Reducing our consumption of sugar-sweetened beverages

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ental caries, or the dental cavity as it is more commonly known, is the most common chronic disease of childhood. Untreated dental cavities, which I will refer to as dental caries for the rest of this article, can negatively affect school performance in children, adolescents and in adults. Untreated dental caries can also lead to a reduction in work productivity and increased work absenteeism. In addition, a previous history of dental caries is a risk factor for the development of further dental caries and dental caries adversely affects a disproportionate number of children, adolescents, and adults from low socio-economic or underserved households.

What is dental caries and how does it develop? How does sugary beverage consumption affect the teeth and the overall health of you and your kids? What can you do to reduce the likelihood of developing dental caries? These are some of the questions I will answer briefly.

Dental caries is a diet-related disease which requires fermentable carbohydrates for the caries process to occur. The cariogenic bacteria in the mouth produce acid as a result of the fermentation of the carbohydrates and the acid demineralizes the teeth resulting in a dental caries lesion. In our society, sugar-sweetened beverages such as soda, sports drinks, and fruit juices, are the dietary items most commonly associated with dental caries in children1. The sugar-sweetened beverages can lead to dental caries because cariogenic bacteria from the sugars present in sugar-sweetened beverages demineralize the teeth as mentioned earlier and this can initiate or increase the progression of dental caries. The important component in sugar-sweetened beverages is sucrose, glucose, or high-fructose corn syrup. Sucrose is the most important cariogenic dietary substrate as it can be fermented by oral bacteria. After the sugar is ingested, it causes the pH or acidity level of the mouth to fall to around 5.0 or below as a result of acid production by acidogenic and acid-tolerant bacteria and this leads to a sustained demineralization of the tooth and the development of dental caries2.

We know that high consumption of sugary beverages such as sodas and sports drinks can lead to increased rates of dental caries and that these are frequently consumed by children and adolescents in the US. However, there are other well-documented side effects of too much sugar-sweetened beverage consumption, and I will mention some of these. The outcomes most commonly associated with excessive sugary beverage consumption besides dental caries are weight gain and obesity, outcomes found in both children and adults. Among adults, high sugary beverage consumption has also been linked to an increase in cardiovascular risk factors, an increase in insulin resistance and an increase in type 2 diabetes. A recent review of the literature concluded that there was clear evidence that the consumption of sugar-sweetened beverages increases the risk of obesity among children and adolescents3. The authors of this review noted that given that children who are overweight are likely to remain so as adults, the adverse consequences of obesity as a result of the consumption of sugary beverages is a problem that requires our attention. This review also identified studies that found associations between caffeinated sugar-sweetened beverages and other health issues including poor sleep quality, headaches, and depression.

High consumption of sugar-sweetened beverage has also been associated with lower bone mineral density among postmenopausal women. One study that included 72,342 postmenopausal women concluded that consuming more than two servings of soft drinks per day on average demonstrated potential associations with a higher risk of hip fracture among postmenopausal women4 .

Now that we are aware of some of the adverse effects of drinking too much sugar-sweetened beverages, what can we do to reduce our consumption and that of our kids? One of the simplest ways we can do that is by choosing to drink water instead of sugary drinks. To reduce environmental pollution, we should choose a refillable water bottle we can keep with us at work or as we move around. Another way is to start by reducing our consumption of sugary beverages like sodas, sweetened iced teas, sport drinks like Gatorade, and juices with high fructose corn syrup and even some 100% juices that still have a high sugar content. We do not have to cut out all of our sugary beverage consumption at once, we can start by cutting back slowly and reducing our daily intake in increments. Finally, it is important that we start reading nutrition labels and ingredients. Some beverages claim to be all-natural or healthy but in fact include large amounts of sugar in the form of sucrose, glucose, or other forms of sugar. It is important that you stop and take the time to read the nutrition label as what manufacturers claim in their commercials may not often be the truth.

For a more comprehensive list of recommended ways to reduce consumption of sugar-sweetened beverages, we can look at the recommendations listed in a recent publication by the Cochrane Database of Systematic Reviews, the gold standard for reviewing the scientific literature5.

In this publication, a team of researchers from Germany and the UK examined the results from 58 studies that assessed a range of approaches that sought to change the physical or social environment where individuals buy or consume sugary drinks such as schools, restaurants, homes and retail outlets. The authors also looked at policy initiatives and the included studies were conducted in 19 different countries from North and South America, Australia, Europe, and South East Asia. In summary, the authors listed specific measures based on sound science that can be used to reduce sugar-sweetened beverage consumption including:

1. Using labels that are easy to understand and that rate the health level of beverages with stars or numbers.
2. Putting limits on the availability of sugary-sweetened beverages in schools.
3. Putting price increases on sugary-sweetened beverages in restaurants, stores, and leisure centers.
4. Putting healthier beverages on children’s menus in chain restaurants instead of sugary beverages as the default.
5. The promotion and better placement of healthier beverages in supermarkets.
6. Preventing the use of government food benefits for the purchase of sugar-sweetened beverages.
7. The use of community campaigns that are focused on supporting healthy beverage choices.
8. The use of measures that improve the availability of low-calorie beverages at home such as increased delivery of bottled water.

Research has also shown that taxation may help reduce the consumption of sugar sweetened beverages, but this was not examined in this review.

Another interesting approach worth discussing is the approach taken by New York City since 2006 to reduce the consumption of sugar-sweetened beverages6. The approaches are summarized below as described in the publication. The New York City Department of Health and Mental Hygiene used a variety of efforts from 2006 to 213 including institutional changes, education, regulatory and legislative policy to reduce sugary beverage consumption. Through the use of these initiatives, the city observed a 35% decrease in the number of New York City adults consuming one or more drinks a day and a 27% decrease in public high school student’s consumption from 2007 to 2013.

The institutional changes included the adoption of nutritional standards for meals and snacks served by city agencies and service providers. These included voluntary nutrition standards for vending machines, patient meals and cafeterias. The educational campaign included a mass media educational approach to raise awareness of the added sugars in sugar-sweetened beverages and their association with weight gain, diabetes and obesity. They also informed New Yorkers on how many miles they would need to walk to burn off the calories from the sugary beverages and utilized a campaign that focused on reducing consumption of sports drinks and energy drinks. They presented this information to over 300 community and faith-based institutions.

The regulatory changes included the passing of nutritional standards for early childcare centers in 2006 and children’s camps in 2012. Other regulatory approaches included the regulation that New York food service establishments with more than 15 locations nationwide post calorie counts on menus and menu boards for all products. Finally, they also introduced a portion cap rule which limited the excessive portion sizes of sugary drinks in food service establishments. The rule was eventually overturned but as a result of the nationwide media coverage, it served to help increase awareness of the association between sugar-sweetened beverage consumption and obesity.

Finally, there were other methods included in the approach including other policy proposals. These included a proposal to tax sugar-sweetened beverages but was it was not able to pass and be implemented in the state budget. In 2010, the State of New York and New York City tried unsuccessfully to have sugar-sweetened beverages removed from US Department of Agriculture (USDA) list of allowable purchases through the Supplemental Nutrition Assistance Program. While these last two approaches may have been unsuccessful, they both garner media attention and therefore help bring more public awareness of the need to reduce sugar-sweetened beverage consumption.

We have discussed how sugar-sweetened beverages can cause dental caries, the other adverse effects of excessive sugar-sweetened beverage consumption and also suggested ways that we can start reducing our own consumption of sugary beverages. We know that abstaining from soda can improve bone health and reduce the likelihood of osteoporosis among postmenopausal women but it can lead to other dietary changes as well including an increased consumption of water or other healthy options. We can start making small changes in the lives of ourselves and our children for better health outcomes.

Sincerely

Dr. Brian Laurence

1. Marshall TA. Levy SM, Broffitt B, Warren JJ, Eichenberger-Gilmore JM, Burns TL, Stumbo PJ. Dental caries and beverage consumption in young children. Pediatrics. 2003;112(3 Pt 1):e184-191.
2. Sheiham A, James WP. Diet and Dental Caries: The Pivotal Role of Free Sugars Reemphasized. Journal of Dental Research. 2015;94(10):1341-1347.
3. Bleich SN, Vercammen KA. The negative impact of sugar-sweetened beverages on children’s health: an update of the literature. BMC Obesity.2018;5.6:doi: 10.1186/s40608-017-0178-9. eCollection 2018.
4. Kremer PA, Laughlin GA, Shadyab AH, Crandall CJ, Masaki K, Orchard T, Snetselaar L, LaCroix AZ. Association between soft drink consumption and osteoporotic fractures among postmenopausal women: the Women’s Health Initiative. Menopause. 2019 Nov;26(11):1234-1241.
5. Von Philipsborn P, Stratil JM, Burns J, Busert LK, Pfadenhauer LM, Polus S, Holzapfel C, Hauner H, Rehfuess. Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health. Cochrane Database of Systematic Reviews. 2019, Issue 6. Art. No:CD012292.
6. Kansagra SM, Kennelly MO, Nonas CA, Curtis CJ, Van Wye G, Goodman A, Farley TA. Reducing sugary drink consumption: New York City’s approach. American Journal of Public Health. 2015;105(4):e61-e64.