity and lipids and decreases fatty acids inhibit insulin activation of insulin receptor intervention study. Am J Clin Nutr 2012;95(2):283–9. insulin sensitivity in overweight/obese humans. J Clin Invest substrate-1 (IRS-1)-associated phosphatidylinositol 3-kinase 23. Marckmann P, Raben A, Astrup A. Ad libitum intake of 2009;119(5):1322–34. activity in muscle. J Biol Chem 2002;277(52):50230–6. low-fat diets rich in either starchy foods or sucrose: Effects 37. Cox CL, Stanhope KL, Schwarz JM, et al. Consumption 51. Ter Horst KW, Gilijamse PW, Ackermans MT, et al. on blood lipids, factor VII coagulant activity and fibrinogen. of fructose-sweetened beverages for 10 weeks reduces net Impaired insulin action in the liver, but not in adipose tissue Metabolism 2000;49(6):731–5. fat oxidation and energy expenditure in overweight/obese or muscle, is a distinct metabolic feature of impaired fasting 24. Stanhope KL, Bremer AA, Medici V, et al. men and women. Eur J Clin Nutr 2012;66(2):201–8. glucose in obese humans. Metabolism 2016;65(5):757–63. Consumption of fructose and high-fructose corn syrup 38. Lecoultre V EL, Carrel G, Theytaz F, Kreis R, Schneiter 52. Gill JM, Brown JC, Bedford D, et al. Hepatic production increase postprandial triglycerides, LDL-cholesterol P, Boss A, Zwygart K, Le KA, Bortolotti M, Boesch C, Tappy of VLDL1 but not VLDL2 is related to insulin resistance in and apolipoprotein-B in young men and women. J Clin L. Effects of fructose and glucose overfeeding on hepatic normoglycaemic middle-aged subjects. Atherosclerosis Endocrinol Metab 2011;96(10):E1596–605. insulin sensitivity and intrahepatic lipids in healthy humans. 2004;176(1):49–56. 25. Stanhope KL, Medici V, Bremer AA, et al. A dose- Obesity (Silver Spring) 2013;21(4):782–85. 53. Otero YF SJ, and McGuinness OP. Pathway-Selective response study of consuming high-fructose corn syrup- 39. Aeberli I, Hochuli M, Gerber PA, et al. Moderate Insulin Resistance and Metabolic Disease: The Importance sweetened beverages on lipid/lipoprotein risk factors for amounts of fructose consumption impair insulin sensitivity in of Nutrient Flux. J Biol Chem 2014;289(30):20462–69. cardiovascular disease in young adults. Am J Clin Nutr healthy young men: A randomized controlled trial. Diabetes 54. Sparks JD, Sparks CE, Adeli K. Selective hepatic insulin 2015;101(6):1144–54. Care 2013;36(1):150–6. resistance, VLDL overproduction and hypertriglyceridemia. 26. U.S. Food and Drug Administration. Code of Federal 40. Bantle JP, Raatz SK, Thomas W, Georgopoulos A. Arterioscler Thromb Vasc Biol 2012;32(9):2104–12. Regulations Title 21. U.S. Department of Health and Human Effects of dietary fructose on plasma lipids in healthy 55. Stanhope KL. Sugar consumption, metabolic disease Services 2015;3. subjects. Am J Clin Nutr 2000;72(5):1128–34. and obesity: The state of the controversy. Crit Rev Clin Lab 27. Ventura EE, Davis JN, Goran MI. Sugar content 41. Cox CL, Stanhope KL, Schwarz JM, et al. Consumption Sci 2016;53(1):52–67. of popular sweetened beverages based on objective of fructose- but not glucose-sweetened beverages for 10 56. Di Angelantonio E, Sarwar N, Perry P, et al. Major laboratory analysis: Focus on fructose content. Obesity weeks increases circulating concentrations of uric acid, lipids, apolipoproteins and risk of vascular disease. JAMA (Silver Spring) 2011;19(4):868–74. retinol binding protein-4 and gamma-glutamyl transferase 2009;302(18):1993–2000. 28. Economic Research Service. Food Availability (Per activity in overweight/obese humans. Nutr Metab (Lond) 57. Hirayama S, Miida T. Small dense LDL: An emerging Capita) Data System. Version 13 September 2013: United 2012;9(1):68. risk factor for cardiovascular disease. Clin Chim Acta States Department of Agriculture Economic Research 42. Schwarz JM, Noworolski SM, Wen MJ, et al. Effect of a 2012;414:215–24. Service. High-Fructose Weight-Maintaining Diet on Lipogenesis and 58. Zheng C. Updates on apolipoprotein CIII: Fulfilling 29. Wilt TJ, Shaukat A, Shamliyan T, et al. Lactose Liver Fat. J Clin Endocrinol Metab 2015;100(6):2434–42. promise as a therapeutic target for hypertriglyceridemia and intolerance and health. Evid Rep Technol Assess (full rep) 43. Havel PJ. Dietary fructose: Implications for dysregulation cardiovascular disease. Curr Opin Lipidol 2014;25(1):35–9. 2010(192):1–410. of energy homeostasis and lipid/carbohydrate metabolism. 59. Krssak M, Falk Petersen K, Dresner A, et al. 30. Yang Q, Zhang Z, Gregg EW, et al. Added sugar intake Nutr Rev 2005;63(5):133–57. Intramyocellular lipid concentrations are correlated with and cardiovascular diseases mortality among U.S. adults. 44. Mayes PA. Intermediary metabolism of fructose. Am J insulin sensitivity in humans: A 1H NMR spectroscopy study. JAMA Intern Med 2014;174(4):516–24. Clin Nutr 1993;58(5 Suppl):754S–65S. Diabetologia 1999;42(1):113–6. 31. Johnson RK, Appel LJ, Brands M, et al. Dietary sugars 45. Teff KL, Grudziak J, Townsend RR, et al. Endocrine and 60. Samuel VT, Shulman GI. Mechanisms for insulin intake and cardiovascular health: A scientific statement metabolic effects of consuming fructose- and glucose- resistance: Common threads and missing links. Cell from the American Heart Association. Circulation sweetened beverages with meals in obese men and women: 2012;148(5):852–71. 2009;120(11):1011–20. Influence of insulin resistance on plasma triglyceride 61. Herman MA, Samuel VT. The Sweet Path to Metabolic 32. DiMeglio DP, Mattes RD. Liquid versus solid responses. J Clin Endocrinol Metab 2009;94(5):1562–9. Demise: Fructose and Lipid Synthesis. Trends Endocrinol carbohydrate: Effects on food intake and body weight. Int J 46. Stanhope K, Schwarz JM, Keim NL, Griffen SC, Bremer Metab 2016. Obes Relat Metab Disord 2000;24(6):794–800. AA, Graham JL, Hatcher B, Cox CL, Dyachenko A, Zhang 62. Bruun JM, Maersk M, Belza A, Astrup A, Richelsen B. 33. Mozaffarian D BE, Go AS, Arnett DK, Blaha MJ, W, McGahan JP, Seibert A, Krauss RM, Chiu S, Schaefer Consumption of sucrose-sweetened soft drinks increases Cushman M, Das SR, de Ferranti S, Després JP, Fullerton EJ, Ai M, Otokozawa S, Nakajima K, Nakano T, Beysen plasma levels of uric acid in overweight and obese subjects: HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd C, Hellerstein MK, Berglund L, Havel PJ. Consuming A six-month randomised controlled trial. Eur J Clin Nutr SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey fructose-sweetened, not glucose-sweetened, beverages 2015;69(8):949–53. RH, Magid DJ, McGuire DK, Mohler ER 3rd, Moy CS, increases visceral adiposity and lipids and decreases 63. Billiet L, Doaty S, Katz JD, Velasquez MT. Review of Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol insulin sensitivity in overweight/obese humans. J Clin Invest hyperuricemia as new marker for metabolic syndrome. ISRN G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez 2009;119(5):1322–34. Rheumatol 2014;2014:852954. CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan 47. Adiels M, Taskinen MR, Packard C, et al. 64. Cai W, Wu X, Zhang B, et al. Serum uric acid levels and TN, Virani SS, Woo D, Yeh RW, Turner MB; American Overproduction of large VLDL particles is driven nonalcoholic fatty liver disease in Uyghur and Han ethnic Heart Association Statistics Committee; Stroke Statistics by increased liver fat content in man. Diabetologia groups in northwestern China. Arq Bras Endocrinol Metabol Subcommittee. Heart Disease and Stroke Statistics-2016 2006;49(4):755–65. 2013;57(8):617–22. Update: A Report From the American Heart Association. 48. Stanhope KL, Griffen SC, Bair BR, et al. Twenty-four-hour 65. Kuwabara M. Hyperuricemia, Cardiovascular Disease Circulation 2016;133(4):e38–e60. endocrine and metabolic profiles following consumption and Hypertension. Pulse (Basel) 2016;3(3–4):242–52.

OCTOBER 2016 625 diabetes risk

CDA JOURNAL, VOL 44, Nº10

66. Viazzi F, Garneri D, Leoncini G, et al. Serum uric sensitivity, visceral fat and intrahepatic lipids: An supplementation in overweight subjects. Am J Clin Nutr acid and its relationship with metabolic syndrome and exploratory trial. Br J Nutr 2011;106(1):79–86. 2002;76(4):721–9. cardiovascular risk profile in patients with hypertension: 83. Reiser S, Bohn E, Hallfrisch J, et al. Serum insulin and 98. Tordoff MG, Alleva AM. Effect of drinking soda Insights from the I-DEMAND study. Nutr Metab Cardiovasc glucose in hyperinsulinemic subjects fed three different levels sweetened with aspartame or high-fructose corn syrup Dis 2014;24(8):921–7. of sucrose. Am J Clin Nutr 1981;34(11):2348–58. on food intake and body weight. Am J Clin Nutr 67. Johnson RJ, Nakagawa T, Sanchez-Lozada LG, et al. 84. Reiser S, Handler HB, Gardner LB, et al. Isocaloric 1990;51(6):963–9. Sugar, uric acid and the etiology of diabetes and obesity. exchange of dietary starch and sucrose in humans. II. Effect 99. Reiser S, Hallfrisch J, Michaelis OE 4th, et al. Isocaloric Diabetes 2013;62(10):3307–15. on fasting blood insulin, glucose and glucagon and on exchange of dietary starch and sucrose in humans. I. 68. Kanbay M, Jensen T, Solak Y, et al. Uric acid in insulin and glucose response to a sucrose load. Am J Clin Effects on levels of fasting blood lipids. Am J Clin Nutr metabolic syndrome: From an innocent bystander to a Nutr 1979;32(11):2206–16. 1979;32(8):1659–69. central player. Eur J Intern Med 2016;29:3–8. 85. Abdul-Ghani MA, DeFronzo RA. Pathophysiology of 100. United States Department of Health and Human 69. Reiser S, Bickard MC, Hallfrisch J, Michaelis OE 4th, prediabetes. Curr Diab Rep 2009;9(3):193–9. Services and U.S. Department of Agriculture. 2015–2020 Prather ES. Blood lipids and their distribution in lipoproteins 86. Matsuda M, DeFronzo RA. Insulin sensitivity indices Dietary Guidelines for Americans. 8th ed. December 2015. in hyperinsulinemic subjects fed three different levels of obtained from oral glucose tolerance testing: Comparison health.gov/dietaryguidelines/2015/guidelines. sucrose. J Nutr 1981;111(6):1045–57. with the euglycemic insulin clamp. Diabetes Care 101. Flegal KM, Carroll MD, Kit BK, Ogden CL. 70. Tate DF, Turner-McGrievy G, Lyons E, et al. Replacing 1999;22(9):1462–70. Prevalence of obesity and trends in the distribution of caloric beverages with water or diet beverages for weight 87. De Gaetano A1 PS, Matone A, Samson A, Vrbikova body mass index among U.S. adults, 1999–2010. JAMA loss in adults: Main results of the Choose Healthy Options J, Bendlova B, Pacini G. Routine OGTT: A robust model 2012;307(5):491–7. Consciously Everyday (CHOICE) randomized clinical trial. including incretin effect for precise identification of insulin Am J Clin Nutr 2012;95(3):555–63. sensitivity and secretion in a single individual. PLoS One THE CORRESPONDING AUTHOR, Kimber L. Stanhope, BS, MS, 71. Campos V, Despland C, Brandejsky V, et al. Sugar- 2013;8(8):e70875. PhD, can be reached at [email protected]. and artificially sweetened beverages and intrahepatic 88. Beysen C, Murphy EJ, McLaughlin T, et al. Whole-body fat: A randomized controlled trial. Obesity (Silver Spring) glycolysis measured by the deuterated-glucose disposal test 2015;23(12):2335–9. correlates highly with insulin resistance in vivo. Diabetes 72. Lustig RH, Mulligan K, Noworolski SM, et al. Isocaloric Care 2007;30(5):1143–9. fructose restriction and metabolic improvement in children 89. Stumvoll M, Mitrakou A, Pimenta W, Jenssen T, Yki- with obesity and metabolic syndrome. Obesity (Silver Järvinen H, Van Haeften T, Renn W, Gerich J. Use of the Spring) 2016;24(2):453–60. oral glucose tolerance test to assess insulin release and 73. Gugliucci A, Lustig RH, Caccavello R, et al. Short-term insulin sensitivity. Diabetes Care 2000;23(3):295–301. isocaloric fructose restriction lowers apoC-III levels and 90. Sperling LS, Mechanick JI, Neeland IJ, et al. The yields less atherogenic lipoprotein profiles in children with CardioMetabolic Health Alliance: Working Toward a New obesity and metabolic syndrome. Atherosclerosis 2016. Care Model for the Metabolic Syndrome. J Am Coll Cardiol 74. Reaven GM. Pathophysiology of insulin resistance in 2015;66(9):1050–67. human disease. Obesity (Silver Spring) 1995;19(4):868–74. 91. Balcells E, Delgado-Noguera M, Pardo-Lozano R, 75. Bremer AA, Auinger P, Byrd RS. Sugar–Sweetened et al. Soft drinks consumption, diet quality and BMI Beverage Intake Trends in U.S. Adolescents and Their in a Mediterranean population. Public Health Nutr Association With Insulin Resistance-Related Parameters. J 2011;14(5):778–84. Nutr Metab 2010;2010. 92. Bermudez OI, Gao X. Greater consumption of 76. Schulze MB, Manson JE, Ludwig DS, et al. Sugar- sweetened beverages and added sugars is associated sweetened beverages, weight gain and incidence of type with obesity among U.S. young adults. Ann Nutr Metab 2 diabetes in young and middle-aged women. JAMA 2010;57(3–4):211–8. 2004;292(8):927–34. 93. Bremer AA, Byrd RS, Auinger P. Differences in 77. DeFronzo RA, Tobin JD, Andres R. Glucose clamp male and female adolescents from various racial technique: A method for quantifying insulin secretion and groups in the relationship between insulin resistance- resistance. Am J Physiol 1979;237(3):E214–23. associated parameters with sugar-sweetened beverage 78. Dube S, Errazuriz I, Cobelli C, Basu R, Basu A. intake and physical activity levels. Clin Pediatr (Phila) Assessment of insulin action on carbohydrate metabolism: 2010;49(12):1134–42. Physiological and nonphysiological methods. Diabet Med 94. Ludwig DS, Peterson KE, Gortmaker SL. Relation 2013;30(6):664–70. between consumption of sugar-sweetened drinks and 79. Brynes AE, Mark Edwards C, Ghatei MA, et al. A : A prospective, observational analysis. randomised four-intervention crossover study investigating Lancet 2001;357(9255):505–8. the effect of carbohydrates on daytime profiles of insulin, 95. Rhee JJ, Mattei J, Campos H. Association between glucose, non-esterified fatty acids and triacylglycerols in commercial and traditional sugar-sweetened beverages and middle-aged men. Br J Nutr 2003;89(2):207–18. measures of adiposity in Costa Rica. Public Health Nutr 80. Raben A, Holst JJ, Madsen J, Astrup A. Diurnal metabolic 2012;15(8):1347–54. profiles after 14 days of an ad libitum high-starch, high- 96. Raben A, Macdonald I, Astrup A. Replacement of sucrose or high-fat diet in normal-weight never-obese and dietary fat by sucrose or starch: Effects on 14-day ad libitum postobese women. Am J Clin Nutr 2001;73(2):177–89. energy intake, energy expenditure and body weight in 81. Shaibi GQ, Davis JN, Weigensberg MJ, Goran MI. formerly obese and never-obese subjects. Int J Obes Relat Improving insulin resistance in obese youth: Choose your Metab Disord 1997;21(10):846–59. measures wisely. Int J Pediatr Obes 2011;6(2–2):e290–6. 97. Raben A, Vasilaras TH, Moller AC, Astrup A. Sucrose 82. Silbernagel G, Machann J, Unmuth S, et al. Effects compared with artificial sweeteners: Different effects on of four-week very-high-fructose/glucose diets on insulin ad libitum food intake and body weight after 10 weeks of

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Advocating for Soda Taxes: How Oral Health Professionals Fit In

Alisha Somji, MPH; Laura Nixon, MPH; Leeza Arbatman, BA; Pamela Mejia, MS, MPH; Alysha Aziz, RN; Karen Sokal-Gutierrez, MD, MPH; and Lori Dorfman, DrPH, MPH

ABSTRACT Our recent analysis of how soda tax debates appear in the news revealed that oral health professionals seldom appear. By elevating their expert voices, oral health practitioners can contribute new and salient arguments for soda taxes to the public discourse and help advance public policy that improves oral health outcomes. We propose media advocacy strategies that oral health professionals can use to increase their visibility in the news to make the case for soda taxes.

AUTHORS

Alisha Somji, MPH, is Leeza Arbatman, BA, Alysha Aziz, RN, is Lori Dorfman, DrPH, educing the consumption of sugary a research consultant for conducts qualitative a registered nurse and MPH, directs Berkeley drinks is a key public health goal, as Berkeley Media Studies and quantitative media public health researcher Media Studies Group. She sugary drinks are the largest source Group. She holds a research at Berkeley passionate about oversees BMSG’s research, master’s degree in public Media Studies Group. integrating scholarship and media advocacy training, of added sugar in the American 1 health from the University of She holds a bachelor’s clinical knowledge. She strategic consultation and diet and are associated with a Toronto. degree in sociology from is a former Fulbright and education for journalists. Rrange of chronic diseases, including obesity, Conflict of Interest the University of California, currently interns for Doctors She has publications on type 2 diabetes, cardiovascular disease and Disclosure: None reported. Santa Cruz. Without Borders. bmsg.org. dental caries.2,3 From the landmark 1954 Conflict of Interest Conflict of Interest Conflict of Interest Laura Nixon, MPH, Disclosure: None reported. Disclosure: None reported. Disclosure: None reported. Vipeholm Study to national surveys and conducts qualitative and recent epidemiologic studies, evidence quantitative media research Pamela Mejia, MS, MPH, Karen Sokal-Gutierrez, suggests there is a direct link between at Berkeley Media Studies directs qualitative and MD, MPH, is a physician sugar consumption and the risk of dental Group. She holds a quantitative media research trained in pediatrics, caries.4-9 Sucrose has specifically been master’s degree in public at Berkeley Media Studies preventive medicine health from the University of Group. She holds master’s and public health, and highlighted in the literature as cariogenic, California, Berkeley. degrees in nutrition science clinical professor at the contributing to increased metabolic Conflict of Interest and public health from the UC Berkeley-UCSF Joint activity and acid production from bacterial Disclosure: None reported. University of California, Medical Program and UC plaque and demineralization of tooth Berkeley. Berkeley School of Public enamel.5,8,9 Recent studies confirm that Conflict of Interest Health. Disclosure: None reported. Conflict of Interest consuming sugary drinks increases the risk 10,11 Disclosure: None reported. of caries among children. Wilder and colleagues found, for example, that among elementary school children in Georgia, each additional serving of sugary drinks consumed per day increased the risk of experiencing cavities by 22 percent.10

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Oral health professionals see the effects public health and health equity issue We found that tax proponents of sugar and sugary drink consumption with oral health consequences. Too often, regularly made the case for soda taxes on their patients every day, particularly however, their voices are absent from the using health-related arguments. In the in low-income and ethnic minority dialogue about these policy strategies. news, journalists, tax advocates and communities.12 Though preventable, News coverage, which sets and reflects the others most often connected sugary dental caries is the most prevalent public debate about public policy, offers a drinks to obesity (38 percent of articles) chronic disease worldwide13 and the most window through which we can understand and diabetes (34 percent). However, tax common chronic childhood disease in the that dialogue. Based on our recent analysis proponents rarely discussed the negative U.S.14 In California and across the U.S., of how soda tax debates were portrayed oral health implications of sugary drink children from low-income households and in news coverage — and specifically, how intake or the oral health benefits of communities of color are at highest risk for oral health and oral health professionals sugary drink taxes. Indeed, oral health acquiring dental caries and being unable appeared — we identify possible strategies was mentioned in only 2 percent of to get treatment for them.15-17 Untreated for the oral health community to support articles about sugary drink taxes. Though tooth decay can lead to substantial mouth soda tax efforts, particularly using media dental caries are the most prevalent pain and is a leading cause of children’s chronic disease worldwide,13 diabetes school absences in the U.S., compromising was discussed 17 times more frequently their educational potential as well.18,19 and obesity 19 times more frequently Because consumption of sugar and Together with other public than were the oral health consequences sugary drinks is a strong risk factor for of sugary drink consumption. dental erosion and caries across the health professionals, oral Even when oral health did appear lifecourse,3,13 oral health professionals health leaders are increasingly in the news, it was rarely discussed recognize the need for limiting the exploring the potential of substantively. Instead, oral health issues consumption of sugary drinks.20 Together were typically mentioned in passing or with other public health professionals, oral soda taxes as a policy lever. listed among other chronic diseases. For health leaders are increasingly exploring example, one San Francisco Chronicle the potential of soda taxes as a policy letter to the editor referred to “… lever.21-28 Indeed, one of the California diabetes, tooth decay, obesity and the Dental Association’s current policy advocacy. By raising their voices, dentists, myriad other problems that result from priorities is reducing consumption of sugary hygienists and other oral health experts the consumption of sugary drinks …” drinks by supporting taxes and warning can contribute new arguments in favor Dental caries and oral health label policies.29,30 These taxes can reduce of soda taxes to the public dialogue may have been left out of the public consumption of sugary drinks and fund and help advance public health policy debate in part because of the absence health promotion programs.21,22,24,28 In 2013, to improve oral health outcomes. of dentists and other oral health Mexico became the first country to pass professionals in media coverage. The a substantial excise tax on sugary drinks, Berkeley and San Francisco’s Soda soda tax debates in Berkeley and San and within the first year of implementation Tax Debates Francisco featured a range of speakers soda sales decreased by 12 percent, with In 2014, Berkeley and San Francisco promoting the taxes, including campaign the sharpest decline among vulnerable low- voters both considered representatives, city officials, public income residents.31 However, the sugary proposals. Berkeley became the first city health advocates, clinicians, researchers drink industry has fought aggressively in U.S. history to pass a sugary drink and community residents. However, against these policies, spending tens of tax. More than half of voters supported though the Berkeley Dental Society millions of dollars against state and local San Francisco’s proposal, but it lacked was a major supporter of Berkeley’s soda tax proposals in recent years.32 the two-thirds majority of votes needed proposal and a local dentist is part of Dentists and other oral health for it to pass. In a previous analysis, we the city’s new panel of experts to advise professionals can take the lead in making examined news coverage, social media and how to allocate the funds collected,34 the case for soda taxes and framing campaign materials to gauge what types oral health experts were almost entirely overconsumption of sugar as a significant of discourse surrounded the initiatives.33 absent from the media we examined.

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Why Oral Health Needs to Be Part of has gone as far as influencing scientific and does not develop future dentists’ the Conversation research to downplay the implications advocacy skills. A study examining the Dental health professionals have a of sugar consumption. Historically, the participation of American Academy of long history of advancing community industry interfered with the agenda Pediatric Dentistry members in advocacy dental health through advocacy. of the National Institute of Dental found that while 90 percent of respondents The Centers for Disease Control and Research, forcing it to shift priorities supported advocacy as a role for dentists, Prevention listed community water toward vaccines against tooth decay less than half reported taking action fluoridation as one of the top 10 greatest and enzymes to remove dental plaque and only 22 percent were specifically public health achievements of the and away from studying how to restrict trained in advocacy during residency.44 20th century — an achievement that sugar consumption to prevent tooth But dental students are eager to be likely would not have been possible decay.42 More recently, Coca-Cola was more involved in shaping policy. At Texas without oral health professionals criticized for providing millions of dollars A&M University’s Baylor College of promoting institutional change.35 to fund misleading research that shifted Dentistry, for example, students created Oral health practitioners have also the blame for obesity to lack of physical an Advocacy Academy and planned a led advocacy efforts specifically targeting lobby day where they gained experience sugary drinks. In Illinois, for example, interacting and building relationships dentists and the Illinois State Dental with state representatives.45 Indiana Society urged policymakers to impose a Oral health advocates made University School of Dentistry also sugary drink tax. In 2009, 200 dentists introduces students to the policy process converged on the State Capitol to show the case for a soda tax, arguing through an annual Health Policy Forum, support and generate media attention.29 that the funds generated could an evaluation of which showed half of Using these and other media advocacy help open dental clinics and students who participated in the 2009 strategies,36 these oral health advocates forum were more likely to get involved in made the case for a soda tax, arguing assist people in need. political advocacy afterward.46 A recent that the funds generated could help open study from the Journal of Dental Education dental clinics and assist people in need.37 found that dental hygiene students benefit The voices of dentists, hygienists from leadership courses that include and other oral health experts, then, activity and away from the consumption training on legislative advocacy, and that can help shift the public conversation of sugary drinks.43 Dental practitioners ongoing mentorship after graduation around sugary drink regulation — a should be alert to industry influence that is necessary so that practitioners can conversation that is often influenced by can distract from their health goals. continue to develop these skills.47 The forces concerned with profits over health. American Student Dental Association Policies to limit sugary drink consumption Recommendations recognizes advocacy as an important face stiff opposition from the soda and What can oral health professionals aspect of leadership development for . Led by the American do to build the capacity of the field dental students and provides opportunities Beverage Association, the nonalcoholic to advocate for policies to combat for members to develop advocacy skills, beverage industry has spent tens of the adverse effects of sugar? Among including national lobby days.48 There millions of dollars since 2009 defeating other strategies, the field can: are also postgraduate programs that the more than two dozen municipal Make advocacy a part of dental incorporate policy advocacy. Dental public and state sugary drink taxes proposed education. While dentists provide clinical health residencies, such as the one at the across the country.32,38,39 During the most care to individual patients, their advocacy University of California, San Francisco, recent soda tax battles in California, the for dental public health policies at the provide training to dentists in planning, soda industry spent $9.1 million in San community, state and federal levels can evaluating and advocating for policies.49,50 Francisco40 and $2.4 million in Berkeley.41 improve the health of whole populations In short, the field needs comprehensive Oral health professionals also need and shape the future of dental practice. and organized efforts to teach dental to be vigilant and vocal “in their own However, dental training largely ignores students core competencies about oral backyards,” because the sugar industry the role of policy in shaping oral health health policy issues and how to lobby

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their local and state governments. in learning about and successfully using they write on public health issues Integration of these skills into dental media advocacy51,52 — we highlight incorporate oral health perspectives. training can help create a new generation here a few key tactics, including: Contact journalists over social media, of professionals who are equipped with Q Identify policy goals and targets. As send them emails and be proactive the tools to advocate for policies that mentioned above, there is a range in putting stories on their radar. guarantee oral health for everyone. of policies with the potential to Q Become visible and vocal spokespeople. Build coalitions with other stakeholders limit sugary drink intake. A first Oral health professionals see the and assume a seat at the table. Oral health step for creating an effective media effects of sugary drink consumption is part of overall health, and risk factors advocacy strategy is to consider every day and can speak to the for oral disease coincide with risk factors what specific policy change you impact of sugary drinks on the lives for other chronic noncommunicable are trying to achieve, who has and health of their patients. As diseases associated with sugary drink the power to create that change experts, they can use the media to consumption, including obesity, diabetes and who the allies are that can educate the public and build support and cardiovascular disease. Established work with you to achieve it. for soda taxes. They can also recruit dental societies and organizations, such community members who have as the California Dental Association and experienced oral health problems the American Dental Association, can use themselves or whose children have their existing leverage and broad reach to Oral health professionals see been affected. These authentic bring oral health professionals together to the effects of sugary drink voices36 can speak powerfully and participate in advocacy efforts. Oral health consumption every day and effectively about the consequences professionals can also form alliances and of tooth decay and the importance coalitions with those in public health and can speak to the impact of of policies to reduce sugary drink health care. These coalitions will be poised sugary drinks on the lives and consumption in guaranteeing that to make a stronger and more cohesive health of their patients. every child has a healthy smile. case for policies that limit soda intake, such as sugary drink taxes, restrictions Conclusion on sugary drink marketing (company Media coverage of Berkeley and San sponsorships for health organizations, Q Put oral health on the agenda using Francisco’s soda tax debates offers insight schools and sports events) and sugary news and opinion space. To increase into the public dialogue around these drink-free health facilities, public buildings, the visibility of dentists and other high-profile issues. We found that oral schools, childcare centers and sports oral health professionals in public health was largely absent from discussions facilities. As part of these coalitions, dental dialogue about health policy and of health around these policies, but that professionals can bring an oral health related issues, submit blog posts and there are many opportunities for oral lens to advocacy efforts, for example by opinion pieces that provide an oral health professionals to become part of the pushing for the money garnered from health perspective. Some examples conversation. By identifying specific policy soda taxes to go toward funding oral of effective springboards for opinion goals, inserting oral health perspectives health prevention efforts along with pieces include breaking news, the into news and opinion coverage and other health promotion programs. release of new research/data about becoming visible spokespeople, oral health Incorporate media advocacy into broader sugary drinks, controversial behavior professionals can position themselves advocacy efforts. Media advocacy, “the from the soda industry, local events to provide new and powerful health strategic use of mass media to support or holidays connected in the public’s arguments to both policymakers and community organizing to advance a social mind with the policy process or with the public. In other words, oral health or public policy initiative,”36 is a tool that sugar consumption, like Election professionals are well poised to build can amplify and accelerate larger strategic Day or Halloween, respectively. their capacity as media advocates and efforts by dentists to advance policies to Also, reach out to and develop advocate for policies that reduce sugary promote oral health. A range of resources relationships with journalists drink consumption and improve the exist to support oral health advocates to ensure that the news stories oral health of whole populations. Q

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ACKNOWLEDGMENTS 16. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. (2015). Dental news coverage. Research reported in this publication was partially supported caries and sealant prevalence in children and adolescents in 34. Dugdale E. (2015). Berkeley’s new soda tax panel begins by the Global Obesity Prevention Center (GOPC) at Johns the United States, 2011–2012. U.S. Department of Health and its work. www.berkeleyside.com/2015/05/20/berkeleys-new- Hopkins and the Eunice Kennedy Shriver National Institute of Human Services, Centers for Disease Control and Prevention, soda-tax-panel-begins-its-work. Child Health and Human Development (NICHD) and the Office National Center for Health Statistics. 35. Centers for Disease Control and Prevention. (1999). Ten of the Director, National Institutes of Health (OD) under award 17. Pourat N, Finocchio L. (2010). Racial and ethnic disparities great public health achievements — United States, 1900-1999. number U54HD070725. The content is solely the responsibility in dental care for publicly insured children. Health Aff 29(7): MMWR Morbid Mortal Wkly Rep 48(12): 241. of the authors and does not necessarily represent the official 1356–1363. 36. Wallack L, Dorfman L, Jernigan DH, Themba-Nixon M. views of the National Institutes of Health. This work was also 18. Jackson SL, Vann WF Jr., Kotch JB, Pahel BT, Lee JY. (1993). Media Advocacy and Public Health: Power for funded in part by the Voices for Healthy Kids program, a joint (2011). Impact of poor oral health on children’s school Prevention. Sage. initiative of the Robert Wood Johnson Foundation and the attendance and performance. Am J Public Health 101(10): 37. Riopell M. (2009). Dentists seeking tax hike on soda, American Heart Association, and the UC Berkeley Food Institute. 1900–1906. energy drinks. www.pantagraph.com/news/dentists-seeking- Thanks to Susan Hoang for assistance with translation and 19. Seirawan H, Faust S, Mulligan R. (2012). The impact of tax-hike-on-soda-energy-drinks/article_7cca37b6-0a99-5f62- Clancey Bateman and Aron Egelko for research assistance. oral health on the academic performance of disadvantaged a22d-ca1dcbd2dd77.html. children. Am J Public Health 102(9): 1729–1734. 38. Pomeranz JL. (2014). Sugary Beverage Tax Policy: Lessons REFERENCES 20. Beaglehole RH. (2015). Dentists and sugary drinks. J Am Learned From Tobacco. Am J Public Health 104(3): e13-e15. 1. Reedy J, Krebs-Smith SM. (2010). Dietary sources of energy, Dent Assoc 146(2): 73–74. 39. Grynbaum M. (2012, July 1). Soda makers begin their solid fats and added sugars among children and adolescents in 21. Han E, Powell LM. (2013). Consumption Patterns of Sugar- push against New York ban. www.nytimes.com/2012/07/02/ the United States. J Am Diet Assoc 110(10): 1477–1484. Sweetened Beverages in the United States. J Acad Nutr Diet nyregion/in-fight-against-nyc-soda-ban-industry-focuses-on-personal- 2. Basen-Engquist K, Chang M. (2011). Obesity and cancer risk: 113(1): 43–53. choice.html?pagewanted=all&_r=1&. Accessed April 30, 2014. Recent review and evidence. Curr Oncol Rep 13(1): 71–76. 22. Brownell KD, Farley T, Willett WC, Popkin BM, Chaloupka 40. Steinmetz K. (2014). Big Soda Fights Bay Area Tax 3. Vartanian LR, Schwartz MB, Brownell KD. (2007). Effects FJ, Thompson JW, et al. (2009). The Public Health and Proposals. of soft drink consumption on nutrition and health: A systematic Economic Benefits of Taxing Sugar-Sweetened Beverages. N 41. Recipient Committee Campaign Statement: No on D, No review and meta-analysis. Am J Public Health 97(4): Engl J Med 361(16): 1599–1605. Berkeley Beverage Tax. www.berkeleyside.com/wp-content/ 667–675. 23. Powell LM, Chriqui JF, Khan T, Wada R, Chaloupka FJ. uploads/2015/02/Big-Sodas-Final-460.pdf. Accessed Oct. 4. Gustafsson BE, Quensel CE, Lanke LS, Lundqvist C, Grahnen (2013). Assessing the potential effectiveness of food and 6, 2015. H, Bonow BE, et al. (1953). The effect of different levels of beverage taxes and subsidies for improving public health: 42. Kearns CE, Glantz SA, Schmidt LA. (2015). Sugar industry carbohydrate intake on caries activity in 436 individuals A systematic review of prices, demand and body weight influence on the scientific agenda of the National Institute of observed for five years. Acta Odontol Scand 11(3–4): outcomes. Obes Rev 14(2): 110–28. Dental Research’s 1971 National Caries Program: A historical 232–364. 24. Chaloupka FJ, Davidson PA. (2010). Applying tobacco analysis of internal documents. PLoS Med 12(3): e1001798. 5. Moynihan P, Kelly S. (2013). Effect on caries of restricting control lessons to obesity: Taxes and other pricing strategies to 43. O’Connor A. (2015). Coca-Cola funds scientists who shift sugars intake systematic review to inform WHO guidelines. J reduce consumption. publichealthlawcenter.org/sites/default/ blame for obesity away from bad diets. well.blogs.nytimes. Dent Res 0022034513508954. files/resources/tclc-syn-obesity-2010.pdf. com/2015/08/09/coca-cola-funds-scientists-who-shift-blame- 6. Moynihan P. (2005). The interrelationship between diet and 25. Andreyeva T, Long MW, Brownell KD. (2010). The impact for-obesity-away-from-bad-diets. oral health. Proc Nutr Soc 64(04): 571–580. of food prices on consumption: A systematic review of research 44. Lopez-Cepero M, Amini H, Pagano G, Casamassimo P, 7. Sheiham A, James WPT. (2014). A reappraisal of the on the price elasticity of demand for food. Am J Public Health Rashid R. (2013). Advocacy Practices Among U.S. Pediatric quantitative relationship between sugar intake and dental 100(2): 216–222. Dentists. Pediatr Dent 35(2): E49–E53. caries: The need for new criteria for developing goals for sugar 26. Andreyeva T, Chaloupka FJ, Brownell KD. (2011). 45. McGill N. (2015). Texas dental students learn about intake. BMC Public Health 14(1): 863. Estimating the potential of taxes on sugar-sweetened beverages advocacy. Am J Public Health Nations Health; 45(3). 8. Sheiham A. (1983). Sugars and dental decay. Lancet to reduce consumption and generate revenue. Prev Med 46. Yoder KM, Edelstein BL. (2012). Oral health policy forum: 321(8319): 282–284. 52(6): 413–416. Developing dental student knowledge and skills for health 9. Zero D. (2004). Sugars — the arch criminal? Caries Res 27. Chaloupka FJ, Powell LM, Chriqui JF. (2011). Sugar- policy advocacy. J Dent Educ 76(12): 1572–1579. 38(3): 277–285. sweetened beverage taxation as public health policy — lessons 47. Rogo EJ, Bono LK, Peterson T. (2014). Developing Dental 10. Wilder JR, Kaste LM, Handler A, Chapple McGruder T, from tobacco. Choices 26(3). Hygiene Students as Future Leaders in Legislative Advocacy. J Rankin KM. (2015). The association between sugar-sweetened 28. Brownell KD, Frieden TR. (2009). Ounces of prevention — Dent Educ 78(4): 541–551. beverages and dental caries among third grade students in the public policy case for taxes on sugared beverages. N Engl 48. American Student Dental Association. National Dental Georgia. J Public Health Dent 2016 Winter;76(1):76–84. J Med 360: 1805–1808. Student Lobby Day. www.asdanet.org/lobbyday. Accessed 11. Armfield JM, Spencer AJ, Roberts-Thomson KF, Plastow K. 29. Staff. (2009). Illinois dentists push for 5 percent soda tax. May 31, 2016. (2013). Water fluoridation and the association of sugar- www.drbicuspid.com/index.aspx?sec=ser&sub=def&pag=dis 49. American Association of Public Health Dentistry. Accredited sweetened beverage consumption and dental caries in &ItemID=301796. dental public health residencies. www.aaphd.org/accredited- Australian children. Am J Public Health 103(3): 494–500. 30. Major Issues and Priorities. www.cda.org/advocacy/ dental-public-health-residencies. Accessed March 25, 2016. 12. Flores G. (2010). Racial and ethnic disparities in the health legislation/major-legislative-issues. Accessed Jan. 7, 2016. 50. University of California San Francisco School of Dentistry. and health care of children. Pediatrics 125(4): e979–e1020. 31. Colchero MA, Popkin BM, Rivera JA, Ng SW. (2016). Postgraduate programs: Dental public health. dentistry.ucsf. 13. Selwitz RH, Ismail AI, Pitts NB. (2007). Dental caries. Beverage purchases from stores in Mexico under the excise edu/admissions/postgraduate-programs/dental-public-health. Lancet 369(9555): 51–59. tax on sugar sweetened beverages: Observational study. bmj Accessed March 25, 2016. 14. General S. (2000). Oral health in America: A report of 352: h6704. 51. Dorfman L, Herbert S, Woodruff K. (2007). the surgeon general. Rockville: National Institute of Dental and 32. California Center for Public Health Advocacy. (2011). Communicating for change: Making the case for health with Craniofacial Research, National Institutes of Health. Soda Industry Ups Political Spending to Fight Proposed Sugary media advocacy. The California Endowment. 15. Dye B, Li X, Thornton-Evans G. Oral health disparities Drink Taxes. www.kickthecan.info/soda-industry-political- 52. Dorfman L, Krasnow ID. (2014). Public health and media as determined by selected Healthy People 2020 oral health spending. Accessed April 30, 2014. advocacy. Public Health; 35. objectives for the United States, 2009–2010. Hyattsville, Md.: 33. Somji A, Bateman C, Nixon L, Arbatman L, Aziz A, National Center for Health Statistics; 2012. www.cdc.gov/nchs/ Dorfman L. (2016). Soda tax debates in Berkeley and San THE CORRESPONDING AUTHOR, Lauren Nixon, MPH, can be products/databriefs/db104.htm. Accessed Oct. 16, 2014. Francisco: An analysis of social media, campaign materials and reached at [email protected].

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CDA JOURNAL, VOL 44, Nº10

Sugar-Sweetened Beverage Warning Labels: Lessons Learned From the Tobacco Industry

Lucy Popova, PhD

ABSTRACT Tobacco warning labels effectively educate consumers about the harms of tobacco and reduce smoking behavior. Lessons from tobacco warning labels can be applied to developing and implementing warning labels for sugar-sweetened beverages (SSBs). Large pictorial rotating warnings are particularly effective. Dental professionals can be an important voice in countering the industry’s efforts to create controversy around the effects of SSBs and in advocating for effective warning labels based on the evidence from the tobacco warning labels.

AUTHOR

Lucy Popova, PhD, is a Sugar, rum and tobacco are commodities health and medical communities have tobacco control researcher which are nowhere necessaries of life, which been calling for regulating added sugars at The Center for Tobacco are become objects of almost universal in a similar way.2 Consumption of added Control Research and Education at the University consumption and which are therefore sugars has been linked to the development 1 3-5 6-8 9 of California, San Francisco. extremely proper subjects of taxation. of dental caries, obesity, diabetes, She is studying how we can fatty liver disease10 and cardiovascular better communicate about he similarities between “sugar, disease.11,12 Sugar-sweetened beverages the harms of tobacco and rum and tobacco” do not end (SSBs) are the leading source of added other products. 13 Conflict of Interest with them being unneeded yet sugars in the diet. SSBs are beverages Disclosure: None reported. ubiquitous consumer products to which sugar or other caloric sweetener and good candidates for taxes, has been added. Examples of SSBs are Tas Adam Smith pointed out almost two soft drinks, fruit drinks, sports drinks, tea and a half centuries ago. Since then, we and coffee drinks and energy drinks.14 learned that sugar, alcohol and tobacco Sometimes sweetened milk products are also detrimental to health. Alcohol, are included in the SSB category as and particularly tobacco, have become well, but with the caveat that unlike subjects of additional regulations, such as other SSBs, milk contains protein and restrictions on advertisements and sales and other nutrients.14 SSBs typically do health warnings. More recently, the public not comprise 100 percent fruit juice.

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Consumption of SSBs is greater mentioning diseases caused by smoking, among African-Americans and Mexican- such as lung cancer and heart attack, Americans than among Caucasians as Iceland first did in 1969.23 Warnings for both men and women and across moved from the side of the packs to the most age groups.15-17 Consumption is front and the back of the pack (first in also greater among low-income and Saudi Arabia in 1987) and grew larger low-education groups.18 These are the — covering 30 percent, 50 percent, same groups that have higher rates of 80 percent and even 90 percent of the 19-22 obesity, diabetes and other diseases. pack, as Nepal did in 2015. Pictures FIGURE 1. Examples of cigarette warning labels in Lessons learned from tobacco illustrating the health effects of smoking the U.S. (left) and Australia (right). control are applicable to developing appeared in Iceland first in 1985.23 and promoting policies around added Finally, the brand colors and logos were sugars. Public health advocates, including removed from the packs and replaced this product is not recommended by the dental professionals, could use the with a drab olive color, pioneered State of South Dakota. The use thereof tools, strategies and policies of tobacco by Australia in 2012 (FIGURE 1). may result in cancer or heart disease.”28 control to reduce the negative impact Previously secret internal tobacco The bill passed in the South Dakota of added sugars on population health. industry documents chronicle the history Senate by a small majority. The tobacco One such policy is warning labels on of the tobacco industry’s resistance to the industry mobilized tobacco distributors, sugar-sweetened beverages. This article implementation of warning labels and agricultural and business groups and provides an overview of what we know reveal that tobacco companies made it others.29 A governor of North Carolina, about tobacco warning labels, what their policy to “avoid health warnings a tobacco-growing state, threatened to types of labels are particularly effective on all tobacco products for just as long retaliate by labeling the farm products and how these lessons can be translated as we can”24 because of their potential from South Dakota as coming from to SSB warning labels policymaking. effectiveness. These internal tobacco the soil with the “highest content in industry documents are housed in the the nation of selenium, a well-known History of Tobacco Warning Labels University of California, San Francisco, poison.”27 Newspapers in other tobacco- The U.S. was the first country in the Truth (formerly Legacy) Tobacco Industry growing states, such as West Virginia, world to require a health warning on Documents Library. This library contains asked whether bread, butter and meat cigarette packages. This earliest warning more than 80 million documents and produced in South Dakota and linked label appeared in 1966 on the side of is available as a free online resource, to obesity and heart disease should be cigarette packs and read, “Caution: industrydocuments.library.ucsf.edu/ labeled with skull and crossbones as well.30 Cigarette Smoking May Be Hazardous to tobacco, to researchers all over the world. The bill was defeated in the House.31 Your Health.” U.S. labels were updated Sen. Wallace Bennett (R-Utah) put Following South Dakota, between slightly over the years to change the forth the first proposal for a warning 1959 and 1961, Utah and New York copy, but remained in the same place label on cigarettes in 1957.25 It read, proposed skull and crossbones labels, — the side of the package. Although “Warning, prolonged use of this product while Massachusetts and Missouri Congress authorized the U.S. Food and may result in cancer, in lung, heart proposed textual health warnings.31 None Drug Administration (FDA) in 2009 to and circulatory ailments and in other of these legislative proposals passed. develop and implement new pictorial diseases.”26 However, the legislation As the momentum of the legislative warning labels, the first set of warning didn’t pass until eight years later, and proposals demanding warnings on labels was struck down in court and today then in a much weaker form, as described cigarettes and continued accumulation of cigarette packs still carry the same four above. The first pictorial warning label scientific evidence linking smoking and labels first introduced in 1985 FIGURE( 1). was proposed to be on state cigarette tax disease made warnings inevitable, tobacco The rest of the world moved on. stamps in South Dakota in 1959 by Sen. companies were determined to influence Driven by the motivation to make Donald Stransky, who was a heavy smoker the content of these warnings to minimize warnings more effective, written himself.27 The picture would feature skull their effectiveness, saying, “it has been warnings became more specific, explicitly and crossbones with the words “The use of our policy to resist any mention of specific

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diseases.”24 The first U.S. cigarette warning tobacco companies claimed that these the majority of residents supported the label, “Caution: Cigarette Smoking labels unjustifiably and inappropriately introduction of pictorial warning labels May Be Hazardous to Your Health” violated their First Amendment rights by between 2007 and 2012, although after was originally proposed by the Federal compelling them to disseminate anti- the specific labels were introduced by the Trade Commission (FTC) as, “Caution: tobacco messages for the government. FDA in 2011 the support among current Cigarette Smoking Is Dangerous to Two different challenges were brought up smokers (those who reported smoking Health. It May Cause Death From Cancer and the courts used somewhat different cigarettes in past 30 days) declined from and Other Diseases.”32 The tobacco standards for constitutional review resulting 62 percent in 2011 to 40 percent in 2012.44 industry succeeded not only in curtailing in different outcomes, but ultimately, the People consider warning labels effective in the wording of this health warning but divided United States Court of Appeals for dissuading themselves or other smokers from also in postponing its implementation the District of Columbia Circuit ruled the smoking and pictorial warning labels were date and in prohibiting (preempting) proposed pictorial warning labels as written perceived as more effective than text.45 any local or state governments from to be in violation of the tobacco companies’ passing any laws related to warnings on constitutional right to freedom of speech.39 Research on Tobacco Warning Labels cigarette packaging or advertising.33 The After the implementation of the passage of this law (Federal Cigarette first warning labels in 1966, the FTC’s Labeling and Advertising Act of 1965) 1981 report concluded that the original was called by The Atlantic, “The Quiet Tobacco companies could warning labels were not novel, overexposed Victory of the Cigarette Lobby: How It disassociate themselves from and too abstract to remember and be 34 46 Found the Best Filter Yet — Congress.” these warnings and continue personally relevant. Warning labels, Tobacco companies also worked like advertisements, wear out over time.47 to “always to have warning clauses to argue that tobacco was Written warning labels wear out faster than attributed to an appropriate government not that harmful and continue graphic ones.48,49 In response, Congress authority.”24 This allowed tobacco to confuse smokers. passed a law mandating four rotating companies to continue to dispute the warnings. Studies on them began appearing claims about the harmful effects of in the late 1980s, demonstrating that tobacco. Because the government was several years after the implementation, the source of the warnings, the tobacco A detailed discussion of the different those written labels on cigarette packs were companies could disassociate themselves levels of scrutiny and the court’s decision also not noticed and not remembered by from these warnings and continue to making is available elsewhere.40,41 In brief, smokers and adolescents.50-53 Since then, argue that tobacco was not that harmful the court ruled that the government did the diffusion and evolution of tobacco and continue to confuse smokers, despite not provide sufficient evidence that the warning labels have been propelled by conclusive scientific evidence.24 proposed warning labels would lower observational and experimental studies The warning created by this act and smoking rates. The FDA chose not to showing the effectiveness of large graphic later weak warnings were successfully appeal to the Supreme Court; instead, it warning labels in informing consumers used by the tobacco companies to seek revoked its pictorial warning regulation about the health harms of smoking and immunity from litigation in state and but promised to continue research and reducing their smoking behavior.45,54 federal jurisdictions35,36 and then in the develop new warning labels.42 As of June Warning labels are noticed, read and Supreme Court.37 They argued that 2016, the FDA had not announced any remembered. Both smokers and nonsmokers the federally mandated warning label further regulatory developments regarding notice warning labels on cigarettes and was sufficient for consumers to be fully pictorial warning labels on cigarettes. recall their content.54 For example, in an informed about the risks of smoking. While tobacco companies oppose Australian study, among the new written Most recently, tobacco companies warning labels, consumers actually warning labels, the most frequently recalled sued the FDA when it required nine new support them. A national survey in were “Smoking kills” and “Smoking in pictorial warning labels to cover 50 percent Brazil showed that 76 percent approved pregnancy harms your baby.”55 A meta- of the front and back of cigarette packs of pictorial warning labels, including analysis of experimental studies showed that and 20 percent of advertisements.38 The 73 percent of smokers.43 In the U.S., pictorial warning labels attract attention

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and keep it longer than written warning determine unique causal effects of warning labels, but that the differences in recalling labels when they are implemented along the content of the warning labels were with other policies, such as smoke-free not significant between written and laws. Nonetheless, a quasi-experimental pictorial labels.45 Another study showed study parsing out the effects of other that graphic warning labels on tobacco policies estimated that implementation of advertisements, compared to small graphic warning labels in Canada reduced copy-only warnings capture attention smoking rates by 2.87 to 4.68 percentage quicker and hold it longer, resulting in points.62 In addition, a recent randomized better recall of the warning’s message.56 clinical trial demonstrated that smokers Warning labels increase knowledge whose packs had large graphic warning of the risks of smoking. Noticing labels were more likely to attempt to quit warning labels is related to a greater smoking during the four-week clinical trial FIGURE 2. California proposed warning knowledge of health risks of smoking.57 than smokers with copy-only warnings labels on sugar-sweetened beverages. (Source: In countries where a specific disease (40 percent versus 34 percent, or 1.29).63 California Center for Public Health Advocacy www. (such as stroke) was mentioned on publichealthadvocacy.org/resources/warninglabel/ sodawarninglabel.html.) health warnings, more people had the History of Warning Labels on knowledge that smoking causes this Sugar-Sweetened Beverages particular disease than in countries As of April 2016, no health warnings requiring advertisements for SSBs without health warnings concerning this on SSBs have been implemented. displayed on billboards, buses, transit disease.57,58 After new written warning However, there is support for this shelters, posters and stadiums within the labels were introduced in Australia, measure. In California, 78 percent city to carry a warning: “WARNING: smokers increased their knowledge of of registered voters support requiring Drinking beverages with added sugar(s) the harmful constituents of smoke.55 text warning labels on soda or other contributes to obesity, diabetes and tooth Warning labels make smokers think about sugary drinks.64 There have been some decay. This is a message from the City and quitting. In countries with pictorial or large attempts to pass laws requiring warning County of San Francisco.”73 Baltimore (50 percent of the pack) written warning labels on SSBs. In February 2012, a City Council has been considering labels, more smokers report that labels led bill was introduced in California that requiring warning signs in businesses them to think about stopping smoking.59 would require SSBs to carry a warning: that sell sugar-sweetened beverages.74 For example, 57 percent of Australian “STATE OF CALIFORNIA SAFETY Just as tobacco companies resisted smokers said that warning labels motivated WARNING: Drinking beverages with warning labels on cigarettes, the food them to think about quitting smoking.60 added sugar(s) contributes to obesity, and beverage industry is fighting the Warning labels make smokers quit smoking diabetes and tooth decay”65 (FIGURE 2). implementation of warning labels on and prevent nonsmokers from starting to However, this bill was held in SSBs. Newly discovered sugar industry smoke. Evidence from countries after the committee and did not advance. Another documents reveal that the cane and beet introduction or changes in warning labels attempt to implement this warning label sugar industries have actually been working indicate that these changes are related was undertaken in 2015, but likewise did to resist regulation of sugars, including to reduced numbers of cigarettes smoked not pass the committee.66 The beverage warning labels, since the 1970s.75,76 Their and fewer smokers.54 A recent systematic industry opposed these bills and lobbied main tactic was to influence research review found that implementation of the legislators to make sure they did agenda of the national agencies (such as strengthened warnings (i.e., a switch not advance.67,68 The California Dental the National Caries Program) and produce from copy-only to graphic warning) was Association lent its support to both their own research that would point at associated with increased quit attempts bills.69,70 Similar bills have been proposed causes other than sugar for health issues and short-term smoking cessation and in New York state,71 Hawaii, Vermont and such as dental caries.77 More recently, decreased smoking prevalence in those Washington,72 but as of July 2016 these the American Beverage Association countries.61 However, in observational bills had not yet been passed into laws. argued that warning labels on SSBs are population-level studies it is difficult to San Francisco passed a law in 2015 misleading, that SSBs are not uniquely

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harmful to health and that singling them out is unfair and will not improve public health.78 They claim that the solution to the obesity and diabetes crises lies not in demonizing the SSBs but in educating people on balancing calories consumed and calories spent through exercise.79 During the hearing on the warning labels ordinance in San Francisco, the American Beverage Association brought in a dietician from Washington, D.C.,80 to repeat this argument.81 After the San Francisco Board of Supervisors unanimously passed the FIGURE 3. Examples of potentially ineffective and effective warning labels for soda. ordinance requiring warning labels on (Source: flickr.com/photos/figgenhoffer/3661358131.) advertisements for SSBs, the American Beverage Association, the California Retailers Association and the California “preventable diseases” in front of the to the recommendations for tobacco State Outdoor Advertising Association disease names and another added “type warning labels that were developed based sued the city of San Francisco.82 Their 2 diabetes” to the list of diseases. Parents on empirical evidence. For example, a motion for preliminary injunction that who saw any of these labels (compared warning label should cover no less than would have prevented the ordinance to parents who saw a beverage with no 30 percent (preferably 50 percent) of the from taking effect was denied by the U.S. label or with the American Beverage primary display area of a package. Warning district judge on May 17, 2016. Expert Association’s “Clear on Calories” label that labels should be rotated frequently to keep testimony countering industry claims, depicted the number of calories) believed them novel. They should appear on the including the evidence linking SSBs to that SSBs were less healthy for their child package and on advertisements. Ideally, health effects (such as dental caries) as well and were significantly less likely to select a picture should accompany the written as evidence of the effectiveness of tobacco an SSB for their child from an online warning to make the message more salient warning labels, played an important vending machine. The variations in the and to communicate the message for those role in the judge’s decision.83 On June 8, wording of the warning label (e.g., “weight with low literacy. All of the currently 2016, however, the same judge granted gain” versus “obesity”) did not have a proposed warning labels for SSBs fall a shorter-term injunction that would significant effect on the parents’ perceptions short of the FCTC recommendations. prevent the ordinance from going into or hypothetical purchasing behavior. Two examples of SSB warning labels are effect until his previous ruling is reviewed presented in FIGURE 3. The soda can on the in the U.S. Circuit Court of Appeals.84 What Should Warning Labels on left features a warning label similar to the Soda Look Like? current U.S. alcohol and tobacco warning Research on SSB Warning Labels Lessons from tobacco warning labels labels. The label is positioned vertically, Some research is emerging evaluating can be applied to SSBs to make these while the main product copy is horizontal. reactions to and short-term effects of textual labels more effective. The World Health The use of all capital letters and a text warnings on SSBs. A study evaluated the Organization (WHO) Framework color that blends in with the background effects of different versions of a California Convention on Tobacco Control may also make this label less effective.87 warning label (“SAFETY WARNING: (FCTC)86 provides specific guidance. In contrast, the soda can on the right Drinking beverages with added sugar(s) Adopted in 2003, the FCTC was the has a prominent pictorial warning label contributes to obesity, diabetes and tooth world’s first global public health treaty, and that could be more effective. The image decay”) on parents of 6- to 11-year-old it was signed by 168 countries (the U.S. covers 50 percent of the front surface, children in an online experiment.85 was not one of them). Article 11 of the which makes it easier to see and attract Labels differed in that one used “weight FCTC could be used to guide the design attention.45,86 The copy and the picture gain” instead of “obesity,” another added of the SSB warning labels according focus on one specific disease (tooth

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decay), but this would be part of the set there is no evidence that putting warning Conclusion of rotating pictorial warnings with other labels on one product automatically leads Health warnings on tobacco products labels focusing on obesity and diabetes. to labeling other undesirable products. have been an effective tool for educating Tobacco companies extensively researched When proposing warning labels consumers about the health risks of visual elements for cigarette packs to for SSBs, whether textual or graphic, tobacco. Warning labels are just one make them more eye-catching.87,88 They localities should work with legal counsel of the tobacco control policies that found that a white background, high- in order to pass judicial review. Among are applicable to SSBs. Other policies color saturation and high contrast made other things, advocates of warning labels include mass media campaigns, taxes the design elements stand out. Yellow on SSBs might need to demonstrate and restrictions on marketing and sales, was the most noticeable and memorable that the current advertising for SSBs among others.2,92,93 Dental professionals color, but consumers did not perceive is deceptive and needs to be corrected, are already educating their patients about it as pleasant, associating it with stress propose labels that are based on facts this and other health issues, such as and anxiety. Based on the findings from and are not unjustifiably burdensome smokeless tobacco. The California Dental tobacco industry research, to increase or too broad and convince the court Association94 and the American Dental visible prominence of labels, black copy Association95 provide online, printable on a yellow background could be used. handouts that dental professionals can The warning does not contain attribution use to educate their patients about a to the government source. Attribution Attribution to a government variety of dental issues, including the to a government authority allows the role of sugar. But dental professionals industry to continue to dispute the authority allows the industry should not only educate their patients. science about the harms of the products. to continue to dispute Health advocates, including dentists, Knowing the history of the resistance the science about harms should familiarize themselves with the of tobacco companies to warning labels of the products. history of the tobacco warning labels, and the incipient resistance from the the industry’s tactics to resist warning beverage and sugar industries, putting label regulations and the research on warning labels on sugar-sweetened the effectiveness of warning labels. The beverages will not be an easy public health industry will continue to challenge the task. It would be helpful for advocates to that warning labels would advance a science on health effects of SSBs and any review the arguments the tobacco industry government’s substantial goal (such efforts to put warning labels, including used to avoid, delay and curtail warning as reduce the rates of obesity, diabetes challenging the content and design of labels,24 as well as other strategies of and other diseases or inform consumers the labels. Dentists can lend support to tobacco companies35 and other industries.2 about the harmful effects of SSBs). policymakers to resist these challenges. There are useful summaries available for When choosing whether to pursue Testifying in front of local city councils the arguments that are commonly used by warnings on products, advertisements or and writing or calling state representatives the tobacco industry to combat warning other locations (such as point of sale), or writing editorials to local newspapers96 labels and the ways to counter them.89 advocates should consider several issues. are just some of the ways to do this. Similar resources are now available for It might be easier politically to require Future proposals for SSB warning advocates promoting regulation and warning labels on advertisements because labels should base the design, content, labeling for SSBs.90 For example, the making separate packages for different size and copy versus graphics on the “slippery slope” argument might have localities or states might be seen as evidence from tobacco research. contributed to the defeat of the early too burdensome to the manufacturers More research on the effectiveness of warning labels in the U.S. In Australia, or distributors. Legally, they should SSB warning labels with the stronger when the ominous predictions of tobacco consider if their proposed warning labels design (such as the one suggested in companies failed to materialize, this might be preempted by the federal this paper) should be conducted to argument seemed to have lost its appeal.24 Nutrition Labeling and Education Act preempt further industry challenges. Tobacco control advocates should point (NLEA), which gives the FDA the Lessons from the tobacco warning out the fallacy in this argument that authority to regulate food labeling.91 labels indicate SSB warning labels

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would not be easy to implement, but by 15. United States Department of Agriculture. Materials From id=gymh0045. Accessed April 4, 2016. the Sixth Meeting of the 2010 Dietary Guidelines Advisory 32. United States Department of Health and Human combining emerging scientific evidence Committee, Additional Resources, Charts and Tables: Energy Services. Preventing tobacco use among young people: A with public support and outreach of health From Sugar-Sweetened Beverages. 2010; origin.www.cnpp. report of the Surgeon General. Atlanta: U.S. Department of professionals, this policy might be able to usda.gov/DGAs2010-Meeting6.htm. Accessed July 15, Health and Human Services; 1994. 2016. 33. Centers for Disease Control and Prevention. Selected move forward and be another important 16. Kumanyika S, Grier S, Lancaster K, Lassiter V. Impact of Actions of the U.S. Government Regarding the Regulation tool to promote making informed sugar-sweetened beverage consumption on Black Americans’ of Tobacco Sales, Marketing and Use (excluding laws decisions for healthier food choices. Q health. 2011. pertaining to agriculture or excise tax). 2012; www.cdc. 17. Taveras EM, Gillman MW, Kleinman K, Rich-Edwards JW, gov/tobacco/data_statistics/by_topic/policy/legislation.

ACKNOWLEDGMENT Rifas-Shiman SL. Racial/ethnic differences in early-life risk Accessed March 23, 2016. 34. Drew E. The Quiet Victory of the Cigarette Lobby: How This work was supported by the National Cancer Institute of the factors for childhood obesity. Pediatrics 2010;125(4):686– It Found the Best Filter Yet — Congress. The Atlantic Monthly National Institutes of Health (K99CA187460). The content is 695. vol 216. 1965:76–80. solely the responsibility of the authors and does not necessarily 18. Han E, Powell LM. Consumption patterns of sugar- 35. Arno PS, Brandt AM, Gostin LO, Morgan J. Tobacco represent the official views of the National Institutes of Health. sweetened beverages in the United States. J Acad Nutr Diet 2013;113(1):43–53. industry strategies to oppose federal regulation. JAMA

REFERENCES 19. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence 1996;275(16):1258-1262. 36. Gostin LO, Brandt AM, Cleary PD. Tobacco liability and 1. Smith A. An Inquiry Into the Nature and Causes of the of obesity and trends in the distribution of body mass index public health policy. JAMA 1991;266(22):3178-3182. Wealth of Nations. 1776. among U.S. adults, 1999-2010. JAMA 2012;307(5):491– 37. Cipollone v Liggett Group, 505 US 504,112 SCt 2608, 2. Nestle M, Bittman M. Soda Politics: Taking on Big Soda 497. 2621, (1992). (and Winning). Oxford University Press, USA; 2015. 20. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of 38. R.J. Reynolds Tobacco Co. v. FDA, (D.D.C. 2011). 3. Moynihan P, Kelly S. Effect on caries of restricting sugars obesity and trends in body mass index among U.S. children 39. R.J. Reynolds Tobacco Co. v. FDA, 696 F.3d 1205 (D.C. intake systematic review to inform WHO guidelines. J Dent and adolescents, 1999-2010. JAMA 2012;307(5):483– Cir. 2012). Res 2013:0022034513508954. 490. 40. Consortium TCL. Cigarette Graphic Warnings and the 4. Sheiham A, James W. Diet and dental caries the 21. Braveman PA, Cubbin C, Egerter S, Williams DR, Divided Federal Courts. FDA Tobacco Project. 2015:1-10. pivotal role of reemphasized. J Dent Res Pamuk E. Socioeconomic disparities in health in the United 41. Kraemer JD, Baig SA. Analysis of legal and scientific 2015;94(10):1341-1347. States: What the patterns tell us. Am J Public Health issues in court challenges to graphic tobacco warnings. Am J 5. Bernabé E, Vehkalahti M, Sheiham A, Lundqvist A, 2010;100(S1):S186–S196. Prev Med 2013;45(3):334–342. Suominen A. The Shape of the Dose-Response Relationship 22. Carter JS, Pugh JA, Monterrosa A. Non-insulin-dependent 42. Holder EH Jr. Eric H. Holder Jr. to John Boehner. March Between Sugars and Caries in Adults. J Dent Res diabetes mellitus in minorities in the United States. Ann Intern 15, 2013. http://www.mainjustice.com/files/2013/03/Ltr- 2016;95(2):167–172. Med 1996;125(3):221–232. to-Speaker-re-Reynolds-v-FDA.pdf 6. Woodward-Lopez G, Kao J, Ritchie L. To what extent have 23. Hiilamo H, Crosbie E, Glantz SA. The evolution of health 43. Cavalcante TM. Labelling and packaging in Brazil. sweetened beverages contributed to the obesity epidemic? warning labels on cigarette packs: The role of precedents, Ginebra, Suiza: World Health Organization. 2003. Public Health Nutr 2011;14(03):499–509. and tobacco industry strategies to block diffusion. Tob 44. Kamyab K, Nonnemaker JM, Farrelly MC. Public support 7. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened Control 2014;23(1):e2–e2. for graphic health warning labels in the U.S. Am J Prev Med beverages and weight gain: A systematic review. Am J Clin 24. Chapman S, Carter S. “Avoid health warnings on all 2015;48(1):89–92. Nutr 2006;84(2):274–288. tobacco products for just as long as we can:” A history of 45. Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper 8. Pereira M. The possible role of sugar-sweetened Australian tobacco industry efforts to avoid, delay and dilute JK, Brewer NT. Pictorial cigarette pack warnings: A beverages in obesity etiology: A review of the evidence. Int J health warnings on cigarettes. Tob Control 2003;12(suppl meta-analysis of experimental studies. Tob Control Obes 2006;30:S28–S36. 3):iii13–iii22. 2015:tobaccocontrol-2014-051978. 9. Johnson RJ, Perez-Pozo SE, Sautin YY, et al. Hypothesis: 25. Cigarette smoking and health and related legislation. 46. Myers M, Iscoe C, Jennings C, Lenox W, Minsky E, Could excessive fructose intake and uric acid cause type 2 1970; industrydocuments.library.ucsf.edu/tobacco/docs/ Sachs A. Federal Trade Commission staff report on the diabetes? Endocr Rev 2009;30(1):96–116. xlhw0098. Accessed April 4, 2016. cigarette advertising investigation, May 1981 (public 10. Lim JS, Mietus-Snyder M, Valente A, Schwarz J-M, Lustig 26. Solon urges cigarette labels. Deseret News Jan. 30 version). Division of Advertising Practices, Federal Trade RH. The role of fructose in the pathogenesis of NAFLD and 1965; news.google.com/newspapers?nid=336&dat=1965 Commission. the metabolic syndrome. Nat Rev Gastroenterol Hepatol 0130&id=a6pSAAAAIBAJ&sjid=138DAAAAIBAJ&pg=456 47. Blair MH. An empirical investigation of advertising 2010;7(5):251–264. 0,5742749&hl=en, 363. wearin and wearout. J Advertising Res 2000;40(06):95– 11. Lustig RH, Schmidt LA, Brindis CD. Public health: The 27. Newsweek. Cigarettes: One man’s meat... 1959; 100. toxic truth about sugar. Nature 2012;482(7383):27–29. industrydocuments.library.ucsf.edu/tobacco/docs/ - 48. Borland R, Wilson N, Fong GT, et al. Impact of 12. Yang Q, Zhang Z, Gregg EW, Flanders WD, Merritt id=yrgm0137. Accessed April 4, 2016. graphic and text warnings on cigarette packs: Findings R, Hu FB. Added sugar intake and cardiovascular 28. The Tobacco Institute I. We have just been informed from four countries over five years. Tob Control October diseases mortality among U.S. adults. JAMA Intern Med that the UPI wire carried a story on the introduction... 2009;18(5):358-364. 10.1136/tc.2008.028043 2014;174(4):516–524. 1959; industrydocuments.library.ucsf.edu/tobacco/docs/ - 49. Yong H-H, Fong GT, Driezen P, et al. Adult smokers’ 13. Reedy J, Krebs-Smith SM. Dietary sources of id=hhgc0086. Accessed April 4, 2016. reactions to pictorial health warning labels on cigarette energy, solid fats and added sugars among children 29. Hill F, Knowlton C. Hill and Knowlton’s Recommendations packs in Thailand and moderating effects of type of cigarette and adolescents in the United States. J Am Diet Assoc to the Tobacco Institute. 1959; industrydocuments.library. smoked: Findings from the International Tobacco Control 2010;110(10):1477–1484. ucsf.edu/tobacco/docs/ - id=xyxp0146. Accessed April 4, Southeast Asia Survey. Nicotine Tob Res 2013:nts241. 14. Centers for Disease Control and Prevention. The 2016. 50. Richardson P. Review of the Research Literature on the CDC guide to strategies for reducing the consumption 30. Williamson News. Skull and crossbones. 1959; Effects of Health Warning Labels: A Report to the United of sugar-sweetened beverages. 2010. www.cdph. industrydocuments.library.ucsf.edu/tobacco/docs/ - States Congress, Silver Spring, Md., Macro Systems, Inc. ca.gov/SiteCollectionDocuments/StratstoReduce_Sugar_ id=lrgm0137. Accessed April 4, 2016. ADM. 1987;281:86–0003. Sweetened_Bevs.pdf. 31. Summary of state labelling legislation. 1959; industrydocuments.library.ucsf.edu/tobacco/docs/ - 51. Fischer PM, Richards JW, Berman EJ, Krugman DM.

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Recall and eye tracking study of adolescents viewing as Research Suggests Efficacy. 2016; civileats. Labels on Parents’ Choices. Pediatrics 2016:peds. 2015- tobacco advertisements. JAMA 1989;261(1):84–89. com/2016/01/14/california-soda-warning-label-bill-dies- 3185. 52. Davis RM, Kendrick JS. The Surgeon General’s Warnings as-research-suggests-efficacy. Accessed July 15, 2016. 86. World Health Organization Framework Convention in Outdoor Cigarette Advertising: Are They Readable? 69. Bill Analysis: SB 1000. www.leginfo.ca.gov/ on Tobacco Control. Elaboration of guidelines for JAMA 1989;261(1):90–94. pub/13-14/bill/sen/sb_0951-1000/sb_1000_ implementation of Article 11 of the Convention. 2008. apps. 53. Richards JW, Fischer P, Conner FG. The warnings on cfa_20140528_131714_sen_floor.html. Accessed April who.int/gb/fctc/PDF/cop3/FCTC_COP3_7-en.pdf. cigarette packages are ineffective. JAMA 1989;261(1):45–45. 4, 2016. 87. Lempert LK, Glantz S. Packaging colour research by 54. Hammond D. Health warning messages on tobacco 70. Fact Sheet: SB 203. www.lchc.org/wp-content/uploads/ tobacco companies: The pack as a product characteristic. products: A review. Tob Control 2011;20:327–337. SB-203-SSB-Safety-Warning-Act-fact-sheet-3-9-15.pdf. Tob Control 2016:tobaccocontrol-2015-052656. 55. Borland R, Hill D. Initial impact of the new Australian Accessed April 4, 2016. 88. Lempert LK, Glantz SA. Implications of tobacco industry tobacco health warnings on knowledge and beliefs. Tob 71. New York State Assembly: Bill No. A02320. assembly. research on packaging colors for designing health warning Control 1997;6(4):317–325. state.ny.us/leg/?default_fld=&bn=A02320&term=2015& labels. Nicotine Tob Res 2016:ntw127. 56. Strasser AA, Tang KZ, Romer D, Jepson C, Cappella JN. Summary=Y&Actions=Y&Text=Y&Votes=Y. Accessed April 89. Campaign for Tobacco-Free Kids. Warning Graphic warning labels in cigarette advertisements: Recall 4, 2016. labels: Countering industry arguments. 2011; global. and viewing patterns. Am J Prev Med 2012;43(1):41–47. 72. Kick the Can. Legislative campaigns. www.kickthecan. tobaccofreekids.org/files/pdfs/en/WL_industry_arguments_ 57. Hammond D, Fong GT, McNeill A, Borland R, Cummings info/legislative-campaigns. Accessed April 4, 2016. en.pdf. KM. Effectiveness of cigarette warning labels in informing 73. Sugar-sweetened beverage warning for advertisements. 90. Public Health Advocates. Kick the Can: Giving the boot smokers about the risks of smoking: Findings from the Ordinance No. 100-15. Article 42, Division 1 Sections to sugary drinks. www.kickthecan.info. Accessed July 15, International Tobacco Control (ITC) Four Country Survey. 4200-06: Sugar sweetened beverage warning ordinance. 2016. Tob Control Jun 2006;15 Suppl 3:iii19-25. 10.1136/ www.sfbos.org/ftp/uploadedfiles/bdsupvrs/ordinances15/ 91. ChangeLab Solutions, National Policy & Legal tc.2005.012294. o0100-15.pdf. Accessed April 4, 2016. Analysis Network to Prevent Childhood Obesity (nplan). 58. Thrasher JF, Hammond D, Fong GT, Arillo-Santillán 74. Cohn M. Baltimore officials want warnings on sugary Model Legislation Requiring a Safety Warning for Sugar- E. Smokers’ reactions to cigarette package warnings drinks. Baltimore Sun 2016. Sweetened Beverages. 2014; www.changelabsolutions.org/ with graphic imagery and with only text: A comparison 75. Kearns CE, Glantz SA, Schmidt LA. Sugar industry publications/SSB-safety-warnings. Accessed July 11, 2016. between Mexico and Canada. Salud publica de Mexico. influence on the scientific agenda of the National Institute 92. Ontario Medical Association. Applying lessons learned 2007;49:s233-s240. of Dental Research’s 1971 National Caries Program: from anti-tobacco campaigns to the prevention of obesity. 59. Hammond D, Fong GT, Borland R, Cummings KM, A historical analysis of internal documents. PLoS Med Ont Med Rev 2012(October):12–15. McNeill A, Driezen P. Text and graphic warnings on cigarette 2015;12(3):e1001798. 93. Pomeranz JL. Advanced policy options to regulate packages: Findings from the international tobacco control 76. Taubes G, Couzens CK. Big sugar’s sweet little lies. sugar-sweetened beverages to support public health. J Public four country study. Am J Prev Med 2007;32(3):202–209. Mother Jones 2012. Health Policy 2012;33(1):75–88. 60. Shanahan P, Elliott D. Evaluation of the effectiveness of 77. The . The Sugar Association calls for 94. California Dental Association. Patient fact sheets. www. the graphic health warnings on tobacco product packaging withdrawal of ‘added sugars’ labeling proposal in comments cda.org/public-resources/patient-fact-sheets. Accessed June 2008. Canberra: Australian Government Department of filed to FDA. 2014; www.sugar.org/sugar-association-calls- 30, 2016. Health and Ageing. 2009. withdrawal-added-sugars-labeling-proposal-comments-filed- 95. American Dental Association. Eating habits for a healthy 61. Noar SM, Francis DB, Bridges C, Sontag J, Ribisl fda. Accessed July 11, 2016. smile and body. J Am Dent Assoc 2010;141(12). KM, Brewer NT. The impact of strengthening cigarette 78. American Beverage Association. Misleading Warning 96. Glassman G. Legislature bows down to Big Soda. pack warnings: Systematic review of longitudinal Labels Won’t Improve Public Health. 2015; www.ameribev. 2016; www.sacbee.com/opinion/op-ed/soapbox/ observational studies. Soc Sci Med 2016. 10.1016/j. org/blog/2015/02/misleading-warning-labels-wont- article59364713.html. Accessed April 4, 2016. socscimed.2016.06.011. improve-public-health. Accessed April 4, 2016. 62. Huang J, Chaloupka FJ, Fong GT. Cigarette graphic 79. American Beverage Association. Warning labels won’t THE CORRESPONDING AUTHOR, Lucy Popova, PhD, can be warning labels and smoking prevalence in Canada: A critical work. 2015; www.ameribev.org/blog/2015/03/warning- reached at [email protected]. examination and reformulation of the FDA regulatory impact labels-won%E2%80%99t-work. Accessed April 4, 2016. analysis. Tob Control 2014;23(suppl 1):i7–i12. 80. GMO Answers. Independent Expert Lisa D. Katic RD. 63. Brewer NT, Hall MG, Noar SM, et al. Effect of Pictorial gmoanswers.com/experts/lisa-d-katic-rd. Accessed April 4, Cigarette Pack Warnings on Changes in Smoking Behavior: 2016. A Randomized Clinical Trial. JAMA Intern Med 2016. 81. CBS SF Bay Area. San Francisco Board of Supervisors 64. Field Research Corporation. Voters see a close linkage Approve Health Warnings for Sugary Beverage Ads. 2015; between kids regularly drinking sugary beverages and their sanfrancisco.cbslocal.com/2015/06/09/san-francisco- developing serious health conditions, like type 2 diabetes. board-of-supervisors-approve-health-warnings-for-sugary- Broad-based support for both government and beverage beverage-ads. Accessed April 4, 2016. company actions to address the problem. 2016; www.field. 82. American Beverage Association et al. v City and com/fieldpollonline/subscribers/Rls2529.pdf. Accessed County of San Francisco, 3:15-cv-03415. www.khlaw.com/ March 23, 2016. webfiles/SF sugar warning lawsuit.pdf. 65. SB-1000 Public health: Sugar-sweetened beverages: 83. Shape Up San Francisco. Lawsuit against warnings Safety warnings. leginfo.legislature.ca.gov/faces/ for SSB advertisements. 2016; shapeupsfcoalition.org/ billHistoryClient.xhtml?bill_id=201320140SB1000. resources/heal-legislation/ssblawsuitinfo. Accessed July 15, Accessed April 4, 2016. 2016. 66. SB-203 Sugar-sweetened beverages: Safety warnings. 84. Egelko B. SF’s soda advertising law on hold as industry leginfo.legislature.ca.gov/faces/billHistoryClient.xhtml?bill_ appeals in court. 2016; www.sfgate.com/bayarea/article/ id=201520160SB203. Accessed April 4, 2016. SF-s-soda-advertising-law-on-hold-as-industry-7971253.php. 67. O’Hara J, Musicus A. Big Soda Versus Public Health. 2015; Accessed June 8, 2016. cspinet.org/new/pdf/big-soda-vs-public-health-report.pdf. 85. Roberto CA, Wong D, Musicus A, Hammond D. The 68. Holt S. California Soda Warning Label Bill Dies Influence of Sugar-Sweetened Beverage Health Warning

640 OCTOBER 2016 Specialists in the Sale and Appraisal of Dental Practices Serving California Dentists since 1966 Practices How much is your practice worth?? Wanted Selling or Buying, Call PPS today!

NORTHERN CALIFORNIA SOUTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (888) 440-5957 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 346937 6112 HEALDSBURGLDSBURG IdealIdeal fforor DDDSDS sseekingeeking ppart-timeart-time ppracticerac in ANTELOPE VALLEY Has grossed $1.8 Million. Fantastic location. highly desirable locale or as foundation to grow. 100% out-of- 60,000 autos pass by per day. 8 ops. Partnership for $250,000 or buy all. network. Trending $200,000 in collections with Profits of $105,000. ARCADIA Facility only. 3-ops equipped. $65,000 or $95,000 with Ortho. 6111 SANTA ROSA Perfectly positioned for next Owner. Best BAKERSFIELD AREA 5-ops, next to McDonalds. 1,800 sq.ft. includes building. Grosses $40,000/month. Full Price with building $350,000. equipment, networked and digital including Pano. 3-days of Hygiene. BAKERSFIELD Established 55 years. 5-ops in 3,000 sq. ft. Will do 2016 trending $520,000+ with profits exceeding $250,000. $1 Million. Full Price $300,000. Building available for $350,000. Conservative Owner. Best location. BELLFLOWER Established 60-years. Grossing $350,000. Full Price 6110 CONCORD Well cared for practice. 2015 collected $260,000 in $240,000. 2015. 3-ops. 580 patients. Great curb appeal. Little done in marketing. EAST LOS ANGELES One million Latinos in service area. PPS sold Great merger opportunity for nearby practice. to Seller in 1985. Will do $1 Million in 18 months. Full Price $300,000. EAST SAN FERNANDO VALLEY Absentee Owner. $8,000/month 6109 CALIFORNIA'S NORTH LAKE TAHOE “Best-of-the-best!” Cap Check. 4-ops. Do a Million within a year. Solid foundation anchored by 8.5 days of Hygiene. Consistent $1 INDIO 4,000 sq.ft. dental building. Full Price $650,000. Million per year performer. Beautiful office with unsurpassed views. LADERA RANCH Grossing $650,000. Shopping center location. Enjoy great Alpine lifestyle. LAGUNA NIGUEL Location, location, location! 4-ops with Panorex. 6107 EUREKA 100% out-of-network with insurance industry. Full Price $185,000. Produced $918,000 and collected $895,000 on 20-hour week. LA JOLLA Established 20-years. 3-ops. Grossed $150,000. Super 'RFWRU VVFKHGXOHEooked 3-months out. 7+ days of Hygiene. Highly opportunity with immediate growth. Full Price $150,000. respected. Full price $250,000. LAWNDALE Hi identity. 2 ops . Full price $125,000. 6106 SACRAMENTO'S EL DORADO HILLS No rush and no LOS ANGELES HMO Grossing $1.2 Million. 5-ops. Full Price $1.2 Million. chaos here. Staff is Dream Team. Beautiful facility. 2015 collected LOS ANGELES HMO Does $4 Million.SOLD $640,000. UCR Fees. Very special opportunity. Median household NORCO – CORONA Will do $1.5 Million. 8-ops. Exquisite. Full Price $1.2 Million. income in 2013 was $104,500. Great schools, growing business parks and very upscale community. NORWALK Fantastic high identity location. 5 ops. Full Price $250,000. SOLD 6105 MODESTO Collected $430,000+ on 3-day week. 3-days of ORAL SURGERY PRACTICE – LOS ANGELES Established 40 years. Hygiene. 5-ops. Central location. Successor should open 4th day. ORANGE Beautiful 10 operatory office ready for merger. 6104 SANTA CLARA – CUPERTINO AREA Restorative practice. PASADENA Established 60 years. 7-ops. Always $1+ Million. Full 2015 collected $1.55 Million with Profits of $694,000. Paperless and Price $600,000. digital. Beautiful office. UCR Fees! Extremely attractive selling REDLANDS Shopping center. Grosses $350,000. Full Price $250,000. features available to retain the goodwill. RIVERSIDE Facility only. 4 ops. Full Price $50,000. SOUTH ORANGE COUNTY BEACH CITY Grosses $650,000. 6103 SAN FRANCISCO’S UNION SQUARE Opportunity to 4 ops. Beautiful! acquire highly regarded practice with condo. Beautiful 5-ops, digital PERIO PRACTICE - PRESTIGIOUS BEACH CITY Established and paperless. 6th op available. 2015 collected $658,000. 40 years. 6100 SANTA CLARA Phenomenal launching pad for next Owner. TORRANCE Established 12 years. 5 star building. 3-ops. Grossing Fantastic location, 5-op facility. Management not taking advantage of $250,000. Full Price $195,000. what is possible even though 2015 collected $758,000 with Profits of TUSTIN Dental building. Full Price $1.5 Million. $323,000. Perfectly positioned to be a $1 Million+ year performer VENTURA - OXNARD 5-ops. Grossing $850,000. High identity. Full immediately! Needs young DDS. Price $685,000. YUCCA VALLEY 8/10th of an acre. Great highway visibility. Full 6098 WEST PETALUMA Petaluma is THE business center of the Price $250,000. North Bay! Business parks are growing and young families are drawn to this great family community per the unique amenities of this Seeking Senior Dentists wishing to have more time to enjoy life, be free historic river city. Collected $468,000 with Profits of $199,000. 3-days of management & overhead to join a Dental Cooperative. Call Tom of Hygiene and starting a 4th day in September. Fitterer at 714-832-0230 or cell 714-345-9659. 6089 MOUNT SHASTA Small town living renowned for outdoor **FOUNDERS OF PRACTICE SALES** lifestyle. Best air and water! Escape Rat Race and corporate intrusion. 120+ years of combined expertise and experience! 3-day week collected $881,000. Available Profits totaled $485,000. 3,000+ Sales - - 10,000+ Appraisals Digital radiography including Pano. Full price $350,000. **CONFIDENTIAL** PPS Representatives do not give our business name when returning your calls. *>4280:8F8<68<@4::8<60<30>>?08@8<634?02A824@5=?=C4? E40?@

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           --- $(*," +$ + '% (6=<3  *  RM Matters CDA JOURNAL, VOL 44, Nº10

Understanding the Role of the Better Business Bureau TDIC Risk Management Staff

s recently as a century ago, When a complaint is filed, the BBB will to respond due to patient privacy concerns. unscrupulous companies automatically send it to the business owner The dentist can then attempt to contact peddled an assortment of for a response. However, responding can put the patient and resolve the matter directly. questionable products to a dentist at risk because HIPAA prohibits “The Better Business Bureau is relieve common medical any disclosure of confidential patient not a regulatory agency and responses Aailments. Persuasive salesmen and information, regardless of whether the are not mandatory,” Davis said. deceptive advertising touted these magic patient disclosed his or her information first. Dentists who are accredited members of tonics as miracle cures. Unfortunately, Even acknowledging that the complainant the BBB are required by the terms of their many of these so-called medicines were was a patient of record is a violation of law accreditation to respond. However, they are ineffective at best and deadly at worst. and can set dentists up for liability claims. still required to follow patient privacy laws. Fed up with shady opportunists making For dentists who are not accredited TDIC recommends they submit a generic false claims that tarnished the public members of the BBB, TDIC recommends response, refraining from identifying the perception of their profession, a group of not responding to complaints at all. Dentists patient or disclosing anything that could advertising executives came together to can send a letter stating that they decline be considered private patient information. boost consumer trust. Promoting self- regulation, ethical business practices and truth in advertising, the group is now known as the Better Business Bureau. While the mission of the BBB has stayed the same, its role has changed significantly. Like other consumer protection entities, it can be either a blessing or a curse for You are not a sales goal. business owners, including dentists. Positive ratings through the BBB can help a business grow, but the opposite can happen should a dissatisfied customer file a complaint. The Dentists Insurance Company, TDIC, reports a case in which a patient was unhappy with a stayplate. He showed up to the dental practice unannounced, threw the stayplate, cursed and demanded a refund. The dentist declined the You are a dentist deserving of an insurance company relentless refund, so the patient filed a complaint in its pursuit to keep you protected. At least that’s how we see with the BBB. In another case, a patient it at The Dentists Insurance Company, TDIC. Take our Risk demanded a partial refund of a dentist’s Management program. Be it seminars, online resources or our consultation fee. When the dentist Advice Line, we’re in your corner every day. With TDIC, declined, the patient filed a complaint. “We have been getting an increase in you are not a sales goal or a statistic. You are a dentist. calls to the Risk Management Advice Line about complaints to the Better Business Bureau,” said Sheila Davis, assistant vice ® Protecting dentists. It’s all we do. president, claims and risk management, TDIC. “It is important for dentists to 800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783 know how to protect themselves should they be the subject of a complaint.”

OCTOBER 2016 643 OCT. 2016 RM MATTERS

CDA JOURNAL, VOL 44, Nº10

In another case reported to TDIC, patient information is only accessible being addressed,” Davis said. “Often, the BBB contacted an accredited member to those authorized to have access.” they just want to be heard.” dentist after reading a negative review TDIC recommends that dentists Finding the right balance between of the dentist on a popular review site. address complaints to the BBB the same consumer protection and patient The BBB asked whether the accusations way they would address any patient privacy can be tricky, but it is a crucial outlined in the review were true, complaint: with professionalism and responsibility of all dentists. By arming questioned the dentist’s practices and compassion. Upset or angry patients yourself with accurate information requested she provide copies of treatment often lodge complaints when they and understanding the role the BBB records. The dentist was advised not feel they have no other option for a plays, it is possible to protect yourself to disclose any patient records and to resolution. Dentists should schedule and your practice from risk. Q withdraw membership from the BBB. a consultation, at no charge, to listen “Dentists who fail to protect to the patient’s concerns and offer TDIC’s Risk Management Advice Line patient information can be subject mutually agreed upon solutions. at 800.733.0634 is staffed with trained to disciplinary action,” Davis said. “Patients sometimes file complaints analysts who can answer consumer and “It is their responsibility to ensure because they feel their issues are not other questions related to dental practice.

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644 OCTOBER 2016 (;3(5,(1&(7+(',))(5(1&( t Lee Skarin and Associates has been serving the dental profession since 1959. t Kurt Skarin has over 30 years experience in dental practice sales. t We have sold more practices than any broker in the state within the last 12 months. t Our experienced practice appraisals are backed with credentials unequaled among dental practice brokers. t We provide in-house legal counsel to advise you in all aspects of the sale and purchase, including the tax consequences of the sale. t Excellent financing is available, in most cases for 100% of the purchase price. t With a reputation for experienced, concientious, and ethical performance, we give our clients personal attention in all aspects of the purchase.

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With scores of Buyers, profiles of their practice interests and financial ability, /HH6NDULQ $VVRFLDWHV is able to find the right buyer for your practice. 2IÀFHV  Experience the difference. Call Lee Skarin and Associates for responses to all of your questions - No obligation!  Visit our website for current listings: www.LeeSkarinandAssociates.com Dental Practice Brokers CA DRE #00863149 800.752.7461

“Matching the Right Dentist CARROLL to the Right Practice” &COMPANY

CComplete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions

4103 SAN FRANCISCO GP 4104 SAN JOSE GP Vibrant downtown location in historic high-rise bldg. Retiring doctor Seller retiring and ready to transition a 29 year practice located oering 30+ years of goodwill. 4.5 days of hygiene, 1,500+ active close to Westgate Center with close proximity to several amenities, patients, 20-25 new patients/mo. Gorgeous, spacious facility in in a well travelled, commercial and residential neighborhood. 2015 approx. 2,500 sq. ft. 2015 GR $796K. 2014 GR $768K. Average GR $354K+. Asking $244K. adjusted net income $274K+ Asking $599K. 4121 NAPA GP 4129 PETALUMA GP Gorgeous, state-of-the-art oce available in beautiful wine GP located in stunning 1,856 sq. ft. seller owned facility. State-of-the- art oce includes 6 ops, sta lounge, reception area, private oce, country! Incredible location with super high visibility on the corner business oce, lab area, sterilization area, consult room, separate of two major cross streets near Queen of the Valley Hospital. 7 storage area, bathroom plus private bathroom. Asking $525K. ops in 3,250 sq. ft. facility. Seller retiring but would like to transition with buyer after the sale. 2,100+ active patients, 9 days of 4126 HONOLULU GP hygiene, 15-20 new patients/mo. 2015 GR $1.56M, 2014 GR 4 ops in 942 sq. foot oce located in popular local mall. Practice est. $1.62M. Average Adjusted net income of $513K. Asking over 35 years ago, 7 years in current location. Equipment includes $1,151K. digital x-ray, pano & laser. Seller transitioning to retirement. Avg. GR $433K. Asking $279K. 4096 MENDOCINO COUNTY GP Seller oering well est. 48 year practice. Located in outdoorsman's 4108 HUMBOLDT COUNTY GP paradise. Just 2 hours North of SF surrounded by redwood forest, Well-established, high performing general practice boasts 6 fully vineyards and mountains. 950 sq. ft. oce in single level building w/ 4 equipped ops. in 2,900 sq. ft. free standing oce w/Digital X- ray, 2 fully equipped ops. 2014 GR $565. Asking $300K. platinum Dexis sensors, & Cerec Omnicam & MCXL units. Loyal & stable pt. base in charming community, w/ a small town feel. Perfect 4099 MT VIEW DENTAL FACILITY for a dentist who wants to escape the grind and live along the Dental facility oered in a desirable location in the heart of silicon valley. coastline.  Avg. GR $1.4M+, 2016 on schedule for $1.5M+. Seller Great patient population including Google, Apple, and many local willing to help for smooth transition. Asking $1,041K. startups. Excellent for a starter oce to build a patient base or grow your existing patient base here. Approx 1,164 sq feet with 5 plumbed 4091 HOLLISTER GP & PEDIATRIC ops. Asking price for facility only $105K. Country living at it’s best ~ small town feel with aordable housing, in quaint bedroom community to Silicon Valley. Fully equipped 1,600 sq. 4093 SAN JOAQUIN VALLEY ORTHO ft. oce with 2 enclosed adult ops and 3 open pedo ops, near Hazel Established over 35 years with a solid reputation, near several referral Hawkins Hospital. Turn-key practice, great opportunity for a pediatric sources in seller owned building. 2,500 sq. ft. oce with 7 chair open dentist. Approx. 565 active patients. 2015 GR $219K. Seller is bay in professional center on a well-travelled street with many retailers. relocating but will help for a smooth transition. Asking price $125K. Avg. Gross Receipts $763K. Seller retiring and willing to help for smooth transition. Asking $561K. The building is available to purchase 4114 CONCORD GP as well for $608K. Well-established practice oering 30+ yrs of goodwill. Concord is on the verge of redevelopment of the old Naval Weapons Base later this 4105 STANISLAUS COUNTY GP year, which will cover 2,300 acres and include 12,000 housing units. Get away to a less demanding commuter friendly town. Seller retiring The project will include Residential/Commercial/Recreational and Open from practice est. over 30 years ago with loyal patient base in Space. This practice opportunity is strategically located for growth charming community with historic small town feel. 3 fully-equipped potential due the slotted re-development. Oce has 3 fully equipped ops. in 1,200 sq. ft. oce. Approx. 1,400 active pts. w/4 doctor days/ ops in 836 sq. Average GR $360K+ on 2 doctor days.Asking $224K. week. 5 year avg. GR $647K+ w/approx. 50% overhead. Seller willing to help for smooth transition. Asking $375K. 4114 WALNUT CREEK GP Walnut Creek practice in gorgeous facility with recent leasehold improvements plus new and upgraded equipment. Practice has 30+ Carroll & Company years of goodwill. Looking for a mature, experienced practitioner for a 2055 Woodside Road, Ste 160 loyal and mature patient base. Located in commercial center with several amenities and marketing opportunities. Doctor works 2 days Redwood City, CA 94061 per week. Owner available for a smooth transition. Asking $432K. P (650) 362-7004 F (650) 362-7007 4120 SF GP [email protected] Well est. downtown family practice grossing over $1M with an avg. www.carrollandco.info overhead of 61%. 5 fully equipped ops., in remodeled oce. Retiring BRE #00777682 seller works 3.5 Dr. days/week. Seasoned, dedicated sta & loyal ?0C84=C 10B4  ,4AA8K2>??>ACD=8CH 5>A 4G?4A84=243  2>=K34=C 34=C8BC  Mike Carroll Pamela Carroll-Gardiner Asking $806K. PENDING

www.carrollandco.info [email protected] P (650) 362-7004 F (650) 362-7007 Regulatory Compliance CDA JOURNAL, VOL 44, Nº10

Nitrous Oxide Safe Practices CDA Practice Support Staff

Nitrous oxide (N2O) is a clear, Systems Using Infrared Exposures to Nitrous Oxide During colorless, oxidizing liquefied gas with a Thermography to Visualize and Anesthetic Administration, 1994. slightly sweet odor that, when mixed with Control Emissions. J Am Dent Assoc Q Waste Anesthetic Gases, 2008. oxygen, is used for dental anesthesia. It is February 2009 140(2): 190-199. Q Anesthetic Gases: Guidelines considered a nonflammable gas. Inhaling Q Nitrous oxide in the dental office. for Workplace Exposure, 2000. pure nitrous oxide can lead to asphyxiation. ADA Council on Scientific Dental practices using nitrous oxide Affairs; ADA Council on Dental Pregnant Employees should utilize scavenging equipment to Practice. J Am Dent Assoc March Once an employer is notified of a minimize employee exposure to the gas. 1, 1997 128(3): 364-365. pregnancy, the first obligation is to assess Cal/OSHA has established a time- The U.S. National Institute for the risks within the workplace for the weighted average permissible exposure level Occupational Safety and Health pregnant employee. We recommend: (PEL) of 50 ppm for nitrous oxide over an (NIOSH) has online resources for Q Assessing the risks to which a eight-hour day. An employer must monitor controlling nitrous oxide exposure: pregnant woman, a woman who has the work environment if the employer Q Control of Nitrous Oxide in recently given birth or a woman or any employee believes individual staff Dental Operatories, 1996. who is breastfeeding is exposed may be exposed to concentrations in Q NIOSH Alert: Controlling and the length of the exposure. excess of the PEL. Monitoring should be performed until such time that the work environment is within the PEL. Title 8 of the California Code of Regulations, Section 5155 Airborne Contaminants When Looking To Invest In Professional establishes the PEL for nitrous oxide. The appendix to section 5155 explains how Dental Space Dental Professionals Choose to compute exposure levels and includes a link to the table of permissible exposure limits for all identified air contaminants. Vendors that provide monitors for assessing employee exposure Linda Brown levels are listed in Glutaraldehyde, Formaldehyde and Nitrous Oxide 30 Years of Experience Serving Monitors on cda.org/practicesupport. the Dental Community Proven Effective scavenging equipment and periodic inspection of equipment should Record of Performance keep nitrous oxide exposures to within acceptable limits. Recommendations • Dental Office Leasing and Sales for the safe use of nitrous oxide in the dental office are included in articles For your next move, • Investment Properties published in the Journal of the American contact: LINDA BROWN • Owner/User Properties Dental Association. These articles may be accessed online at jada.ada.org. • Locations Throughout Direct: (818) 466-0221 Q Donaldson M, et al. Nitrous Southern California oxide-oxygen administration: Office: (818) 593-3800 When safety features no longer Email: [email protected] are safe. J Am Dent Assoc February Web: www.TOLD.com 2012 143(2): 134–143. Cal BRE: 01465757 Q Rademaker A, et al. Evaluation of Two Nitrous Oxide Scavenging

OCTOBER 2016 647 OCT. 2016 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 44, Nº10

Q Informing any employee concerned Other Regulations b) Inside of buildings, store cylinders with identified risks with information The Dental Board does not require in a well-protected, well-ventilated, on the control/protective measures a permit to administer nitrous oxide to dry location at least 20 feet from that will be put in place. patients. highly combustible materials. The Q Determining the practical measures Dental practices that use nitrous storage space must be located where to be implemented in the workplace oxide and have 10 or more employees cylinders will not be damaged by to protect against the risks. should post a Proposition 65 notice. The passing or falling objects or subject to To be cautious, it is best to have notice, an FAQ and patient fact sheet are tampering by unauthorized persons. a pregnant staff member, or one who available on cda.org/practicesupport. Store cylinders in places away from is trying to conceive, refrain from Piped systems for compressed gases elevators or stairs. being in the same operatory when must comply with local fire code. Portable c) Not keep cylinders in unventi- nitrous oxide is being administered, cylinders of compressed gas must be stored lated enclosures such as lockers and unless the employee’s physician states and handled according to Cal/OSHA cupboards (with the exception of fire otherwise. Even the best scavenger regulation, 8 CCR 4650. Dental practices extinguishers). system does not prevent exposure to with compressed gas cylinders must: nitrous oxide gas as patients can have a) Store the cylinders in areas where d) Store oxygen cylinders separate from their mouths open during procedures they are protected from external fuel gas cylinders or combustible allowing the gas to escape. heat sources. materials (especially oil or grease) a minimum distance of 20 feet or by a noncombustible barrier at least 5 feet high or a minimum of 18 inches (46 centimeters) above the tallest cylinder and having a fire-resistance Integrity. rating of at least one hour. Relationships. e) Transport and store compressed gas Peace of Mind. cylinders in a manner that prevents them from creating a hazard by tip- ping, falling or rolling. That’s the PARAGON way. f) Ensure all cylinders that are designed to accept valve protection devices PARAGON has guided thousands of buyers and sellers with are equipped with such devices when superior dental transition services and support. Our clients are the cylinders are not in use or con- FRQ´GHQWWKHLUJRDOVDUHEHLQJPHWZLWKIDLUQHVVDQGLQWHJULW\ nected for use. Your local PARAGON g) Unless cylinders are secured on a dental transition consultant special truck or rack, regulators shall Trish Farrell be removed and valve-protection de- vices, when provided for, shall be put in place before cylinders are moved. h) Securely fasten and transport compressed gas cylinders in suitable trucks. All gas cylinders in service must be secured to other rigid struc- 866.898.1867 Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance tures so that they will not fall or be LQIR#SDUDJRQXVFRP by a state or provincial board of dentistry or AGD endorsement 4/1/2016 to 3/31/2020 knocked over. For short distances, SDUDJRQXVFRP Provider ID# 302387. cylinders may be moved by tilting and rolling them on their bottom edges.

648 OCTOBER 2016 DENTAL PRACTICE BROKERAGE Making your transition a reality.

Dr. Lee Dr. Thomas Dr. Dennis Dr. Russell Jim Kerri Mario Jaci Steve Thinh Maddox Wagner Hoover Okihara Engel McCullough Molina Hardison Caudill Tran LIC #01801165 LIC #01418359 LIC #0123804 LIC #01886221 LIC #01898522 LIC #01382259 LIC #01423762 LIC #01927713 LIC #00411157 LIC #01863784 (949) 675-5578 (916) 812-3255 (209) 605-9039 (619) 694-7077 (925) 330-2207 (949) 566-3056 (949) 675-5578 (949) 675-5578 (951) 314-5542 (949) 675-5578 25 Years in Business 40 Years in Business 36 Years in Business 33 Years in Business 42 Years in Business 35 Years in Business 35 Years in Business 26 Years in Business 25 Years in Business 11 Years in Business

PRACTICE SALES • PARTNERSHIPS • MERGERS • VALUATIONS/APPRAISALS • ASSOCIATESHIPS • CONTINUING EDUCATION

NORTHERN CALIFORNIA ROSEVILLE: 4 Equipped Ops, 1 add’l BEVERLY HILLS: 5 Ops, EagleSoft, PASADENA AREA: Practice & Building - BAY AREA: New Listing! 2,120 sq. ft. plumbed, 1,650 sq. ft. w/Digital X-ray, Digital, CEREC. Long-term staff, newer 3 Ops, Dentrix, Dexis, CEREC, established Perio practice, 6 Ops, Digital X-rays, Laser, Dentrix software. 2015 GR $564K+. equipment. 2015 GR 1.2M+, #CA210 for 50+ yrs. #CA282 Pulse Oximeter, Endoscope, Piezosurgery, #CA3233 Dentrix software. 2015 GR $1M. #CA373 BURBANK: New Listing! General/Prosth/ S. ORANGE COUNTY: Pedo Practice with SACRAMENTO:VTIWRI¿FHZ Implant practice. 15 years of goodwill,retail 4 Ops, 1 year new Equipment, Digital, Pano. BENICIA: VTIWRI¿FHRSV Equip. Ops, 2 add’l Plumbed. DentalMate center. 5 Ops, 3 equipped, EasyDental, 2015 GR $363K with room to grow. #CA222 GR $305K 2 day/week. Sister practice- software. 2015 GR $110,427 #CA332 Digital. 2015 GR $291K, $118K Adj. Net. #CA322, sale combined or separate. #CA321 #CA348 SANTA BARBARA: 4 Ops, est. for 40+ SACRAMENTO: 8 Ops w/Schick digital \HDUVGD\V+\JLHQHZHHNORQJWHUPVWDII CAMPBELL: New Listing! 2050 sq. ft., x-ray, Pano, Laser, and Eaglesoft software. CARSON: 3 Ops Paperless, EagleSoft, FFS. GR of $827K. #CA291 5 ops, CAD/CAM, Digital Pan, MacPractice 2015 GR $1.9M. #CA337 Digital, Pano. All Equip. <3 yrs. old. 2014 software. 2015 GR $1,000,007, 100% fee for SAN FRANCISCO: Periodontal Practice & GR $143K. #CA280 TEMECULA: New Listing! 5 Ops, 4 service. #CA374 Condo Unit. 1,160 sq. ft. w/4 Op, 2014 GR Equipped, Newer equipment, Digital, Pano, 3 $714K w/$363K Adj. Net. #CA274 CENTRAL ORANGE COUNTY: 3 Ops, day work week w/1 day of hygiene. 2015 GR CASTRO VALLEY: New Listing! Paperless, digital, busy retail center. 2015 GR of $561K #CA VTIWRI¿FHZ2SV*5 SAN FRANCISCO: )LQDQFLDO'LVWULFWRI¿FH of 381K with 156K Adj. Net. #CA328 $530,000. Eaglesoft PMS, Digital X-Ray, 5 Ops, room for 6th, 1760 sq. ft. 2015 GR VICTORVILLE: 3 Ops, 3 Plumbed, Fiber Optics & Laser. Owner retiring. #CA368 $1.2 mil, Adj. Net. $480,000. #CA357 COASTAL ORANGE COUNTY: New 2,150 Sq. Ft. Est. 34 yrs., SoftDent. 2015 GR SAN JOSE: CAN’T RENEW LEASE! Listing! 2SV3URI%OGJ'LJLWDO&$ $277K. #CA149 Price Reduced! CITRUS HEIGHTS: Prosthodontic practice 2015 GR $568K on 2½ day week. 4 ENCINO: New Listing! 4 Ops, Est. WHITTIER: 4 Ops, 3 Equipped. Dentrix, & stand-alone building for sale. 3 Ops, 2015 Equipped ops, 2 add’l Plumbed, 2,200 Sq. GR of $601,617. #CA326 40+years, EagleSoft, Digital, intra-oral Dexis. Est for 50+ yrs. on Main Street. 2015 )W(='HQWDO'H[LV¿OPEDVHG3DQRUDPLF camera. 2015 GR of $450K and $182K GR $195K. #CA276 EL DORADO COUNTY: 960 sq. ft. w/4 #CA330 Adjusted Net. #CA372 Ops, intraoral camera, digital x-ray, Practice SAN RAFAEL: New Listing! General & FULLERTON: 6 Ops, 4 Equipped, 13 years SAN DIEGO Works software. 2015 GR $466K. #CA339 ,PSODQWVTIWRI¿FH2SV*5 of Goodwill, Dentrix, Digital, Paperless. CHULA VISTA EAST: 3 Ops. Est. 19 GREATER EL DORADO HILLS: $796,000, 3 day week, 55% overhead. Great location. 2015 GR of $410K. #CA352 VTIWRI¿FH2SV'LJLWDO3DQ'LJLWDO #CA358 years. Professional Bldg. 2015 GR $421K. Sensors, Eaglesoft software. 2015 GR $737K. SAN RAMON-FACILITY: New Listing! GREATER LOS ANGELES: Perio #CA304 #CA343 4 op facility w/high-end Pelton & Crane Practice. 5 Ops, 34 Yrs. of Goodwill. Dentrix, LA JOLLA: 3 Ops, FFS and Delta Premier. Equipment, Digital X-Ray, Digital Pan, I.O. Digital, Laser, great referral base, 2015 GR 2015 GR of $558K. Owner retiring. #CA278 GREATER ROSEVILLE/AUBURN: Cameras, 1654 sq. ft. corner suite. #CA370 $728K, Adj. Net $307K. #CA173 OWNER RETIRING! Practice & Bldg, 1,600+ sq. ft. w/5 Ops. 2015 GR $850,000. #CA338 SANTA ROSA: General Dentistry & INLAND EMPIRE: 7 Ops, Dentrix, Digital, NORTH COUNTY, SAN DIEGO: Building. 3 Ops. 2013 GR $542K w/Adj. 3DQR\UVJRRGZLOOòGD\VRI+\JLHQH New Listing! 5 Ops, 26 years of Goodwill, GREATER ROSEVILLE/ROCKLIN: Net $182K. #CA200 #CA283 332ZLWKVRPH+02*5RI. 1,300 sq. ft., 4 Ops, IO camera, digital x-rays, with low overhead. #CA354 STOCKTON: 7 Ops, 2052 sq. ft., great INLAND SOUTH BAY, LOS ANGELES: digital Pano, 3M Scanner, Dentrix software. lease and options to renew. GR $750,000 NORTH COUNTY, INLAND: 2015 GR$697K. #CA350 6 Ops, 5 Equipped, 35+ years Goodwill. ZLWK332+02DQG))6SDWLHQWV&$ Paperless, Digital, Dentrix, Pano. 2015 GR of 3 Ops, Digital X-Rays, EagleSoft, Excellent Location, Bright and Modern Facility. 2015 GREATER ROSEVILLE/ROCKLIN: VACAVILLE: VTIWRI¿FHRSV $833K and $368K Adj. Net. #CA346 4 Ops w/IO, Digital X-ray, Laser, Dentrix GR of $397K. #CA376 2015 GR $519K 3 day/week. Sister practice- LAGUNA BEACH: General Dentistry. software. Established 20+ years, 2015 GR #CA321, sale combined or separate. #CA322 SAN DIEGO: New Listing! +LJKJURVVLQJ $945K. #CA331 5 Ops, 3 Equipped. Great Location. 2014 practice, 44 years of Goodwill. Shopping YOLO COUNTY: Pediatric practice, 2 GR $503K. #CA303 center location. #CA GREATER SACRAMENTO: 7 Ops, equip. Op, approx. 1,000 sq. ft., Intra-oral, LAKEWOOD: 4 Ops, 3 Equipped, retail SAN DIEGO: Modern Restorative/Implant 3,079 Sq. Ft. (Shared w/2nd DDS – Separate Open Dental software. 2014 GR $245K. Practices), 2013 GR $974K. #CA140 center location on busy corner. 38 years of Practice. State of the art, Digital, i-CAT, Lab, #CA301 Goodwill, Dentrix, Digital. 2015 GR $264K. 2SV6SHFLDOW\5RRPV+LJKJURVVLQJ HAYWARD: 2 Fully-Equipped ops, 2 CENTRAL CALIFORNIA #CA341 #CA334 add’l Plumbed. 2014 GR $186K. 3100 sq. ft. SAN DIEGO: New Listing! 6 Ops, building w/rental income for sale. #CA316 FRESNO: *UHDWVWDUWXSRUVDWHOOLWHRI¿FH LONG BEACH: New Listing! 5 Ops, 4 Equipped, Est. for 50+ years, 1,850 sq. ft., 3 Equipped, FFS/PPO, Dentrix, Digital, 4 Ops, 1480 sq. ft., great lease. 2015 GR Curbside Exposure. Excellent opportunity. MARIN COUNTY: 1250 sq. ft. 3 $237,000 and priced to sell. #CA349 digital. 2015 GR $359K. #CA363 operatories. Fee for service 2014 GR $370K, #CA359 on pace for same in 2015. #CA302 HANFORD: 4 days hygiene, 1,345 active LOS ANGELES: 3 Ops and 50+ years of SAN DIEGO: 3 Ops, EagleSoft, Excellent patients. 2015 GR $509K. Digital x-rays, Goodwill. Pano, Digital, Laser, and Intra-oral Strip Mall Location. Priced to sell. #CA340 MTN. VIEW:VTIWRI¿FHLQJUHDW Intra-oral cameras, and Imaging System. camera. 2015 GR $241K and Adj.Net of location w/4 ops, Dentrix software, digital #CA336 $121K on 2 days/wk. #CA345 SOUTH BAY AREA: 4 Ops, PPO/FFS, x-rays. 2015 GR $371,000. #CA335 MODESTO: Dental Air Space EagleSoft, Digital, Modern and Spacious. NEWPORT BEACH: New Listing! 5 Ops, Practice & Building for Sale. #CA313 OAKLAND: 12 ops in 5000 sq. ft. modern Condominium. 1,511 sq. ft. dental condo unit. 3 Equipped, EagleSoft, Digital, Paperless, RI¿FH*5RIZLWK332+02 Sale price $286,000. #CA333 Pano, Intra-Oral Camera. 2015 GR and FFS patients. #CA360 $550K+.#CA366 OUT OF CALIFORNIA SOUTHERN CALIFORNIA MAUI, HAWAII: 7 Ops, 5 Equipped, OAKLAND: Appx. 1,500 sq. ft. w/4 Ops, NEWPORT BEACH: New Listing! 4 Ops, ALISO VIEJO: New Listing! Turnkey 3 Equipped, Dentrix, Digital, and all high-end Modern Design, CEREC. 2014 GR Dentrix software, Dexis Digital X-ray. 2014 00+, GR $869K, adj. net $370K. #CA293 Leaseholds Sale-5 Ops, 3 Equipped, Retail equipment that is less than 10 years old. Est. Plaza. Great Signage, move-in ready. 21+ years. #CA375 CENTRAL OAHU, HAWAII: OROVILLE: 1,000 sq. ft.. Dentrix & Includes computers, x-rays & instruments. 3 Ops in Central Oahu. Dentrix, Dexis, Pano. ORANGE COUNTY: Endo practice with *5.+, Dentrix software, Digital Pan & X-rays, #CA365 6 Ops, Digital and Paperless, 5 year old Laser, Intra-Oral. 2014 GR $512K. #CA287 BELL: 3 Ops, Dentrix, Digital in a Free- equipment. Strong referral base for 25+ years. HONOLULU, HAWAII: New Listing! OROVILLE: 3 Ops, recently remodeled. standing Building. PPO/Denti-Cal. 2015 GR #CA327 6 Ops, 5 Equipped, Dentrix, Digital Great satellite or startup practice. Owner $453K with $259K Adj. Net. #CA317 CEREC Blue Cam, Est. 37 years. 2015 GR PALM SPRINGS: New Listing! 4 Ops, 30 .+, retiring. #CA288 BEVERLY HILLS: Perio practice. years of goodwill. Good location, Doctor PASO ROBLES AREA: $2.25M GR, Beautifully designed, 4 Ops, Desirable prof. wants to remain and work part time if HONOLULU, HAWAII: 3 Ops, 52% overhead. Buyer needs to be skilled bldg. Dentrix, 24 years of Goodwill. 2015 possible, 2015 GR $549K. #CA351 Dentrix, Digital, FFS/PPO. 2014 GR $356K. in restorative, surgical procedures, implant GR of $382K. +, placement. #CA355 ќџѡѕђџћȱюљіѓќџћіюȱѓѓіѐђ ќѢѡѕђџћȱюљіѓќџћіюȱѓѓіѐђ 1.800.519.3458 www.henryscheinppt.com 1.888.685.8100 Ž—›¢ȱŒ‘Ž’—ȱ˜›™˜›ŠŽȱ›˜”Ž›ȱǛŖŗŘřŖŚŜŜ OCT. 2016 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 44, Nº10

i) Not use valve protection devices to lift cylinders, except when a device is designed for allowing manual lift- ing of the cylinder. Do not use bars under valves or valve protection caps to pry cylinders loose when frozen to the ground or otherwise fixed; the use of warm (not boiling) water is recommended. j) Close cylinder valves when work is finished and before moving cylinders. Paul Maimone It is a Great Time to Sell! Inventory & Broker/Owner k) Close valves of empty cylinders. Rates are Still Low & Buyer Demand is High! Call for a Free in Office Valuation! l) Not allow cylinders to be dropped,

ARCADIA – (4) op comput G.P. Located in a well known Prof. Bldg. on a main thoroughfare. struck or permitted to strike each Cash/Ins/PPO pt base. Annual Gross Collect $300K+ on a (3) day week. PENDING other violently. GROVER BEACH - (3) op Turnkey Office w included charts (not guaranteed). (2) ops eqt’d w newer eqt. 3rd plmbed. Digital Pano & x-ray. Dentrix. In a strip ctr. LL incentives. SOLD m) Ensure keys or handles on valve HUNTINGTON BEACH - (5) op plumbed space for lease. Some eqt available. TI’s too. NEW OXNARD #9 - (3) op comput G.P. & a Prof Office Condo for sale. Located on a main spindles or stems are on cylinder thoroughfare. (3) ops eqt’d. Annual Gross Collect $200K+ p.t. Cash/Ins/PPO/HMO $4.5K/mos valves while cylinders are in service. Cap Cks. Digital x-rays. Low overhead. Buy & Combine or open a satellite. NEW PANORAMA CITY – (5) op comput G.P. located in a free stand. bldg. w exposure /visibility. In multiple cylinder installations, Cash/PPO/Denti-Cal. Was doing $600K+ f.t. Now doing $300K p.t. Needs new f.t. DDS. NEW only one key or handle is required PORT HUENEME – (3) op comput. G.P. located in a large strip ctr. with exposure, visibility, & for each manifold. signage. 2.5 - 3.5 year old eqt. Mostly associate run. Gross Collect $200K p.t. w no adv. NEW SANTA BARBARA COUNTY – (3) op comput G.P. & a 1,900 sq ft Bldg. that houses the practice & a residential unit that can be rented or lived in. “Fee for Service.” No PPO, HMO or n) Not use leaking regulators, cylinder Denti-Cal. 2015 Gross Collections ~ $275K on a relaxed 3½ day week. Seller refers all O.S., valves, hose, piping systems, ap- Perio, Ortho, Endo & implant placement. Seller retiring but will assist w transition. So. EAST KERN COUNTY - (5) op comput. G.P. located in a free stand bldg. w exposure/ paratus and fittings. Do not tamper visibility & signage. VERY LIMITED COMPETITION. 2015 Collect $600K. Cash/Ins/PPO. or attempt to repair cylinder valves. Digital x-rays & CT Scan. (6) sensors, Bldg. also available. Seller retiring. Report problem and the cylinder’s se- SAN FERNANDO VALLEY #9 - (8) op comput. G.P. w modern eqt. In a prof. bldg. on a main thoroughfare. Cash/Ins/PPO/HMO. Cap Ck approx $7K/mos. 2015 Collect $1.4M+ SOLD rial number to the supplier promptly. SAN FERNANDO VALLEY #10 - Located in an exclusive area of the Valley. (5) op comput Supplier’s instructions as to its G.P. w high end buildout. Digital x-ray and CT Scan, Laser, Dentrix s/w & (5) year old eqt. Gross Collect $1M+/yr. Cash/Ins/PPO pts. Reasonable overhead, high Net! NEW disposition must be followed. Avoid SAN GABRIEL VALLEY - (4) op comput G.P. w newer P&C Chairs/Eqt, All the toys & complete removal of the stem from a whistles. Paperless, Schick digital x-rays, Solaris Steril Ctr, Soprocare Intra Oral Camera, diaphragm-type cylinder valve. Velscope Cancer Screen, The Wand, Air Abrasion, Electric Hand Pieces, Laser, etc. FFS, 2015 Gross Collect. $881K+ on a 3½ day week. (4) days of Hygiene. Seller retiring. SOLD SANTA ANA - absentee owned (6) op fully eqt’d G.P. First floor street front location on a main o) Never use cylinders as rollers or sup- thoroughfare. Exposure/visibility/signage. Cash/Ins/PPO. No HMO & No Denti-Cal. Pano eqt’d ports, whether full or empty. & Comput. Annual Gross Collect. $400K- $500K on a (3) to (4) day week. PENDING THOUSAND OAKS (4) ops/(2) eqt’d comput. Turnkey Office w included charts. Chart included but not guaranteed. Sirona Eqt. Located in a condo in a Prof. Bldg. PENDING p) Not place cylinders where they WESTLAKE VILLAGE - Turnkey Office. (4) ops/(3) eqt’d. Located in a smaller prof. bldg. might form part of an electric circuit. Very reasonable Lease terms. Newer build out & some newer eqt. Comput. & digital. NEW UPCOMING PRACTICES: Bakersfield, Beverly Hills, Central Coast, Covina, Downey, q) Not use a cylinder’s contents for Duarte, Goleta, Oxnard, Pasadena, Pomona, San Gabriel, Torrance, Van Nuys, & West L.A.. purposes other than those intended D&M SERVICES: by the supplier. Q Q Practice Sales and Appraisals Q Practice Search & Matching Services Q Practice and Equipment Financing Q Locate and Negotiate Dental Lease Space Regulatory Compliance appears monthly and Q Expert Witness Court Testimony Q Medical/Dental Bldg. Sales & Leasing features resources about laws that impact Q Pre - Death and Disability Planning Q Pre - Sale Planning P.O. Box #6681, WOODLAND HILLS, CA. 91365 dental practices. Visit cda.org/practicesup- Toll Free 866.425.1877 Outside So. CA or 818.591.1401 www.dmpractice.com port for more than 600 practice support Serving CA Since 1994 CA BRE Broker License # 01172430 resources, including practice management, CA Representative for the National Association of Practice Brokers (NAPB) employment practices, dental benefits plans and regulatory compliance.

650 OCTOBER 2016 Ethics CDA JOURNAL, VOL 44, Nº10

Timely Referrals — Our Ethical Obligations to Our Colleagues Robert D. Stevenson, DDS

n important, but often founded on trust, which is based in In some instances, the patient may overlooked, element of part on open, honest communication exercise his or her autonomy by refusing professionalism is conduct and on perceived competence. The the referral.5 In other instances, the between dental practitioners.1 patient must also be aware of this trust. patient may inform the consulting Because dentists possess Professionalism is also notably dentist of his or her refusal to return to Aspecialized knowledge and skills that important. Among the many the referring dentist. Consulting dentists are not readily available to the public, courtesies that are extended among must carefully consider their response we are obligated to “work together for collaborating professionals, clear and when autonomy appears to conflict with the collective best interest of society.”2 effective communication is essential continuity of care. The guiding principle Although we may be competent in in facilitating continuity of care. is the consideration of “the benefit of the many areas, occasionally situations arise The referring dentist should clearly patient as [the] primary goal.”6 Regardless that demand a higher level of expertise convey the requested treatment, the of the outcome, this refusal should be than we can provide. These cases are reason for referral and, if possible, how communicated with the referring dentist. best referred to a qualified specialist. the procedure fits in with the overall By considering these and other Management of the referral process may treatment plan. The consulting dentist principles, dentists will protect the patient’s be taken for granted, but it is an important is obligated to discuss treatment results, right to competent, comprehensive process nonetheless. A good relationship, prognosis and needed follow-ups with care from their dental providers. Q including appropriate communication the referring dentist. If treatment is between the referring dentist and the extended, periodic updates should Robert D. Stevenson, DDS, is clinical consulting dentist,3 helps to ensure be given. If complications arise, the managing partner and associate professor continuity of care for the patient and consulting dentist should discuss this at Western University of Health Sciences, benefits the individual practices as well. in a timely manner with the referring College of Dental Medicine. He is a Section 9 of the CDA Code of Ethics dentist so that modifications can be member of the CDA Judicial Council. informs us that, “Whenever the delivery considered in the larger treatment plan. of care to a patient requires diagnostic and If a treatment plan involves multiple For further assistance with any additional therapeutic modalities that are beyond a specialists, this communication becomes questions related to referrals, contact dentist’s scope of services, the dentist has exponentially more important. The your local ethics committee, or Britney the obligation to inform the patient of all referring dentist should take the lead Ryan, CDA judicial council manager, at available treatment options and to refer in transmitting information among 800.232.7645. the patient to a provider who is qualified the various consulting dentists. Each 4 to provide consultation or necessary care.” consulting dentist should know how his REFERENCES What are the ethical obligations or her responsibility fits in the larger 1. CDA Code of Ethics, 2012, Introduction, p. 1. that the referring dentist and the picture, and the consulting dentists 2. CDA Code of Ethics, 2012, p. 1. 3. American Dental Association, General Guidelines for consulting dentist owe to one another? should share their follow-up information Referring Dental Patients, 2007, p. 2. Because referrals are not Competence is a significant value with all the dentists involved. limited to general dentist referring to specialists, the referring dentist in the referral process. The ability of Another essential part of this is defined here as the primary care provider and the consulting dentist is the dentist who is not the primary care provider. the referring dentist to assess his or her discussion is autonomy. Each patient 4. CDA Code of Ethics, 2012, Section 9. own competence, as well as his or her has the right to self-determination. 5. It is not within the scope of this article to discuss confidence in the consulting dentist are Respect for autonomy insists that management of this scenario. 6. ADA Principles of Ethics, 2012, Preamble, p. 3. both central to the referral process. the patient be informed of the risks, Another value involved in this benefits and alternatives of the proposed professional connection is veracity. The referred treatment. The patient has relationship between the referring dentist the right to consider the available and the consulting dentist is obviously options and make a decision.

OCTOBER 2016 651    BAY AREA BAY AREA CONTINUED

AC-335 SAN FRANCISCO: 'ƌĞĂƚ WƌĂĐƚŝĐĞ͊ ϮϭϬϬƐĨ͕ CC-552 SAN RAFAEL: 3ops in 800sf. Practice & Lease /DUJHVW 8ops in desirable location of SF. Call for Details Concession: $225,000 / Charts Only: $175,000 + an $475k add’l amt for EQ AC-566 SAN FRANCISCO: Spectacular views of CC-567 ST. HELENA: Live and Practice in beautiful %URNHULQ Washington Square. 3ops +2 add’l plumbed in Wine Country, 5ops in 1842sf, single-story bldg. 1400sf office $225k Price Reduced $790k AG-564 SAN FRANCISCO: Over 25 yrs goodwill. Large CC-599 SANTA ROSA: Wonderful & stable pts base in 1RUWKHUQ 5,600+ sf w/ 9 ops near Land’s End $2.225M well-respected Practice, 3ops in 1040sf. $250k AG-576 SAN FRANCISCO: Part time practice w/ CC-611 SOUTHERN MARIN COUNTY: Desirable, well- Amazing Growth Potential. Perfect for 1-3 DDS 4 ops established neighborhood, 20npts/mo 3ops in &DOLIRUQLD 1.400 sf $550k 1100sf $650k AG-615 SAN FRANCISCO: Move-In Ready Facility in CG-537 MARIN COUNTY: Rare Opportunity in up- charming desirable neighborhood. 1400 sf w/ 4 ops scale, highly desirable area. State of the art office.  $125k 2400 sf w/ 7 ops $1.1M AN-514 SAN FRANCISCO Facility: Located in the bus- CG-583 SEBASTOPOL: Practice & Real Estate. Seller ([WHQVLYH%X\HU ƚůŝŶŐĮŶĂŶĐŝĂůĚŝƐƚƌŝĐƚ͊ϭ͕ϬϬϳƐĨǁͬϰŽƉƐ͘ $125k͊ Willing to consider all reasonable offer. Health Forc- AN-565 SAN FRANCISCO: This remarkable opportuni- es Sale $875K includes building ƚLJĐŽƵůĚďĞLJŽƵƌ͞ĚƌĞĂŵĐŽŵĞƚƌƵĞ͊͟Ϯ͕ϬϲϳƐĨǁͬϲ CG-607 FAIRFIELD: dŚŝƐƉƌĂĐƟĐĞŝƐƚƌƵůLJĂůůĂďŽƵƚ 'DWDEDVH  ops. $1.05M ůŽĐĂƟŽŶ ĂŶĚ ǀŝƐŝďŝůŝƚLJ͊ ϭ͕ϯϯϯ ƐĨ ǁͬ ϯ ŽƉƐ н ϭ ĂĚĚ͛ů͘ AN-592 SAN FRANCISCO: Imagine accessibility, visi- $160k w/ Cerec͊ 8QVXUSDVVHG ďŝůŝƚLJΘĨƌĞĞƉĂƌŬŝŶŐŝŶ^ĂŶ&ƌĂŶĐŝƐĐŽ͊ϭ͕ϬϬϬƐĨǁͬϮ CG-616 NAPA: State of the Art Practice - Seller mov- ops + 1 add’l $100k ŝŶŐŽƵƚŽĨƐƚĂƚĞ͊Call for Details͊ BC-361 OAKLAND: ƐƚĂďůŝƐŚĞĚ ĨŽƌ ŽǀĞƌ Ϯϯн LJĞĂƌƐ͊ DC-480 SILICON VALLEY: Multi-Specialty Practice, ([SRVXUHDOORZV 2,200 sf w/ 7 ops. Seller is retiring. $330k 14+ ops in 7500sf, Owner Financing avail-Terms & BC-432 PITTSBURG: Own this family-oriented Prac- Priced to Sell $1.075M XVWRRIIHU\RX ƚŝĐĞ͊ϭ͕ϲϰϬƐĨǁͬϲŽƉƐ͘^ĞůůĞƌŝƐZĞƚŝƌŝŶŐ$350k DC-476 DUBLIN: Shared Facility. Great for Specialist - BC-520 HAYWARD Facility: Located in Downtown, Endo, Pedo or Ortho. 1100 sf w/ 2 ops+1 add’l  1500 sf, 4 equipped ops, X-Rays in 3 ops. Call for $125k  Details $65k DC-604 LIVERMORE Facility: Turn Key Facility in fast   BC-549 LAMORINDA AREA Facility: Excellent Loca- growing city, 3ops +3 add’l plumbed in 2380sf mod- ƚŝŽŶ͊,ŝŐŚůLJsŝƐŝďůĞ͕ϵϬϬƐĨǁͬϯŽƉƐнϭƉůƵŵďĞĚĂĚĚ͛ů͘ ern office, $110k $75k DN-497 PLEASANTON Facility: 'ƌĞĂƚ>ŽĐĂƚŝŽŶ͊ϴϳϬƐĨ BC-563 BERKELEY: Excellent, Well-established, w/ 3 ops + 1 add’l. Owner Financing w/10% Down͊ Family-oriented Practice, 4ops in 1382sf 10pts/ Reduced͊ $95k day, 35npts/mo $450k DG-519 SANTA CLARA Facility: DŽǀĞ/ŶZĞĂĚLJ͊ϮϮϰϬ BC-614 SAN LEANDRO Charts Only: Increase your sf w 6 fully equipped ops $225k Production & continue TX to this stable patient DG-530 SAN JOSE: Highly respected quality prac- base $150k ƟĐĞ͊ϮϬϭϱĐŽůůĞĐƟŽŶƐΨϭDнPriced at $899k BG-570 SAN LEANDRO: 30+ yrs goodwill w/focus DG-581 SAN JOSE: 'ŽƌŐĞŽƵƐ WƌĂĐƟĐĞ͕ ƐƚĂďůĞ ƉĂͲ on C&B. 2100 sf w 5 ops. Room for 6th op. Over ƟĞŶƚďĂƐĞΘůŽLJĂůƐƚĂī$496k $908k in 2015 $625k DG-582 SAN JOSE: ŽůůĞĐƟŽŶƐŽǀĞƌΨϵϬϬŬ͊ϯϬϬϬƐĨ BN-504 RICHMOND: Established Practice and Real ǁͬϴŽƉƐ͘dŽƉŽĨƚŚĞ>ŝŶĞƵŝůĚŽƵƚƐ͊$550k ƐƚĂƚĞ͊ ϭ͕ϰϱϬ ƐĨ ǁͬ Ϯ ŽƉƐ н Ϯ ĂĚĚ͛ů $100k /RE DN-542 FREMONT Facility: ^ƉĂĐŝŽƵƐΘďĞĂƵƟĨƵůůLJ $700k equipped State-of-the-ƌƚ͊ϯ͕ϰϬϬƐĨǁͬϱŽƉƐнϰ BN-575 PLEASANT HILL: Do not pass up this re- add’l. $295k ŵĂƌŬĂďůĞŽƉƉŽƌƚƵŶŝƚLJ͊ϭ͕ϰϱϬƐĨǁͬϱŽƉƐ. $330k DN-557 SALINAS: ϯ͕ϬϬϬ ƐĨ ǁͬ ϳ ŽƉƐ ĂŶĚĐŽůůĞĐƟŶŐ BN-586 BRENTWOOD: hŶůŝŵŝƚĞĚ ŐƌŽǁƚŚ ƉŽƚĞŶƟĂů͊ over $2.225M. Priced at only $1.4M ĂƌƌLJŽŶƚŚĞƐƚĞůůĂƌƌĞƉƵƚĂƟŽŶŽĨƚŚĞWƌĂĐƟĐĞ͊Ϯ͕ϴϬϬ DG-619 SAN JOSE: KŶĞŽĨƚŚĞŵŽƐƚƵŶŝƋƵĞƉƌĂĐƟĐͲ sf w/ 8 ops. $1.4M ĞƐLJŽƵǁŝůůĞǀĞƌƐĞĞ͊ϭ͕ϰϱϬƐĨǁͬϱŽƉƐ͘$1.1M

:36#68&&(('1(7 Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD

NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED

EC-525 SACRAMENTO͗'ƌĞĂƚ>ŽĐĂƚŝŽŶ͊džĐĞůůĞŶƚsŝƐŝďŝůŝƚLJ͊ϭ͕ϱϬϬƐĨǁͬϯŽƉƐ͕ GN-546 CHICO AREA: ĂƚĞƌŝŶŐƚŽĨĞĂƌĨƵůƉĂƟĞŶƚƐ͕ƚŚŝƐŽĸĐĞŝƐǁĞůů-known 10-15 new pts/mo $220k ĨŽƌŽīĞƌŝŶŐƋƵĂůŝƚLJĚĞŶƟƐƚƌLJǁŝƚŚƐĞĚĂƟŽŶ͘Ϯ͕ϲϬϬƐĨǁͬϰŽƉƐ͘$350K EC-531 GREATER SACRAMENTO: PracƟce and Real Estate for Sale͊ 1,750sf GN-606 BUTTE COUNTY: Hesitate and you will miss out on this oneͲŽĨͲĂͲŬŝŶĚ w/ 4ops + 1 add’l, 8npts/mo $800k ŽƉƉŽƌƚƵŶŝƚLJ͊ϭ͕ϳϬϬƐĨǁͬϰŽƉƐ͘$295k EN-464 ROCKLIN Facility: ŽŶ͛ƚŵŝƐƐŽƵƚŽŶƚŚŝƐƌĞŵĂƌŬĂďůĞŽƉƉŽƌƚƵŶŝƚLJ͊ GN-605 CHICO Facility: Turn-ŬĞLJ͊/ĚĞĂůƚŽŵĞƌŐĞŽƌŵŽǀĞLJŽƵƌĞdžŝƐƟŶŐƉĂͲ 2,150 sf w/ 4 ops. Now Only: $100k ƟĞŶƚďĂƐĞŝŶƚŽ͊ϭ͕ϲϬϬƐĨǁͬϯŽƉƐ͘$50k EG-556 SACRAMENTO: Near CSUS Campus. Long-term 2nd generation HC-461 SONORA: In the beautiful Sierra Foothills, 4ops, 1350sf, free- office. 935 sf w/ 4 ops $389k standing bldg.. Practice $700k & RE Also Available͊ EG-589 SACRAMENTO: WĞƌĨĞĐƚŽǁŶƚŽǁŶ>ŽĐĂƟŽŶŶĞĂƌĂƉŝƚŽů͘Ϯ͕ϯϬϬƐĨǁͬ HN-213 ALTURAS: dŚŝƐǁĞůůŵĂŶĂŐĞĚƉƌĂĐƟĐĞĐŽŶƟŶƵĞƐƚŽŚĂǀĞĐŽŶƐŝƐƚĞŶƚ 6 ops $475k ƌĞǀĞŶƵĞƐ͊Ϯ͕ϮϬϬƐĨǁͬϯŽƉƐнϭĂĚĚ͛ů͘$115k EN-534 ROSEVILLE Facility: >ŽĐĂƟŽŶ͕ >ŽĐĂƟŽŶ͕ >ŽĐĂƟŽŶ͊  dƵƌŶ-key…just HN-280 NO EAST CA: Only Practice in Town 900 sf w/ 2 ops REDUCED͊ ONLY ŶĞĞĚƐLJŽƵ͊Ϯ͕ϬϬϬƐĨǁͬϰŽƉƐ͘$45k $60k EG-560 CARMICHAEL: &ŽĐƵƐŝŶŐ ŽŶ ƚŚĞ ƉŚŝůŽƐŽƉŚLJ ŽĨ ƚƌĞĂƟŶŐ ƉĂƟĞŶƚƐ ĂƐ ĨĂŵŝůLJ͊ϭ͕ϮϬϬƐĨǁͬϯŽƉƐнϭĂĚĚ͛ů͘ $130k CENTRAL VALLEY EN-573 SACRAMENTO: dŚĞŐŽĂůĂŶĚĨŽĐƵƐŽĨƚŚŝƐƉƌĂĐƟĐĞŝƐƚŽƉƌŽǀŝĚĞĞdžͲ ĐĞůůĞŶƚƐĞƌǀŝĐĞ͊ϭ͕ϬϳϱƐĨǁͬϮŽƉƐ͘$93.1k IC-468 SAN JOAQUIN VALLEY: High-End ZĞƐƚŽƌĞWƌĂĐƟĐĞ͊ϲŽƉƐŝŶϮϱϬϬнƐĨ EG-579 ROCKLIN Perio/Gen: AƩƌĂĐƟǀĞ͕ ǁĞůů-ĂƉƉŽŝŶƚĞĚ ƉƌĂĐƟĐĞ ŝŶ the ŽĸĐĞ͘ĂůůĨŽƌĞƚĂŝůƐ͊$425k ƉƌĞƐƟŐŝŽƵƐ tŚŝƚŶĞLJ KĂŬƐ ĂƌĞĂ͘ ϭ͕ϲϬϬ ƐĨ ǁͬϯ ŽƉ н ϭ ĂĚĚ͛ů͘ NOW ONLY IC-572 MODESTO: In desirable Dental/Medical Professional building of town, $235k 3ops in 1300sf office. $160k EN-588 SACRAMENTO: well-ĞƐƚĂďůŝƐŚĞĚ ƉƌĂĐƟĐĞ ĂǁĂŝƚƐ LJŽƵƌ ƚĂůĞŶƚ ĂŶĚ IN-506 TURLOCK: WƌĂĐƚŝĐĞŝŶƚŚĞŚĞĂƌƚŽĨƚŚĞĞŶƚƌĂůsĂůůĞLJ͊Ϯ͕ϬϬϬƐĨǁͬ skill͊ 1,500 sf w/ 4ops. Now Only $295k 5ops + 1 add’l. $425k EN-603 ELK GROVE: Absolutely one of California’s most desirable com- IN-577 W. STANISLAUS CO: Offering that “Main Street” feel and quality of ŵƵŶŝƟĞƐƚŽďŽƚŚůŝǀĞĂŶĚǁŽƌŬ͘ϭ͕ϯϬϬƐĨǁͬϯŽƉƐ͘$318k life. 1,800 sf w/ 4ops + 1 add’l. $250k EN-609 SACRAMENTO: Truly a “cut above”, this remarkable, well- JC-541 FRESNO Facility: ϭ͕ϮϭϬƐƋƵĂƌĞĨĞĞƚĂŶĚĐŽŶƐŝƐƚƐŽĨϮĨƵůůLJĞƋƵŝƉƉĞĚ ĞƐƚĂďůŝƐŚĞĚŽƉƉŽƌƚƵŶŝƚLJŐƌŽƐƐĞƐŵŽƌĞƚŚĂŶΨϭ͘ϳŵŝůůŝŽŶĂŶŶƵĂůůLJ͊ϯ͕ϳϬϬƐĨǁͬ ŽƉƐĂŶĚƉůƵŵďĞĚĨŽƌĂĚĚ͛ůŽƉ Call for Details͊ 10 ops. $1.7M JN-551 COALINGA AREA: SĞƌǀŝŶŐ ƚŚŝƐ ĐŽŵŵƵŶŝƚLJ ŽĨ ǁŽƌŬŝŶŐ ĨĂŵŝůŝĞƐ͊ FC-415 FT. BRAGG: džĐĞůůĞŶƚWƌĂĐƚŝĐĞ͊Dr. avgs 18+ pts/day & 20+ npts/mo, WĂƉĞƌůĞƐƐWƌĂĐƟĐĞ͘ϭ͕ϮϬϬƐĨǁͬϯŽƉƐ͘REDUCED͊ $395k͊ 1,800 sf w/ 5 ops + 1 hyg. Op $425k JN-593 FRESNO: Change smiles in this quality family-ŽƌŝĞŶƚĞĚ ƉƌĂĐƟĐĞ͊ FC-489 CLEARLAKE: Located on “4-Corners” of Hwy 53, 4ops in shared 2,430 sf w/ 6ops. $375k 3600sf facility. $470k / 50% interest in RE Also Available FN-527 TRINITY COUNTY: ĞƚŚĞŽŶůLJĚĞŶƚŝƐƚŝŶƚŽǁŶ͊ ͞WƌŝĚĞ/ŶƐƟƚƵƚĞ͟ĚĞͲ SPECIALTY PRACTICES ƐŝŐŶĞĚ͊2350sf w/ 5 ops +1 add’l. $250k GC-472 ORLAND: Live & Practice in charming small town community. 1,000 sf AC-601 SAN FRANCISCO Perio: High quality practice, 30npts/mo, 3ops in w/ 2ops. Seller Retiring. $160k shared 1963sf office, Seller workback for smooth transition $800k GG-386 REDDING: ŵĂnjŝŶŐWƌĂĐƚŝĐĞ͘>ĞĂƐĞŽƌƵLJZĞĂůƐƚĂƚĞ͊Ϯ͕ϴϲϬƐĨǁͬϰ BC-544 ALAMEDA COUNTY Pedo: 1,056sf w/ 4 chairs in growing, revital- ŽƉƐ͘WůƵŵďĞĚĨŽƌϮĂĚĚ͛ů͊ONLY $260k ized community, Seller Retiring $225k GG-453 CHICO: ϱ͕ϬϬϬƐĨǁͬϳŽƉƐWĞƌĨĞĐƚĨŽƌϭŽƌŵŽƌĞĚĞŶƚŝƐƚƐ͊$325k BG-517 NORTH EAST BAY Endo: Ϯ͕ϳϱϬƐĨǁͬϴŽƉƐ͊^ƚƌŽŶŐWƌĂĐƚŝĐĞ͊$500k GG-454 PARADISE: ΕϮ͕ϱϱϬƐĨǁͬϵŽƉƐ͘ϰϬLJƌƐŐŽŽĚǁŝůů͊ŵĂnjŝŶŐKƉƉŽƌƚƵŶŝͲ BC-600 CONCORD PEDO & ORTHO Charts Only: Continue treatment to ƚLJ͊$525k ƚŚĞƐĞWĞĚŽΘKƌƚŚŽƉĂƚŝĞŶƚƐĂůůĨŽƌĞƚĂŝůƐ͊$400k GG-574 SIERRA FOOTHILLS: Popular Professional Plaza. Spacious 3,000 sf CC-346 SO MARIN CO Perio: Beautiful 1,142 sf w/ 3 ops. No reasonable w/ 7 ops $875k oīer will be refused͊ Reduced $150k GG-617 YUBA CITY: Rare Opportunity to purchase Dental Facility with CG-424 NAPA Prostho: Office has Digital X-ƌĂLJΘEtϯ/ŵĂŐŝŶŐhŶŝƚ͊ Z>^dd͊Only $350k Ready for Experienced, high-ĞŶĚWƌŽƐƚŚŽĚŽŶƚŝƐƚ͊KŶƚƌĂĐŬƚŽĐŽůůĞĐƚũƵƐƚ GN-244 OROVILLE: DƵƐƚ^ĞĞ͊'ŽƌŐĞŽƵƐ͕^ƉĂĐŝŽƵƐ͘Ϯ͕ϱϬϬƐĨǁͬϱŽƉƐ͊ŽůͲ under $1m $690k lections over $450k in 2013. Only $315k DC-459 SF PENINSULA Perio: ϱϬйWĂƌƚŶĞƌƐŚŝƉƵLJ/Ŷ͊ĂůůĨŽƌĞƚĂŝůƐ͊$600k GN-399 REDDING: Loyal patient base and relaxed workweek schedule. 1,440 EG-579 ROCKLIN Perio/Gen: AƩƌĂĐƟǀĞ͕ ǁĞůů-ĂƉƉŽŝŶƚĞĚ ƉƌĂĐƟĐĞ ŝŶ the sf w/3 ops. $150k ƉƌĞƐƟŐŝŽƵƐtŚŝƚŶĞLJKĂŬƐĂƌĞĂ͘ϭ͕ϲϬϬƐĨǁͬϯŽƉнϭĂĚĚ͛ů͘$325k GN-507 CHICO: /ƚũƵƐƚĚŽĞƐŶ͛ƚŐĞƚĂŶLJďĞƚƚĞƌƚŚĂŶƚŚŝƐ͊ϯ͕ϱϬϬƐĨǁͬϳŽƉƐ͘ FN-536 LAKE COUNTY Pedo: Focusing on Prevent dental problemsďĞĨŽƌĞ Practice $535k ƚŚĞLJďĞŐŝŶ͊1,750 sf w/ 3ops. Now Only: $225k͊

“ASK THE BROKER” CAN NOW BE FOUND AT WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 44, Nº10

A look into the latest dental and general technology on the market

ILIFE V5s Robot Vacuum Cleaner Truebill (Free) ($189, ILIFE) Every day, more users are shifting to the subscription model for many Robot vacuum cleaners have become increasingly popular online services that feed daily productivity and recreation. With with the Roomba among the most well-known. Roombas and many of these accounts linked to credit cards and bank accounts, other top-of-the line robot vacuums, however, can be expensive spending money is now easier than ever. Keeping tabs of how much (anywhere from $300 to $900). New competitors have is spent on these services is a daunting challenge. Without a means sprouted up offering cheaper price tags and more features. to track these recurring expenditures, there is high potential that The ILIFE V5s Robot Vacuum Cleaner is less than $200 and it some people do not even know they are paying for some services. vacuums and mops. It can vacuum up anything from fur to dust Truebill seeks to make users aware of these charges and helps them and can be programmed to begin vacuuming at any time of save by canceling the things they no longer want or need. Once an the day. The setup is relatively easy. Simply plug the charging account is created, Truebill requires linking to credit card and bank docking station into the wall, turn the device on and let it charge. accounts in order to analyze statements and offer suggestions on Push the “Clean” button either on the top of the device or on how users can save money. The company assures users that bank- the remote to get started. The remote control is handy and helps level security with read-only access to statements is used. The service users manually direct the device if it needs some help finding never asks the user for a credit card number in order to charge its way. The V5s comes with a dustbin that is easy to clean them; it only requires the user to give login account information out and a water tank for the mopping feature. The vacuuming for their bank accounts in order to work as advertised. This could is effective, as the device is able to sweep up a pile of coffee be a hard selling point because the user has to trust this company grounds with ease. It navigates around the house on its own and in order for the service to work. After users link their accounts, the can go easily from hard wood to carpet and is thin enough to service uses sophisticated algorithms to find and track bills and fit under couches. The bumper on the front detects obstructions subscriptions. Depending on the specific financial institutions and and quickly redirects the device. It isn’t the sharpest tool in the number of accounts needed to link, it may take several hours or shed, however. It doesn’t remember the layout of a home all days for the service to obtain all statements. When the analysis is that well and can get stuck often. Users will need to have their complete, users receive a dashboard of all their subscriptions, bills spaces clear of random chairs, kid or pet toys, etc., for it to and other recurring payments in a simple, yet comprehensive display function completely. And it doesn’t alert the user when it is stuck, listing. Selecting a subscription from the dashboard reveals details which can lead to a battery drain. In other words, it requires a on how much money was spent on it in previous months. Users can little babysitting. The mopping feature isn’t terribly effective, but get detailed, step-by-step directions on how to cancel a subscription it is better than nothing. Overall, the V5s gets the job done at a directly from the app. In addition, the service looks for ways to save decent price and will take some of the pressure off those who money on other things like auto insurance, credit monitoring and must constantly vacuum. cellphone service. The dashboard for every user varies based on his or her subscriptions and services. On average, users will be surprised — Blake Ellington, Tech Trends editor at what Truebill can find in order to save money. There may be subscriptions that users don’t realize they have. Users may be paying too much for services and utilities they currently have. Users will find this app and service useful in analyzing their spending habits and taking action to reduce the amount of money wasted every month. — Hubert Chan, DDS

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