The Dangers of Sugar-Sweetened Beverages: Dental Professionals Must Respond

The threat to health posed by over-consumption of sugar-sweetened beverages (SSB) is well documented. These beverages include sodas, energy and vitamin drinks, fruit juice and other soft drinks containing added sugars.1Bleich SN, Vercammen KA. The negative impact of sugar-sweetened beverages on children’s health: an update of the literature. BMC Obesity 2018;5:6,2Hu FB. Resolved: There is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev 2013;14(8):606-19.,3Luger M, Lafontan M, Bes-Rastrollo M, Winzer E, Yumuk V, Farpour-Lambert N. Sugar-sweetened beverages and weight gain in children and adults: A systematic review from 2013 to 2015 and a comparison with previous studies. Obes Facts 2017;10:674-93. SSB promote weight gain and the adverse health effects associated with being overweight or obese.2Hu FB. Resolved: There is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev 2013;14(8):606-19.,3Luger M, Lafontan M, Bes-Rastrollo M, Winzer E, Yumuk V, Farpour-Lambert N. Sugar-sweetened beverages and weight gain in children and adults: A systematic review from 2013 to 2015 and a comparison with previous studies. Obes Facts 2017;10:674-93.

This has led to a call for renewed efforts to reduce SSB consumption, including taxation, labeling changes and behavioral interventions.4Lee BY, Ferguson MC, Hertenstein DL, Adam A, Zenkov E, Wang PI, Wong MS, Gittelsohn J, Mui Y, Brown ST. Simulating the impact of sugar-sweetened beverage warning labels in three cities. Am J Prev Med 2018;54(2):197-204. doi: 10.1016/j.amepre.2017.11.003.,5Abdel Rahman A, Jomaa L, Kahale LA, Adair P, Pine C. Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: a systematic review and meta-analysis. Nutr Rev 2018;76(2):88-107. doi: 10.1093/nutrit/nux061. The role of dental professionals in this effort must also be considered. This is in relationship to the larger issue of dental professionals applying a common risk factor approach to emphasize the importance of prevention as fundamental to controlling the development and progression of many oral and systemic diseases.

Health Impact of SSB

In a systematic review of 30 studies conducted between January 2013 and October 2015, a significant association was found for SSB consumption and weight gain in children and adults.3Luger M, Lafontan M, Bes-Rastrollo M, Winzer E, Yumuk V, Farpour-Lambert N. Sugar-sweetened beverages and weight gain in children and adults: A systematic review from 2013 to 2015 and a comparison with previous studies. Obes Facts 2017;10:674-93. Further, in an Australian study of children 2 to 16 years-of-age, consuming at least 2 servings of SSB daily (>250 g/day) carried a 26% greater risk of being overweight or obese compared to consuming less.6Grimes CA, Riddell LJ, Campbell KJ, Nowson CA. Dietary salt intake, sugar-sweetened beverage consumption, and obesity risk. Pediatrics 2013;131(1):14-21. A majority of studies in another review also support a relationship between SSB consumption and insulin resistance in children and adolescents.1Bleich SN, Vercammen KA. The negative impact of sugar-sweetened beverages on children’s health: an update of the literature. BMC Obesity 2018;5:6. Since childhood obesity is associated with asthma, attention-deficit disorder, and reduced quality of life and educational achievement,7Bussiek P-BV, De Poli C, Bevan G. A scoping review protocol to map the evidence on interventions to prevent overweight and obesity in children. BMJ Open 2018;8:e019311. reduction in SSB consumption is an important public health initiative. Studies further highlight a relationship between adult consumption of SSB, and diabetes mellitus (DM) and cardiovascular disease, with a direct dose-response observed for long-term weight gain and DM.2Hu FB. Resolved: There is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev 2013;14(8):606-19. Globally, an estimated 184,000 deaths per year are associated with intake of SSB, with 72.3%, 24.2% and 3.5% of these deaths attributed to DM, cardiovascular disease and cancers, respectively.8Singh GM, Micha R, Khatibzadeh S, Lim S, Ezzati M, Mozaffarian D; Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE). Estimated global, regional, and national disease burdens related to sugar-sweetened beverage consumption in 2010. Circulation 2015;132:639-66. (Figure 1)

Globally, an estimated 184,000 deaths per year are associated with intake of SSB



Consumption of SSB is clearly associated with dental caries. Third graders in one study from the United States were found to consume an average of 2 SSB per day.9Wilder JR, Kaste LM, Handler A, Chapple-McGruder T, Rankin KM. The association between sugar-sweetened beverages and dental caries among third-grade students in Georgia. J Public Health Dent 2016;76:76-84. After adjusting for socioeconomic status and maternal oral health, a 22% increase in dental caries was found for each additional SSB consumed daily. Greater SSB consumption has also been found to result in up to a four-fold increased risk of severe early childhood caries.10Evans EW, Hayes C, Palmer CA, Bermudez OI, Cohen SA, Must A. Dietary intake and severe early childhood caries in low-income, young children. J Acad Nutr Diet 2013;113(8):1057-61. In adolescents, intake of SSB has been found to be associated with toothache and food avoidance due to dental discomfort, with consumption of energy and sports drinks noted to be of particular concern.11Hardy LL, Bell J, Bauman A, Mihrshahi S. Association between adolescents’ consumption of total and different types of sugar-sweetened beverages with oral health impacts and weight status. Aust N Z J Public Health 2018;42(1):22-6. doi: 10.1111/1753-6405.12749.

Greater SSB consumption has also been found to result in up to a four-fold increased risk of severe early childhood caries.

Effect of Reduced Intake of SSB

Recent randomized controlled clinical trials have confirmed health improvements following reduced intake of SSB.1Bleich SN, Vercammen KA. The negative impact of sugar-sweetened beverages on children’s health: an update of the literature. BMC Obesity 2018;5:6.,2Hu FB. Resolved: There is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev 2013;14(8):606-19.,12de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in children. N Engl J Med 2012;367(15):1397-406. In a Dutch study, more than 600 children 4 to 11 years-of-age, and of normal weight, received 8 oz. (250 ml) of a sugar-free drink or an SSB daily for 18 months. Reduced weight gain was observed in the group receiving sugar-free drinks.12de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in children. N Engl J Med 2012;367(15):1397-406. In another study, among English children ages 7 to 11 years, fewer children in the group receiving 4 educational sessions that discouraged SSB consumption were overweight at the end of the school year than in the control group, although this benefit was not sustained.13James J, Thomas P, Kerr D. Preventing childhood obesity: two year followup results from the Christchurch obesity prevention programme in schools (CHOPPS). BMJ 2007;335(7623):762. In a third study with more than 200 adolescents, weight reductions were again observed in the intervention group at the end of 12 months, but not sustained.14Ebbeling CB, Feldman HA, Chomitz VR, Antonelli TA, Gortmaker SL, Osganian SK, Ludwig DS. A randomized trial of sugar-sweetened beverages and adolescent body weight. N Engl J Med 2012;367(15):1407-16.

Policy Interventions to Reduce SSB Consumption

Policy-based strategies aimed at reducing SSB consumption include taxation, labeling changes, reformulation of products to reduce sugar content, and reducing access to SSB.7Bussiek P-BV, De Poli C, Bevan G. A scoping review protocol to map the evidence on interventions to prevent overweight and obesity in children. BMJ Open 2018;8:e019311.,15Moise N, Cifuentes E, Orozco E, Willett W. Limiting the consumption of sugar sweetened beverages in Mexico’s obesogenic environment: a qualitative policy review and stakeholder analysis. J Public Health Policy 2011;32(4):458-75.,16Tierney M, Gallagher AM, Giotis ES, Pentieva K. An online survey on consumer knowledge and understanding of added sugars. Nutrients 2017;9:37. In Mexico, a 10% tax resulted in a 6% decline in SSB consumption, and the impact of taxation was greater for families with a lower socioeconomic status.3Luger M, Lafontan M, Bes-Rastrollo M, Winzer E, Yumuk V, Farpour-Lambert N. Sugar-sweetened beverages and weight gain in children and adults: A systematic review from 2013 to 2015 and a comparison with previous studies. Obes Facts 2017;10:674-93.,17Bollard T, Maubach N, Walker N, Mhurchu CN. Effects of plain packaging, warning labels, and taxes on young people’s predicted sugar-sweetened beverage preferences: an experimental study. Int J Behav Nutr Phys Activity 2016;13:95. A number of countries in Europe have also introduced taxes on SSB.3Luger M, Lafontan M, Bes-Rastrollo M, Winzer E, Yumuk V, Farpour-Lambert N. Sugar-sweetened beverages and weight gain in children and adults: A systematic review from 2013 to 2015 and a comparison with previous studies. Obes Facts 2017;10:674-93.,18Euromonitor International: Sin tax in food and beverages – strategies, outcomes and learnings. London 2016. www.euromonitor.com/sin-tax-in-food-and-beverages-strategies-outcomes-and-learnings/report. The impact of tax increases on intent to purchase SSD was unchanged, however, in an online survey with the theoretical imposition of a 20% tax.16Tierney M, Gallagher AM, Giotis ES, Pentieva K. An online survey on consumer knowledge and understanding of added sugars. Nutrients 2017;9:37.
Placement of health warning labels on SSB regarding their association with obesity, DM and tooth decay may reduce intent-to-purchase. In an online survey of more than 2000 parents, 40% of parents would select an SSB with a warning label.
In comparison, 53% and 60% of parents, respectively, would select an SSB if the label included calorie information or did not include any information on health risks or calories.19Roberto CA, Wong D, Musicus A, Hamond D. The influence of sugar-sweetened beverage health warning labels on parents’ choices. Pediatrics 2016;137(2):e20153185. Similarly, information on calories did not influence hypothetical beverage choices among more than 2000 adolescents, while warning labels reduced the likelihood of selecting SSB.20VanEpps EM, Roberto CA. The influence of sugar-sweetened beverage warnings: A randomized trial of adolescents’ choices and beliefs. Am J Prev Med 2016;51(5):664-72. In a model simulation for three major US cities, it was concluded that warning labels would reduce the prevalence of adolescent obesity and being overweight.4Lee BY, Ferguson MC, Hertenstein DL, Adam A, Zenkov E, Wang PI, Wong MS, Gittelsohn J, Mui Y, Brown ST. Simulating the impact of sugar-sweetened beverage warning labels in three cities. Am J Prev Med 2018;54(2):197-204. doi: 10.1016/j.amepre.2017.11.003. There is also evidence that school nutrition policies influence SSB consumption.21Levy DT, Friend KB, Wang YC. A review of the literature on policies directed at the youth consumption of sugar sweetened beverages. Adv Nutr 2001;2:182S-200S.,22Taber DR, Chriqui JF, Vuillaume R, Kelder SH, Chaloupka FJ. The association between state bans on soda only and adolescent substitution with other sugar sweetened beverages: a cross-sectional study. Int J Behav Nutr Phys Activity 2015;12(Suppl 1):S7. The results of interventional controlled trials are supportive of the positive impact of school-based education, follow-up modules and sustained interventions.23Avery A, Bostock L, McCullough F. A systematic review investigating interventions that can help reduce consumption of sugar sweetened beverages in children leading to changes in body fatness. J Hum Nutr Diet 2015;28 (Suppl 1):5264.


Figure 2.
Influence of taxes and labeling on consumption and selection of SSB

Role of Dental Professionals

Dental professionals have been urged to promote the importance of healthy weight and reduced intake of SSB.24Dooley D, Moultrie NM, Sites E, Crawford PB. Primary care interventions to reduce childhood obesity and sugar-sweetened beverage consumption: Food for thought for oral health professionals. J Public Health Dent 2017;77(Suppl 1):S104-S127. Dental professionals are well-positioned to provide nutritional and obesity education, and have frequent contact with children, adolescents and adults.25Mallonee LF, Boyd LD, Stegeman C. A scoping review of skills and tools oral health professionals need to engage children and parents in dietary changes to prevent childhood obesity and consumption of sugar-sweetened beverages. J Public Health Dent 2017;77(Suppl 1):S128-S135.,26Wright R, Casamassimo PS. Assessing attitudes and actions of pediatric dentists toward childhood obesity and sugar-sweetened beverages. J Pub Health Dent 2017;77:S79-S87. Expansion of the scope of dental practice can include advice about diet and modifications of poor lifestyle behaviors,27Lamster IB, Myers-Wright N. Oral health care in the future: expansion of the scope of dental practice to improve health. J Dent Educ 2017;81:eS83-eS90. and there is considerable discussion about how dental professionals can adopt this new aspect of practice.
A recent review of interventions for Native American children and adolescents in Alaska concluded that a variety of approaches should be emphasized, including education of the entire family and a community-based approach.28Chi DL. Reducing Alaska Native paediatric oral health disparities: a systematic review of oral health interventions and a case study on multilevel strategies to reduce sugar-sweetened beverage intake. Int J Circumpolar Health 2013;72:21066. This analysis emphasized the need for culturally-appropriate interventions. Another review examined interventions that could help children younger than 12 years-of-age.
Two studies involving dental offices were identified, in which dental
hygienists provided advice on a healthy diet and physical activity, as well as medical referrals for children who were overweight or at risk of being overweight. Reductions in Body Mass Index were observed. Active listening and motivational interviewing were identified as appropriate techniques, and the review confirmed the positive role that dental professionals can play.25Mallonee LF, Boyd LD, Stegeman C. A scoping review of skills and tools oral health professionals need to engage children and parents in dietary changes to prevent childhood obesity and consumption of sugar-sweetened beverages. J Public Health Dent 2017;77(Suppl 1):S128-S135.
In an online survey of pediatric dentists and dental residents, 94% of more than 1600 respondents indicated that they provided information and advice on SSB.26Wright R, Casamassimo PS. Assessing attitudes and actions of pediatric dentists toward childhood obesity and sugar-sweetened beverages. J Pub Health Dent 2017;77:S79-S87. While only 17% offered additional interventions for childhood obesity, a majority of the remaining respondents stated that they would be interested in doing so. Weight and height measurements, and advice were most frequently provided. Other surveys also indicate that few dental professionals provide obesity interventions or are comfortable discussing weight.29Curran AE, Caplan DJ, Lee JY, Paynter L, Gizlice Z, Champagne C, Agans R. Dentists’ attitudes about their role in addressing obesity in patients: a national survey. J Am Dent Assoc 2010;141(11):1307-16.,30Braithwaite AS, Vann J, William F, Switzer BR, Boyd KL, Lee JY. Nutritional counseling practices: how do North Carolina pediatric dentists weigh in? Pediatr Dent 2008;30(6):488-95. (Table 1)
Table 1. Roles for dental professionals
Nutritional and obesity education for patients
Patient education on a healthy lifestyle and physical activity
Community-based education
Medical referrals for overweight and at-risk individuals
Motivational interviewing and active listening
Weight and height measurements

Barriers to Interventions by Dental Professionals

Barriers to providing education and other interventions for childhood obesity in the dental office include a perceived lack of parental interest and acceptance, parental dissatisfaction, fear of offending parents and giving the appearance of being judgmental.26Wright R, Casamassimo PS. Assessing attitudes and actions of pediatric dentists toward childhood obesity and sugar-sweetened beverages. J Pub Health Dent 2017;77:S79-S87.,29Curran AE, Caplan DJ, Lee JY, Paynter L, Gizlice Z, Champagne C, Agans R. Dentists’ attitudes about their role in addressing obesity in patients: a national survey. J Am Dent Assoc 2010;141(11):1307-16.,31Lee JY, Caplan DJ, Gizlice Z, Ammerman A, Agans R, Curran AE. US pediatric dentists’ counseling practices in addressing childhood obesity. Pediatr Dent 2012;34(3):245-50.,32Bell KP, Phillips C, Paquette DW, Offenbacher S, Wilder RS. Incorporating oral-systemic evidence into patient care: practice behaviors and barriers of North Carolina dental hygienists. J Dent Hyg 2011;85(2):99-113. Lack of time, the lack of trained personnel, limited personal knowledge or training on nutrition and obesity, absence of appropriate referral options, and lack of or inadequate reimbursement are also barriers.26Wright R, Casamassimo PS. Assessing attitudes and actions of pediatric dentists toward childhood obesity and sugar-sweetened beverages. J Pub Health Dent 2017;77:S79-S87.,29Curran AE, Caplan DJ, Lee JY, Paynter L, Gizlice Z, Champagne C, Agans R. Dentists’ attitudes about their role in addressing obesity in patients: a national survey. J Am Dent Assoc 2010;141(11):1307-16.,31Lee JY, Caplan DJ, Gizlice Z, Ammerman A, Agans R, Curran AE. US pediatric dentists’ counseling practices in addressing childhood obesity. Pediatr Dent 2012;34(3):245-50.,32Bell KP, Phillips C, Paquette DW, Offenbacher S, Wilder RS. Incorporating oral-systemic evidence into patient care: practice behaviors and barriers of North Carolina dental hygienists. J Dent Hyg 2011;85(2):99-113. Eighty-one percent of respondents believed that parents accept advice on SSB consumption while only 14% and 7%, respectively, held the same belief with respect to obesity education and screening.26Wright R, Casamassimo PS. Assessing attitudes and actions of pediatric dentists toward childhood obesity and sugar-sweetened beverages. J Pub Health Dent 2017;77:S79-S87. In contrast, in another study the dental setting was considered appropriate for height and weight measurements, and information on a healthy diet and physical activity, by 88% and 95% of parents, respectively.33Tavares M, Chomitz V. A healthy weight intervention for children in a dental setting: a pilot study. J Am Dent Assoc 2009;140(3):313-6. In a 2017 systematic review only three studies were found that reported nutritional or obesity-related training in dental and dental hygiene schools.34Divaris K, Bhaskar V, McGraw KA. Pediatric obesity-related curricular content and training in dental schools and dental hygiene programs: systematic review and recommendations. J Public Health Dent 2017;77(Suppl 1):S96-S103. The World Health Organization, however, recommends that nutritional training be incorporated globally into the dental curriculum.35Moynihan P. Sugars and dental caries: Evidence for setting a recommended threshold for intake 1–3. Adv Nutr 2016;7:149-56.

Conclusions

Reducing intake of SSB requires the efforts of the entire community, including active participation and collaboration by all members of the health care team.9Wilder JR, Kaste LM, Handler A, Chapple-McGruder T, Rankin KM. The association between sugar-sweetened beverages and dental caries among third-grade students in Georgia. J Public Health Dent 2016;76:76-84. Dental professionals can to play an important role in this effort by educating patients on the risks associated with SSB, and by influencing policy.36Sanghavi A, Siddiqui NJ. Advancing oral health policy and advocacy to prevent childhood obesity and reduce children’s consumption of sugar-sweetened beverages. J Public Health Dent 2017;77(Suppl 1):S88-S95. Standardized training and continuing education programs are required to provide dental professionals with the knowledge to fulfil this role.35Moynihan P. Sugars and dental caries: Evidence for setting a recommended threshold for intake 1–3. Adv Nutr 2016;7:149-56. Further research is required on interprofessional collaboration to address childhood obesity and oral disease, and on evidence-based interventions that will be most effective.7Bussiek P-BV, De Poli C, Bevan G. A scoping review protocol to map the evidence on interventions to prevent overweight and obesity in children. BMJ Open 2018;8:e019311.,24Dooley D, Moultrie NM, Sites E, Crawford PB. Primary care interventions to reduce childhood obesity and sugar-sweetened beverage consumption: Food for thought for oral health professionals. J Public Health Dent 2017;77(Suppl 1):S104-S127.,25Mallonee LF, Boyd LD, Stegeman C. A scoping review of skills and tools oral health professionals need to engage children and parents in dietary changes to prevent childhood obesity and consumption of sugar-sweetened beverages. J Public Health Dent 2017;77(Suppl 1):S128-S135. In the meantime, there is increasing awareness among dental professionals of their role in educating patients and parents on both dental caries and childhood obesity.36Sanghavi A, Siddiqui NJ. Advancing oral health policy and advocacy to prevent childhood obesity and reduce children’s consumption of sugar-sweetened beverages. J Public Health Dent 2017;77(Suppl 1):S88-S95.

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