by Karen Davis, RDH, BSDH
Many people believe that “No High Fructose Corn Syrup” or “Organic Raw Sugar” stamped on a container of food or drink means it’s OK. This topic could be considered controversial depending on the sources. However, here are some facts that cannot be disputed:
- Americans consume an average of 22 to 30 teaspoons of empty calories daily from sugar added during the processing of foods and beverages.1
- The intake of added sugar has jumped 20% since 1970, and a growing body of evidence indicates that sugar-sweetened beverages boost the risk of disease in America.1
- Energy drinks, sports drinks, sweetened teas, and sodas make up the leading source of added sugars in the U.S. diet.1
- Over two thirds of the adult population in America is overweight as defined by a body mass index of 25 to 29.9, or obese as defined by a body mass index of 30 or higher.2
- “Diabesity” refers to diabetes occurring in the context of obesity and represents a substantial economic burden. The U.S. has the highest known expenditure on diabesity worldwide.3
- In 2009 the American Heart Association published a statement called “Dietary Sugars Intake and Cardiovascular Health,” and recommended Americans slash added sugar intake from the daily average of around 100 grams to 26 grams for women and 38 grams for men daily.1
The growing obsession with sugar in our diets should be routinely discussed with patients in the dental office. Dental professionals see their patients more frequently than do most physicians; therefore the dental team is in the perfect position to help initiate changes in behavior regarding sugar consumption.
A great place to start is to understand what added sugar means. It is sweetener that has calories, and it is added during the processing or manufacturing of foods and drinks. It does not include natural sugars found in fruits and vegetables. Current labeling in the U.S. lists total sugar and does not differentiate added sugar from natural sugar. However, unless a food or beverage contains dairy, fruit, or vegetables, most sugar listed is added sugar.
Added sugars go by many names, such as sucrose (table sugar), fructose, glucose, agave syrup, honey, raw or organic brown sugar, high fructose corn syrup (HFCS), and juice concentrates. Sucrose or table sugar is broken down in the body to half fructose and half glucose. At that point it is essentially identical to high fructose corn syrup, which is 55% fructose and 45% glucose. Added sugars typically have a higher glycemic index with little or no nutritional value, which means it raises the blood sugar quickly. Added sugars do not provide nutrients essential for maintaining good health, such as calcium and magnesium; hence the reason they are referred to as “empty calories.” Too much consumption of these calories can reduce the desire for foods or drinks that do provide essential nutrients.
The American Heart Association raised the red flag about sugar consumption based on the growing pandemic of obesity and cardiovascular diseases worldwide. This became the rationale for the revised diet and lifestyle guidelines that recommend reducing the intake of food and beverages with added sugars. In order to make this dramatic change in the average diet, it is helpful to examine just how quickly one can exceed those daily recommendations. Table 1 reveals the added sugar and caloric content of common foods and drinks in the American diet.
Fructose and sugary drinks
What about high fructose corn syrup, or fructose added to foods and drinks? Isn’t that the real culprit? Research here is interesting, and there is a need for more placebo-controlled studies that take confounding factors into consideration to get a more accurate answer. But current data on overconsumption of beverages that contain fructose or high fructose corn syrup is generally unfavorable from a health perspective.
Fructose ends up in the liver, whether or not one needs the calories for energy, whereas glucose is not retained in the liver if one doesn’t need the calories. What happens to fructose in the liver is that it is converted into fat. Consumption of soft drinks with fructose have been shown to increase the prevalence of nonalcoholic fatty liver disease (NAFLD), independent of metabolic syndrome.4 Metabolic syndrome includes insulin resistance, abdominal obesity, elevated blood pressure, and abnormal lipid panels (low levels of HDL and elevated levels of triglycerides). NAFLD is a significant health problem affecting 20% to 30% of the adult population. A study published in Circulation showed that soft drink consumption is linked to obesity and results in an increased risk of metabolic syndrome. Individuals consuming more than one soft drink per day had a higher risk of metabolic syndrome than those consuming less than one drink per day.5
The association of Type II diabetes and consumption of sugar-sweetened beverages was assessed in an eight-year prospective study of 51,603 women, and after adjusting for confounders, discovered that women consuming one or more sugar-sweetened soft drink daily had a higher relative risk of developing Type II diabetes compared to those who consumed less than one soft drink per month.6
According to the recently published “International Study of Macro/Micronutrients and Blood Pressure” in early 2011, people who routinely drink sugared sodas or juices are more likely to have high blood pressure and weigh more than those who do not consume those beverages.7
Research published in 2009 showed that in obese or overweight individuals, fructose-sweetened but not glucose-sweetened beverages promoted abnormal amounts of lipids in the blood, impaired insulin sensitivity, increased visceral fat deposition, and increased blood triglyceride levels.8 Results of this study raised questions about the effect sugar-sweetened beverages might have on individuals of normal weight. A study published this year in the American Journal of Clinical Nutrition revealed that within just three weeks in healthy young men, low to moderate consumption of sugary drinks showed potentially harmful effects on markers of cardiovascular risk such as LDL cholesterol levels, fasting glucose levels, and C-reactive protein.9
Over a period of time, a high fructose diet has been shown to block the production of the hormone leptin, which signals the brain to recognize when one has had enough calories. If someone doesn’t get that signal, their body thinks they are still hungry. An absence of leptin can lead to uncontrolled food intake, resulting in obesity.10 Fructose from fresh fruit remains a highly recommended dietary component of a healthy diet, but chronic consumption of large amounts of dietary fructose added to foods and beverages can lead to adverse effects on health.
On the other side of this controversy, supporters of continued use of fructose in the form of HFCS point out that it is a relatively inexpensive sweetener and cannot be fully implicated in the obesity crisis in this country.11 Indeed, obesity, diabetes, and cardiovascular diseases are complicated conditions, and a single factor such as sugary drinks cannot take all of the blame for development of such conditions; however, the wake-up call from the American Heart Association to slash added sugar from the diet should be taken seriously.
Substitutes for added sugar
The FDA has approved several types of nonsugary substitutes as sweeteners that are on the Generally Recognized as Safe (GRAS) list, or on the list approved as a food additive. Table 2 provides a list of various sweeteners currently used as substitutes to added sugars. Regardless of which list these sweeteners are on, there must be evidence that the substance is safe for the conditions of its intended use.
One type of sugar substitute, sugar alcohols, naturally occur in many fruits and vegetables, contain fewer calories than sugar, and have a lower glycemic index than sugar. Sugar alcohols are generally considered noncariogenic, although caution should be given for prolonged exposure because most have not been studied carefully under those conditions, and there have been reports of prolonged exposure to some sugar alcohols promoting dental caries.12
Most sugar alcohols are not completely absorbed in the body, and high intakes of foods or drinks containing some sugar alcohols can lead to abdominal gas and diarrhea. Foods that contain sorbitol or mannitol must include a warning on their label that says, “Excessive consumption may have a laxative effect.” Sugar-free products sweetened with sugar alcohols are not calorie-free; therefore they should not be consumed in unlimited quantities.
Xylitol, one of the sugar alcohols dental professionals are familiar with, can be substituted for sugar in cooking since it is heat stable, measures the same as sugar, and is noncariogenic. Xylitol is also a good choice when added to gum and mints for individuals that need increased salivary flow to help with xerostomia, or to reduce caries risk.
Soft drink impact on the oral environment in children
Patterns of fluid consumption of children ages two to 10 were studied to determine the significance of soft-drink consumption and dental caries on primary teeth. The sample size consisted of 5,985 U.S. children, and data was compiled from a 24-hour dietary recall interview in the Third National Health and Nutrition Examination Survey (NHANES III). Carbonated soft drinks comprised 8.5% of total fluid consumption. Milk and juice comprised less than 20%, and water comprised about 32% of total fluid consumption. Children with a high carbonated soft drink consumption pattern showed significantly higher caries experience, even compared with those children with a high juice consumption pattern.13 According to the Centers for Disease Control, over 19% of children ages two to 19 have untreated dental caries. The CDC states, “A child’s complete preventive dental program should include fluoride, twice-daily brushing, wise food choices, and regular dental care.”14
Role of the dental professional
Dental professionals may not study the topic of sugar consumption in depth, but can appreciate the fact that most patients do not give nearly enough consideration to the adverse effects sugar consumption can have on their health, either systemically or orally. Dental professionals have an opportunity to influence patients’ behaviors regarding daily sugar intake, and should also identify patients at increased risk for caries and be proactive. They can make recommendations for fluoride varnishes such as Vanish Varnish™ by 3M ESPE or Colgate PreviDent® Varnish, state-of-the-art plaque removal devices such the Philips Sonicare DiamondClean, Sonicare for Kids, or Oral-B Braun, and xylitol products such as Spry Gum and Mints by Xlear, or Xyli-Tot Lollies by CariFree®.
The following tips can be implemented to reduce daily sugar habits.
1. Read labels to determine sugar content prior to purchasing or consuming.
2. Strive to limit added sugar consumption to 100 calories or 26g for women daily and 150 calories or 38g for men daily.
3. Strive to eliminate sugary drinks with empty calories from daily consumption.
4. Continue to consume natural sugars found in dairy products, fruits, and some vegetables.
5. Substitute noncaloric sugar sweeteners or sugar alcohols in foods and drinks, in moderation.
Disclosure: Karen Davis is an independent consultant to the Philips Corporation
Karen Davis, RDH, BSDH, is founder of Cutting Edge Concepts, and is a practicing dental hygienist in Dallas, Texas. She is a trainer with the JP Institute and an international speaker in the dental profession. Karen serves as an independent consultant to Philips Oral Healthcare, Inc. She received her bachelor of science in dental hygiene from Midwestern State University and can be reached at [email protected].
1. Johnson RK, Appel LF, Brands M, et al. Dietary sugars intake and cardiovascular health: A scientific statement from the AHA. Circulation 2009; 120: 1011-1020.
2. http://www.cdc.gov/obesity/index.html Accessed Sept. 29, 2011
3. Youssef MK, Gavalla MR. Diabesity: an overview of a rising epidemic Nephrol Dial Transplant 2011; 26: 28-3
4. Nseir W, Nassar F, Assy N. Soft drinks consumption and nonalcoholic fatty liver disease. World J Gastroenterol 2010; 16: 2579-2588
5. Dhingra R, Sullivan L, Jacques PF, et al.. Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. Circulation 2007; 116: 480-488
6. Schulze MB, Mason JE, Ludwig DS, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA 2004; 292: 927-934
7. Brown IJ, Stamler J, Van Horn L, et al. Sugar-sweetened beverages, sugar intake of individuals, and their blood pressure. Hypertension 2011; 57:695-701
8. Hofmann SM, Tschop MH. Dietary sugars: a fat difference. J Clin Invest 2009; 119(5);1089-1092
9. Aeberli I, Gerber PA, Hochuli M, et al. Low to moderate sugar-sweetened beverage consumption impairs glucose and lipid metabolism and promotes inflammation in healthy young men: a randomized controlled trial. Am J Clin Nutr 2011; 94:479-85
10. Scarpace PJ, Zhang Y. Leptin resistance: a predisposing factor for diet-induced obesity. Am J Physiol Regul Intergr Comp Physiol 2008; 296: R493-500
11. White JS. Straight talk about high-fructose corn syrup: what it is and what it ain’t. Am J Clin Nutr 2008: 88 (suppl): 1716S-21S
12. Mayo JA, Ritchie JR. Acidogenic potential of “sugar-free” cough drops. Open Dentistry J 2009; 3:26-3
13. Sohn W, Burt BA, Sowers MR. Carbonated soft drinks and dental caries in the primary dentition. J Dent Res 2006; 85:262-267
14. http://www.cdc.gov/Features/dsUntreatedCavitiesKids/ Accessed October 3, 2011
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