Sugar: the Demonisation of a Product Or Fair Culprit?

FEATURE

:the demonisation of a product ©OcusFocus/iStock/Thinkstock or fair culprit?

It’s in our food and it’s now all over the news. So we ask what is the deal with sugar?

t seems every day there’s another Sugar Nutrition UK natural and ‘added’ story in the press calling out sugar By Dr Alison Boyd*, Director, Sugar Nutrition sugars.1 Naturally as the root of all evil in society. Or UK, RD, RNutr, MBDA occurring and at least that’s how it feels. Things Sugar is undoubtedly in the spotlight. Over ‘added’ sugars are chemically identical.2 were exacerbated by NHS England’s the last 18 months, we’ve seen numerous Neither your body nor any chemical detection Chief Executive Simon Stevens headlines linking sugar with all manner of ills method can distinguish between the two; for Ilabelling sugar as a ‘poison’ on his most recent from obesity to cancer; with claims of sugar example sucrose is broken down in the same appearance on the Andrew Marr Show, and it even being ‘poisonous’. But is there robust way in your body whether it came from table got me thinking. Are we unfairly demonising science behind the media hyperbole? And sugar, an apple or tomato soup. sugar and turning a blind eye to our shocking what does this mean for dental health? We all know that there is a dynamic relation dietary habits, or are some of the measures Perhaps the first concern is one of between sugars and oral health3 and most being discussed – sugar tax, sugary drinks definition – the term ‘sugar’ is continually would agree that levels of dental decay in all duty – the right way to eliminating sugar and used in public health discourse, when in fact age groups remain unacceptably high. We turning round the titanic that is childhood we should be correctly using the term ‘sugars’. also know that tooth decay can largely be caries? We asked two leading organisations on ‘Sugar’ is generally understood to refer to prevented by a combination of approaches.4 their views. table sugar – sucrose – the type of sugar which So should we focus on sugars as the only people add into their tea or use in baking. cause of (all) our oral health problems? The term ‘sugars’ however, covers the full Should dental health advice focus on reducing * Dr Alison Boyd became Director of range of mono– and disaccharide molecules the amount of sugars we consume as opposed Sugar Nutrition UK in 2007, having been which are relevant to this discussion (for to other fermentable carbohydrates for Research Director for 6 years. She was example fructose, sucrose, glucose, lactose example? The answer to these questions is no educated at the University of Ulster and and maltose). Sugars are carbohydrates. They – the situation is more complex and there is gained a PhD in Diabetes. Alison is a occur naturally in fruits, vegetables and dairy, robust scientific evidence to suggest that other registered Dietitian and before joining Sugar Nutrition, held a clinical role as as well as being an ingredient used in a wide factors need to be considered. a Senior Dietitian at The Royal Hospitals range of foods and drinks. This is important, Firstly, all fermentable carbohydrates, Trust in Belfast. Dr Boyd is a member of particularly in relation to dental health, as it can provide the substrate for actions of the British Dietetic Association, Nutrition clarifies a common misunderstanding about oral bacteria to produce acid and therefore Society and the European Association for the nutritional science of sugars – namely potentially lead to tooth demineralisation.5 the Study of Diabetes. that our body can distinguish between While dentists may understand the meaning

of this, many people may not appreciate The notion that sugar is a poison is 5. European Food Safety Authority. that eating rice or chomping on crisps can misleading and inappropriate – as already Scientific Opinion on dietary reference have the same impact on teeth as enjoying outlined sugars are a form of carbohydrate values for carbohydrates and dietary fibre. some sweets. and they occur naturally in a wide range of The EFSA Journal.2010, 8: 1462. Secondly, there is currently strong evidence fruits, vegetables and dairy products. Sugars 6. Anderson C.A., Curzon M.E.J, Van to show that other dietary factors in addition have been part of our diet for thousands Loveren C., et al. Sucrose and dental to the quantity of fermentable carbohydrate of years. caries: a review of the evidence. Obesity consumption is crucial in preventing tooth Scientists and Expert Committees have Reviews. 2009, 10: 41-54. decay. Current evidence has shown that reviewed the concept of food addiction. 7. WHO Oral health database, Malmö University. Available online at http:// www.mah.se/CAPP/Country-Oral- ‘THE NOTION THAT SUGAR IS A POISON IS Health-Profiles/EURO/European-Union- and-European-Economic-Area--/Dental- MISLEADING AND INAPPROPRIATE’ Caries-for-12-year-olds/. (Accessed July 2015). 8. Children’s Dental Health Survey England, frequency of consumption of fermentable The consensus of the scientific evidence Wales and Northern Ireland, 2013. carbohydrates is more important than the in humans, most recently the NeuroFAST Available online at http://www.hscic.gov. amount.3,6 This would strongly indicate that Consensus Statement14,15, is that there is a lack uk/catalogue/PUB17137/CDHS2013- discouraging snacking or grazing between of any credible scientific support for the claim Executive-Summary.pdf (accessed July meals – particularly on crisps, fruits and that sugar, or any other food, is addictive. 2015). sweets – would have greater dental health Pointing the finger at sugars solely 9. Children’s Dental Health in the United benefits than aiming to reduce the overall increasing obesity may be cited currently, but Kingdom 2003. Available online at http:// quantity of sugars in the diet. it is neither supported by current scientific www.ons.gov.uk/ons/guide-method/ Thirdly, and perhaps most importantly, evidence nor helpful to the general public, method-quality/specific/health- good oral hygiene needs to continue to be especially when we know that obesity is such methodology/dental-health/dental- emphasised. Since the late 1970’s, dental a complex area. The findings of numerous health-of-children/index.html (accessed caries has declined substantially in the UK expert scientific bodies2,5 for example, July 2015). and in many other developed countries.7 the European Food Safety Authority and 10. Fejerskov O., Antoft P., Gadegaard E. The latest data from the Children’s Dental the Institute of Medicine of the National Decrease in caries experience in Danish Health Survey (2013)8 showed that 34% of Academies) have concluded that sugar in children and young adults in the 1970’s. J 12 year olds had evidence of decay, with a itself has no specific causal role in obesity, Dent Res. 1982, 61: 1305-1310. mean DMFT of 0.8, compared to 43% in rather the overconsumption of all calories is 11. O’Mullane D.M. The changing patterns 2003.9 While this trend is moving in the right to blame. of dental caries in Irish schoolchildren direction, the levels of decay remain far too Despite current perceptions, the reality is between 1961 and 1981. J Dent Res. 1982, high. It is agreed by many that increased use that average ‘free sugars’ intakes amongst the 61: 1317-1320. of fluoride is the most influential factor.10,11 UK population have been gradually declining 12. Jackson RJ, Newman HN, Smart GJ, et al. Indeed, the use of fluoride toothpaste for many years. Eating a varied, balanced The effects of a supervised tooth brushing and good oral hygiene have been shown diet, leading a healthy, active lifestyle and programme on the caries increment of repeatedly to be the best measures that can be practicing good oral hygiene is the best way primary school children, initially aged 5-6 taken to prevent dental caries.12 to prevent obesity, lifestyle diseases and years. Caries Res. 2005, 39: 108-115. Of course frequent, excessive consumption dental decay. 13. Department of Health. Delivering better of sugars should be discouraged. If oral health: an evidence-based toolkit for following good oral hygiene practices, References prevention. 2014. including brushing teeth twice a day with 1. Schorin D., Sollid K., Smith Edge M., et 14. NeuroFAST consensus opinion on food fluoride toothpaste, teeth can cope with the al. The Science of Sugars, Part I A Closer addiction. Available online at: http://www. consumption of any fermentable carbohydrate Look at Sugars. Nutrition Today 2012, 47: neurofast.eu/digitalAssets/1455/1455240_ up to four times daily without an increased 96 – 101. consensus.pdf. (Accessed July 2015). risk of decay.13 The point is not to deny the 2. Institute of Medicine of the National 15. Hebebrand J. et al. ‘Eating addiction, role that sugars as a fermentable carbohydrate Academies. Dietary Reference Intakes rather than ‘food addiction’, better play in dental caries, but rather focus on for Energy, Carbohydrate, Fiber, Fat, captures addictive-like eating behaviour. solid, scientific evidence of the most effective Fatty Acids, Cholesterol, Protein, and Neuroscience & Biobehavioural Reviews. interventions and behaviours that can Amino Acids (Macronutrients) 2005. The 2014; 47: 295–306. be established to improve dental health National Academies Press, Washington. for everyone. 3. Touger-Decker R. & van Loveren C. Sugar Nutrition UK is a not for profit, But are there broader physiological benefits Sugars and dental caries. Am J Clin Nutr. scientific organisation that is a leading to cutting sugars consumption? After all, 2003, 78: 881S–92S. source of expertise on sugars and we’ve heard sugars are a ‘poison’, ‘addictive’ 4. Cottrell R. Dental Disease: Etiology and health in the UK. Sugar Nutrition UK was and cause obesity. The reality is that none of Epidemiology. Encyclopedia of Human established in 1964 and is principally these claims have current robust evidence to Nutrition. Third Edition. Volume 2. 2013, funded by UK sugar manufacturers. support them. pp. 527–534. www.nature.com/BDJTeam BDJ Team 10 © 2015 British Dental Association. All rights reserved FEATURE ©Stockbyte/Thinkstock

Claire Stevens* of the British Society of Paediatric Dentistry on why sugar isn’t so sweet

irst it was all about fat, then reason for a child aged 5-9 to be admitted exactly how salt and now it appears that to hospital in England,18 the collective good much sugar is in sugar is the latest villain we all are out to identify the culprit and sugar is their food? We need to help people to make need to be concerned about. an obvious target. As a society we are always healthy choices by empowering and educating Everywhere you turn there is looking to apportion blame. ‘It’s the parents them to read and understand the information a celebrity going sugar-free fault – it’s neglect’, but to what degree is sugar provided on food labels. We need to combat or promoting their low sugar diet and with and the food industry to blame? Well let’s start the lack of understanding and education. F 17 Damon Gameau’s ‘That Sugar Film’ recently with the facts. Could we make it any easier? released in the UK, sugar is certainly taking Last year we consumed an average of 230 A bottle of Fridj milkshake contains a centre stage. litres of soft drinks per capita.19 We are a whopping 46g of sugar. Would as many So why the sudden fuss? I don’t think it is nation of snackers and grazers, many favour parents think about buying this product if a coincidence that children’s oral health and processed food over cooking from scratch and there was an image of a teaspoon of sugar obesity also remain in the media spotlight. obesity is a national epidemic and costing the saying ‘this product contains 11 and a half When dental decay is the most common NHS millions to treat. teaspoons of sugar’? I think not. At the There are four major sources of sugar in the moment there is no incentive for industry to * Claire Stevens BDS (Bristol), MFDS RCS Ed, British diet, namely soft drinks, confectionery, improve their labelling. M Paed Dent RCPS, MPhil (Newcastle), baked goods and breakfast cereal. To date, the FDS (Paed Dent) RCS Ed. is Honorary main focus on tackling obesity and reducing Sugar tax or incentivising Secretary to the British Society of sugar consumption in children has been healthy food? Paediatric Dentistry. education, urging consumers to eat healthier There has also been talk of a sugar tax but the A Consultant in Paediatric Dentistry foods but this has not been successful. So effects may be small. There have been two at Central Manchester Hospitals NHS what can be done? How do we go about theoretical modelling studies on taxation; Trust, Claire developed and led the reducing childhood sugar consumption? a 10% tax reduced consumption of sugary Adolescent Intravenous Sedation Service drinks by 7.5ml per person and a 20% tax which provides care for highly anxious Improving Food labelling reduced consumption of sugar by only 1g per young people. Claire is the recipient of a Some may argue that clearer labelling person.21 However, on the back of the success Research for Patient Benefit Grant which would help to stop the rot. How many of of the sugar tax introduced in Mexico, UK is supporting her team to investigate the lay public knows the daily reference Doctors are now calling for a 20% tax on the patient acceptability of intravenous intake for sugar or who has read the latest sugary drinks.22 New taxes are also politically propofol sedation in adolescent dental care. She is mother to two young recommendations from the Scientific difficult making their adoption unlikely, 20 children, author of www.toothfairyblog. Advisory Committee on Nutrition? With especially after the notorious ‘pasty tax’ revolt org which aims to educate parents a lack of standardised food labelling and of 2012. New food laws may be perceived as to improve the oral health of children indeed the absence of a legal requirement to the ‘nanny state’ and a penalty for industry, and media spokesperson for the British use a system such as the traffic light system, rather than seen as producing the desired Society of Paediatric Dentistry. can we expect the consumer to understand consumer protection.

Making ‘healthy’ foods cheaper would proven health risks of sugar not outweigh the References also make them more appealing to families unproven concerns about sweeteners? 17. That Sugar Film. Available online athttp:// on tight financial budgets. Research looking thatsugarfilm.com (accessed July 2015). at consumer habits during the recession Marketing of foods 18. Health and Social Care Information demonstrated a decline in the average But it’s not as simple as cutting out the fizzy Centre. Children in Hospital Episode nutritional quality of foods purchased, with drinks and sugar-laden snacks. You could Statistics – July 2012 to June 2013. Online a move towards processed sweet and savoury argue that if you chose to consume these information available at www.hscic.gov. food and away from fruit and vegetables products you know what you are letting uk/catalogue/PUB11758/prov-mont-hes- which was most pronounced in families with yourself in for. But those marketed as ‘healthy’ admi-outp-ae-apr-jun-13-14-toi-rep.pdf young children.23 Healthy foods are not being or targeted at children is another matter. (accessed July 2015). adequately incentivised and this must change. As the focus of ‘The Sugar Film’17 Damon 19. The 2014 UK Soft drinks report. Available Instead, many companies are adding extra Gameau consumes 40 teaspoons of sugar online at: www.britishsoftdrinks.com/ margin onto healthier products, in the belief per day, in line with the average Australian. write/MediaUploads/Publications/ that these products are being purchased by The catch is that he only eats foods that are Revised_BSDA_Annual_Report_2014.pdf more affluent consumers. This is immoral. commonly perceived as ‘healthy’ such as (accessed July 2015). The consequence is the nutritional exclusion baked beans, yoghurts, cereal bars and fruit 20. Carbohydrates and Health (2015) of the poor.24 We need to explore ways juices. Inevitably, his weight soars and his Available online at https://www.gov.uk/ of incentivising healthy choices for both general health declines. Gameau believes government/uploads/system/uploads/ consumers and industry. that some of the packaging is ‘deliberately attachment_data/file/445503/SACN_ ambiguous’ and that parents are ‘horribly let Carbohydrates_and_Health.pdf (accessed Re-formulating foods – down by the lack of integrity in marketing July 2015). de-sweetening or use of sweeteners and packaging strategies.’ He continues, ‘You 21. Meeting notes from APPG on a Fit If people do not chose to eat healthy foods can put a bee and a sunset and say it’s mother and Healthy Childhood, 8 April 2014. despite decades of education programmes at nature’s bounty and people will believe that Professor David Walker, Deputy Chief vast expense, perhaps it is time to focus on and not realise that those products have as Medical Officer for Health in England, and improving the nutritional value of the foods much, if not more, sugar in them as perceived Professor Jack Winkler, Former Professor they do eat? Urging food manufacturers to junk foods like chocolate bars.’ of Nutrition Policy, London Metropolitan adopt voluntary ‘nutritional reformulation’ University. Available online at www. of popular products is the principal strategy The role of the government royalpa.co.uk/?p=childhood_notes_ proposed by the Chief Medical Officer, Dame Campaigns such as ‘Change4Life’ have details&idja=5 (accessed July 2015). Sally Davies, in her recent annual report.25 been successful and the Science Advisory 22. http://www.bbc.co.uk/news/ In the case of sugar, one option is the Committee is also reviewing the role of sugar- health-33479118 (accessed July 2015). gradual reduction in the amount of sugar sweetened beverages. Ministers have also 23. Food expenditure and nutritional quality added to foods, as urged by the group, pledged to monitor the nutritional content of over the Great Recession. IFS Briefing ‘Action on Sugar’.26 In fact this process is children’s food. Note BN143 www.ifs.org.uk/bns/bn143. pdf (accessed July 2015). ‘I’D LIKE CONSISTENT AND CLEAR FOOD LABELLING 24. The Grocer article, 20 December 2013. Soft drinks: Making the healthy choice the TO BE MANDATORY ON ALL PRODUCTS’ cheaper choice. Available online at www. thegrocer.co.uk/home/topics/soft-drinks- making-the-healthy-choice-the-cheaper- already underway, although it is not always But each one of these potentially sugar- choice/353070.article (accessed July 2015). publicised. For example the children’s reducing solutions is not enough in isolation. 25. Annual Report of the Chief Medical breakfast cereal, Sugar Puffs contained 49% of So what would I like? I’d like consistent and Officer 2012. Our Children Deserve sugar in the early 1990s compared to a current clear food labelling to be mandatory on Better: Prevention Pays (2013). Available 31%. Although this remains a high sugar all products, I’d like us to urgently explore online at www.gov.uk/government/ product, the 37% reduction is significant.21 the feasibility of incentivising healthy food uploads/system/uploads/attachment_data/ Recently Tesco’s announced that it would be and as healthcare professionals I’d like us to file/255237/2901304_CMO_complete_ reducing the sugar content of its own brand continue to educate and support our patients. low_res_accessible.pdf (accessed July carbonated beverages27 and Sainsbury’s have To tell them that no added sugar does not 2015). a sugar reduction policy28 as part of their equal sugar free, to educate and help them 26. Action on Sugar http://actiononsugar.org/ ‘Responsibility’ pledge. understand food labelling and get them used 27. BBC News release, 22 May 2015. Tesco Another approach is to use sugar to looking at the back of the packet. We need to cut soft drinks sugar contenthttp:// substitutes such as aspartame, or new more a collective and committed approach which www.bbc.co.uk/news/health-32835245 natural forms, like stevia. Despite persistent would see professionals and government (accessed July 2015). controversy, they have been repeatedly tested working with industry. 28. J. Sainsbury plc. Responsibility. Available and found to be safe. Many would say we At the end of the day, if we, as consumers online at www.j-sainsbury.co.uk/ need to be de-sweetening products without and professionals unite, and demand product responsibility/case-studies/2014/sugar- the use of sweeteners or, if we are going to reformation with increased lower sugar and reduction/ (accessed July 2015). embrace a pro-sweetener approach, then sugar-free products, industry will be prompted their use should be more widespread. Do the to action. The power is in our hands. bdjteam2015107