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Quantitative relationship between free sugars intake and early childhood caries among preschoolers in Sri Lanka
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The importance of nutrition in human health has been understood for over a century. However, debate is ongoing regarding the role of added and free sugars in physiological and neurological health. In this narrative review, we have addressed several key issues around this debate and the major health conditions previously associated with sugar. We aim to determine the current evidence regarding the role of free sugars in human health, specifically obesity, diabetes, cardiovascular diseases, cognition, and mood. We also present some predominant theories on mechanisms of action. The findings suggest a negative effect of excessive added sugar consumption on human health and wellbeing. Specific class and source of carbohydrate appears to greatly influence the impact of these macronutrients on health. Further research into individual effects of carbohydrate forms in diverse populations is needed to understand the complex relationship between sugar and health.
The present study aims to develop a quantitative food frequency questionnaire (FFQ) to assess free sugar intake as a whole and at the food group levels, retrospectively, over the past 3 months among 4 to 5-year-old preschool children in the Colombo district, Sri Lanka. Then, to assess its reliability and relative validity. In the development phase, three 24-hour dietary recalls (24 hDRs) of 518 preschool children were collected from caregivers. Based on that, a 67-item FFQ was developed, including commonly consumed free sugar-containing food items. The validation study was conducted among another 108 preschool children. The relative validity of the FFQ was assessed by comparing it with the 24 hDRs. The test–retest reliability was assessed by repeated application of the FFQ to the same population after 6 weeks. Wilcoxon sign rank test, cross-classification with weighted Kappa statistic, Spearman rank correlation and Bland–Altman plots were used for comparison. Comparing the free sugar intake calculated by the two methods showed no difference ( P = 0⋅13), a good correlation (0⋅89), good agreement in cross-classifying participants (78⋅4 % correctly classified) and a good agreement in Bland–Altman plots. Repeated application of the FFQ yielded; no differences in free sugar intake values ( P = 0⋅45) a good correlation (0⋅71), acceptable agreement in cross-classifying participants (52⋅3 % correctly classified) and acceptable agreement in the Bland–Altman plot. Results were the same for all food groups. According to the results, the newly developed quantitative FFQ provides a relatively valid and reliable measure for quantifying free sugar intake among preschool children as a whole or by food group.
Abstract Background Excessive free sugar intake tends to be associated with unpleasant health consequences, such as dental caries and unhealthy weight gain in children, as well as a number of noncommunicable diseases in adults. The WHO suggests that the best method for addressing these issues is to reduce free sugar consumption throughout life, in order to be successful, these measures should be implemented as early as possible. This makes the early formative years of preschool an important point for possible intervention. To confirm this, baseline information on current sugar intake levels is needed, as well as identification of factors associated with high levels of consumption. Methods This cross-sectional study was conducted in the district of Colombo, Sri Lanka. The probability proportionate to size technique combined with cluster sampling was used to select a representative sample of 813 children aged 4-5-years from 82 preschools. We developed, and validated a quantitative food frequency questionnaire (FFQ) to assess free sugar consumption. Data on correlated factors were collected from caregivers using a pre-tested self-administered questionnaire. Results Based on the data, the daily median (IQR) free sugar intake of preschool children was 57.9 (33.2-95.8) grams/day (approximately to 14.5 (8.3-23.9) teaspoons/day) or 21.1% (12.5-34.9%) of their daily energy requirements. The WHO recommends limiting sugar intake to less than 5% of total energy intake; however, the current level is fourfold, and 96% of children consume higher percentage of energy from free sugar than recommended. In terms of total daily sugar consumption, bakery products accounted for 27%, followed by biscuits (15%), and table sugar (15%). Increasing maternal education level significantly reduced sugar intake (p = 0.04). Children of other ethnicities ate more sugar than the Sinhala children (p = 0.01). There was higher sugar intake among those who ate while returning from preschool (p
In the first 2 years of life, it is important to limit exposure to foods high in free sugars, in order to lay foundations for lifelong eating patterns associated with a reduced risk of chronic disease. Intake data at this age is limited, so compliance with recommendations is not known. This analysis describes free sugars intakes, food sources and determinants of high consumption among Australian children at 2 years of age. Free sugars intakes were estimated using a customized Food Frequency Questionnaire, and median usual free sugars intake at 2 years was 22.5 (Interquartile Range (IQR) 12.8–37.7) g/day, contributing a median 8% of the estimated energy requirement (EER). Based on the EER, most children (71.1%) exceeded the World Health Organization recommendation that <5% of energy should come from free sugars, with 38% of participants exceeding the <10% recommendation. Children from households with the greatest socioeconomic disadvantage were more likely to exceed the 10% recommendation (Prevalence Ratio (PR) 1.44, 95% Confidence Interval (95% CI) 1.13–1.84), and be in the top tertile for free sugars intake (PR 1.58, 95% CI 1.19–2.10) than the least disadvantaged. Main sources of free sugars were non-core foods, such as fruit juice, biscuits, cakes, desserts and confectionery; with yogurt and non-dairy milk alternatives the two notable exceptions. Improved efforts to reduce free sugars are needed from the introduction of solid food, with a particular focus on fruit juice and non-core foods.
Objectives:
To assess the relationship between health care system and economic factors and early childhood caries (ECC) data availability and prevalence.
Methods:
We estimated ECC data for 193 United Nations countries from studies published between 2007 and 2017. We obtained other variables from the World Health Organization and the World Bank databases. We assessed association with ECC data availability by using logistic regression and with ECC prevalence by using linear regression.
Results:
We included 190 publications from 88 (45.6%) countries. The mean ECC prevalence was 23.8% and 57.3% in children younger than 36 months and children aged 36 to 71 months, respectively. The odds of ECC data availability were significantly higher for countries with more physicians and more dentists. In children younger than 36 months, ECC prevalence was associated with universal health coverage (B = -6.56). In children aged 36 to 71 months, it was associated with growth of gross national income (B = 0.27).
Conclusions:
Countries with more physicians and more dentists were more likely to have ECC data. Among those with data, countries with higher economic growth had higher ECC prevalence. (Am J Public Health. Published online ahead of print June 21, 2018: e1-e7. doi:10.2105/AJPH.2018.304466).
The Global Burden of Disease 2015 study aims to use all available data of sufficient quality to generate reliable and valid prevalence, incidence, and disability-adjusted life year (DALY) estimates of oral conditions for the period of 1990 to 2015. Since death as a direct result of oral diseases is rare, DALY estimates were based on years lived with disability, which are estimated only on those persons with unmet need for dental care. We used our data to assess progress toward the Federation Dental International, World Health Organization, and International Association for Dental Research’s oral health goals of reducing the level of oral diseases and minimizing their impact by 2020. Oral health has not improved in the last 25 y, and oral conditions remained a major public health challenge all over the world in 2015. Due to demographic changes, including population growth and aging, the cumulative burden of oral conditions dramatically increased between 1990 and 2015. The number of people with untreated oral conditions rose from 2.5 billion in 1990 to 3.5 billion in 2015, with a 64% increase in DALYs due to oral conditions throughout the world. Clearly, oral diseases are highly prevalent in the globe, posing a very serious public health challenge to policy makers. Greater efforts and potentially different approaches are needed if the oral health goal of reducing the level of oral diseases and minimizing their impact is to be achieved by 2020. Despite some challenges with current measurement methodologies for oral diseases, measurable specific oral health goals should be developed to advance global public health.
Dental caries affects ≤80% of the world's population with almost a quarter of US adults having untreated caries. Dental caries is costly to health care and negatively affects well-being. Dietary free sugars are the most important risk factor for dental caries. The WHO has issued guidelines that recommend intake of free sugars should provide ≤10% of energy intake and suggest further reductions to <5% of energy to protect dental health throughout life. These recommendations were informed by a systematic review of the evidence pertaining to amount of sugars and dental caries risk, which showed evidence of moderate quality from cohort studies that limiting free sugars to ≤10% of energy reduced, but did not eliminate, dental caries. Even low levels of dental caries in children are of concern because caries is a lifelong progressive and cumulative disease. The systematic review therefore explored if there were further benefits to dental health if the intake of free sugars was limited to <5% of energy. Available data were from ecologic studies and, although classified as being of low quality, showed lower dental caries when free sugar intake was <5% of energy compared with when it was >5% but ≤10% of energy. The WHO recommendations are intended for use by policy makers as a benchmark when assessing intake of sugars by populations and as a driving force for policy change. Multiple strategies encompassing both upstream and downstream preventive approaches are now required to translate the recommendations into policy and practice.
Objectives:
The WHO has recently proposed to halve the recommendation for free sugar intake from 10 to 5 % of energy intake to reduce the incidence of diseases such as obesity and dental caries. The Japanese population is suitable to confirm the appropriateness of this proposal, because dietary sugar intake in Japan is exceptionally low among developed countries. We sought to establish a method to estimate dietary sugar intake in Japan and to examine the relationship between sugar and the number of dental caries using data obtained from the Japan Nursery School SHOKUIKU study.
Methods:
Dietary intake during the preceding month and the number of caries was examined in children aged 5-6 years using a brief-type self-administered diet history questionnaire for Japanese preschool children completed by their guardians and another questionnaire on lifestyle. Multivariate Poisson regression models were used for the analysis.
Results:
When subjects were ranked into quintiles by the proportion of energy from free sugar, those in higher quintiles had more caries than those in the lowest quintile. On close analysis, the number of caries among children with a relatively small proportion of energy intake from free sugar (3.18-3.77 %) was not significantly different from that in the lowest group (0.95-3.17 %).
Conclusions:
The recent proposition of WHO might be valid, because the adverse effect of relatively small proportion (approximately less than 5 %) of energy intake from free sugar on caries was not detected among the subjects in this study. However, more study will be necessary to reach a conclusion.
We measured the impact of dental diseases on the academic performance of disadvantaged children by sociodemographic characteristics and access to care determinants
We performed clinical dental examinations on 1495 disadvantaged elementary and high school students from Los Angeles County public schools. We matched data with academic achievement and attendance data provided by the school district and linked these to the child's social determinants of oral health and the impact of oral health on the child's school and the parents' school or work absences.
Students with toothaches were almost 4 times more likely to have a low grade point average. About 11% of students with inaccessible needed dental care missed school compared with 4% of those with access. Per 100 elementary and high school-aged children, 58 and 80 school hours, respectively, are missed annually. Parents averaged 2.5 absent days from work or school per year because of their children's dental problems.
Oral health affects students' academic performance. Studies are needed that unbundle the clinical, socioeconomic, and cultural challenges associated with this epidemic of dental disease in children.
Several cross-sectional studies report that caries in primary teeth is correlated with caries in permanent teeth. This eight-year cohort study sought to determine if caries in the primary dentition can predict caries in the permanent dentition of the same individuals and, if so, with what degree of prediction accuracy. A total of 362 Chinese children, from 3 to 5 years old at the time of the 1992 baseline study, were re-examined in 2000. The study found statistically significant associations between caries prevalence in primary and permanent dentitions (p < 0.01). Children having caries in their primary teeth were three times more likely to develop caries in their permanent teeth (relative ratio = 2.6, 95% CI = 1.4-4.7; p < 0.001). Caries on primary molars had the highest predictive value (85.4%). This study demonstrates that caries status in the primary teeth can be used as a risk indicator for predicting caries in the permanent teeth.
Previous studies have indicated that rinsing the mouth with a beaker of water after toothbrushing may compromise the caries reducing effect of fluoride toothpaste. A 3-year clinical trial of daily supervised brushing with fluoride toothpaste at school was used to test the effect of post-brushing rinsing with water on caries increment. A total of 407 children, mean age 11.8 years, attending three schools in Kaunas, Lithuania were enrolled following informed consent of the children and their parents. Caries was recorded at baseline and annually for 3 years. During the study, children in two schools (A and B) performed daily supervised brushing with a 1,500-ppm fluoride toothpaste. Children in school A rinsed their mouths thoroughly with a beaker of water after toothbrushing whereas children in school B were only permitted to spit out once after brushing. Furthermore, the children in these schools were supplied with toothpaste and toothbrushes for use at home and in school. A third school (C), without daily brushing and without supply of toothpaste, served as control. Compliance with the protocol was consistently better in school B. After 3 years 276 children were available for examination. Three-year DMFS increments, including non-cavitated lesions (mean, 95% CI), were: school A, 6.8 (5.3; 8.3); school B, 6.2 (4.6; 7.8), and school C, 12.4 (10.6; 14.1). Mean increments for schools A and B did not differ significantly but were both significantly lower than those of school C (p< 0.001). It is concluded that post-brushing rinsing with water, under the conditions of this study, does not significantly affect the caries reducing effect of a fluoride toothpaste.
The aim of the present review was to describe the updated prevalence of early childhood caries (ECC) among 5‐year‐old children globally. Two independent reviewers performed a systematic literature search to identify English publications from January 2013 to December 2017 using MEDLINE, ISI Web of Science, and Scopus. Search MeSH key words were “dental caries” and “child, preschool”. The inclusion criteria were epidemiological surveys reporting the caries status of 5‐year‐old children with the decayed, missing, and filled primary teeth (dmft) index. The quality of the publications was evaluated with the modified Newcastle‐Ottawa Scale. Among the 2410 identified publications, 37 articles of moderate or good quality were included. Twenty of the included studies were conducted in Asia (China, India, Indonesia, Korea, Nepal, and Thailand), seven in Europe (Greece, Germany, Great Britain, and Italy), six in South America (Brazil), two in the Middle East (Saudi Arabia and Turkey), one in Oceania (Australia), and one in Africa (Sudan). The prevalence of ECC ranged from 23% to 90%, and most of them (26/37) were higher than 50%. The mean dmft score varied from 0.9 to 7.5. Based on the included studies published in the recent 5 years, there is a wide variation of ECC prevalence across countries, and ECC remains prevalent in most countries worldwide.
Early childhood caries (ECC) is a common childhood disease with highest prevalence found in poor, socially disadvantaged, and minority groups. The main risk factors for ECC are frequent sugar consumption, lack of tooth brushing, and enamel hypoplasia. Contributory factors include environmental and psychosocial stresses that modify caregiver behaviors. Strategies for prevention include preventing mutans streptococci transmission, restricting dietary sugars, tooth brushing, topical fluoride applications, and early dental examinations. This article provides an overview of ECC based on current understanding of its cause, prevention, and management.
The importance of sugars as a cause of caries is underemphasized and not prominent in preventive strategies. This is despite overwhelming evidence of its unique role in causing a worldwide caries epidemic. Why this neglect? One reason is that researchers mistakenly consider caries to be a multifactorial disease; they also concentrate mainly on mitigating factors, particularly fluoride. However, this is to misunderstand that the only cause of caries is dietary sugars. These provide a substrate for cariogenic oral bacteria to flourish and to generate enamel-demineralizing acids. Modifying factors such as fluoride and dental hygiene would not be needed if we tackled the single cause-sugars. In this article, we demonstrate the sensitivity of cariogenesis to even very low sugars intakes. Quantitative analyses show a log-linear dose-response relationship between the sucrose or its monosaccharide intakes and the progressive lifelong development of caries. This results in a substantial dental health burden throughout life. Processed starches have cariogenic potential when accompanying sucrose, but human studies do not provide unequivocal data of their cariogenicity. The long-standing failure to identify the need for drastic national reductions in sugars intakes reflects scientific confusion partly induced by pressure from major industrial sugar interests.
© International & American Associations for Dental Research 2015.
Objective: To analyse whether developing countries have sufficient health dollars to treat existing diseases in general and dental caries in particular in their child population. Methods: Assessments of the costs of treating existing and future caries by the conventional approach. Analysis of WHO dental databases and spreadsheet calculations of costs based upon population projections, prevalence and trends in patterns of caries. Findings: Even though the caries levels are low and most of the disease occurs on the occlusal and the buccal/lingual surfaces, more than 90% of the dental caries remains untreated in Third World countries. Calculations reveal that to restore the permanent dentition of the child population of low-income nations using traditional amalgam restorative dentistry would cost between £1,024 (US3513) per 1,000 children of mixed ages from 6 to 18 years. This exceeds the available resources for the provision of an essential public health care package for the children of 15 to 29 low-income countries. Conclusions: To treat caries with the traditional method of restorative dentistry is beyond the financial capabilities of the majority of low-income nations, as three-quarters of these countries do not even have sufficient resources to finance an essential package of health care services for their children.
Dental caries (decay) is an international public health challenge, especially amongst young children. Early childhood caries (ECC) is a serious public health problem in both developing and industrialized countries. ECC can begin early in life, progresses rapidly in those who are at high risk, and often goes untreated. Its consequences can affect the immediate and long-term quality of life of the child's family and can have significant social and economic consequences beyond the immediate family as well. ECC can be a particularly virulent form of caries, beginning soon after dental eruption, developing on smooth surfaces, progressing rapidly, and having a lasting detrimental impact on the dentition. Children experiencing caries as infants or toddlers have a much greater probability of subsequent caries in both the primary and permanent dentitions. The relationship between breastfeeding and ECC is likely to be complex and confounded by many biological variables, such as mutans streptococci, enamel hypoplasia, intake of sugars, as well as social variables, such as parental education and socioeconomic status, which may affect oral health. Unlike other infectious diseases, tooth decay is not self-limiting. Decayed teeth require professional treatment to remove infection and restore tooth function. In this review, we give detailed information about ECC, from its diagnosis to management.
Early childhood caries is a significant international public health problem. The aim of this paper was to review the current evidence of the risk factors for dental caries in disadvantaged children under 6 years of age. Medline, Cochrane, and PubMed database searches were conducted. Systematic reviews were used where available, or meta-analyses; randomized, controlled trials; and cohort, case-control, and cross-sectional studies (in that order). Studies were restricted to those published in English from 1990 to October 2010. Early childhood caries has a complex etiology with biological, behavioral, and sociodemographic influences. Evidence suggests that young children are most likely to develop caries if Streptococcus mutans is acquired at an early age, although this is influenced by other factors, such as oral hygiene, fluoride, diet, dental visit patterns, socioeconomic status, ethnicity, and health literacy. Etiological pathways should be taken into consideration when designing interventions to prevent dental caries in disadvantaged preschool children.
The tooth surfaces are unique in that they are the only body part not subject to metabolic turnover. Once formed, the teeth are, under the correct conditions, essentially indestructible, as witnessed by their importance in fossil records and forensic medicine. Yet in the living individual, the integrity of the teeth is assaulted by a microbial challenge so great that dental infections rank as the most universal affliction of humankind. The discomfort caused by these infections and their enormous cost (dental infections rank third in medical costs, behind heart disease and cancer, in the United States) gives dental diseases prominence despite their non-life-threatening nature. This chapter reviews the bacterial aspects of dental caries and periodontal disease and suggests that, in the future, treatment will be directed toward eliminating or suppressing certain bacterial species that appear to be overt pathogens in the dental plaque.
The objective of this research was to identify top dietary sources of energy, solid fats, and added sugars among 2- to 18-year-olds in the United States.
Data from the National Health and Nutrition Examination Survey, a cross-sectional study, were used to examine food sources (percentage contribution and mean intake with standard errors) of total energy (data from 2005-2006) and energy from solid fats and added sugars (data from 2003-2004). Differences were investigated by age, sex, race/ethnicity, and family income, and the consumption of empty calories-defined as the sum of energy from solid fats and added sugars-was compared with the corresponding discretionary calorie allowance.
The top sources of energy for 2- to 18-year-olds were grain desserts (138 kcal/day), pizza (136 kcal/day), and soda (118 kcal/day). Sugar-sweetened beverages (soda and fruit drinks combined) provided 173 kcal/day. Major contributors varied by age, sex, race/ethnicity, and income. Nearly 40% of total energy consumed (798 of 2,027 kcal/day) by 2- to 18-year-olds were in the form of empty calories (433 kcal from solid fat and 365 kcal from added sugars). Consumption of empty calories far exceeded the corresponding discretionary calorie allowance for all sex-age groups (which range from 8% to 20%). Half of empty calories came from six foods: soda, fruit drinks, dairy desserts, grain desserts, pizza, and whole milk.
There is an overlap between the major sources of energy and empty calories: soda, grain desserts, pizza, and whole milk. The landscape of choices available to children and adolescents must change to provide fewer unhealthy foods and more healthy foods with less energy. Identifying top sources of energy and empty calories can provide targets for changes in the marketplace and food environment. However, product reformulation alone is not sufficient-the flow of empty calories into the food supply must be reduced.
The aim was to examine recent literature and review the caries-preventive effect of fluoride toothpaste in children.
Based on three comprehensive systematic reviews published in 2003, a broad search of the PubMed and Cochrane library databases was conducted for papers published 2002-2008 using "fluoride toothpaste", "fluoride dentifrice" and "fluoride dental cream" as index terms. Relevant publications were identified after assessment of their abstracts. Papers were selected if they reported a prospective controlled design with caries data reported at baseline and at the end of the study. The targeted papers were critically assessed concerning design, methodology and performance according to a pre-determined checklist.
The initial search revealed 179 papers of which 15 met the inclusion criteria. There was strong evidence that daily use of fluoride toothpaste has a significant caries-preventive effect in children compared with placebo (prevented fraction 24%). The effect was boosted by supervised tooth brushing, increased brushing frequency to twice daily, and use of a toothpaste concentration of 1,500 ppm fluoride. There were few studies of high quality reporting findings from the primary dentition. There were no studies available, and therefore insufficient evidence, on when to commence brushing with fluoride toothpaste as well as on the post-brushing behaviour. The use of "adult" toothpaste in very young children seemed to increase the risk for mild dental fluorosis in low-caries communities but not in socially deprived high-caries populations.
The results reinforced the outstanding role of fluoride toothpaste as an effective caries preventive measure in children.
Abstract Dental caries is a transmissible bacterial disease process caused by acids from bacterial metabolism diffusing into enamel and dentine and dissolving the mineral. The bacteria responsible produce organic acids as a by-product of their metabolism of fermentable carbohydrates. The caries process is a continuum resulting from many cycles of demineralization and remineralization. Demineralization begins at the atomic level at the crystal surface inside the enamel or dentine and can continue unless halted with the end-point being cavitation. There are many possibilities to intervene in this continuing process to arrest or reverse the progress of the lesion. Remineralization is the natural repair process for non-cavitated lesions, and relies on calcium and phosphate ions assisted by fluoride to rebuild a new surface on existing crystal remnants in subsurface lesions remaining after demineralization. These remineralized crystals are acid resistant, being much less soluble than the original mineral.
The global burden of oral diseases, in fact, has been outlined in a very recent Bulletin of the World Health Organization: The vast majority of diseases affecting the soft and hard tissues of the oral cavity, in fact, have a chronic nature, are strongly associated with socio-behavioral risk factors, and represent a larger problem in underprivileged groups in both developing and developed countries (Petersen et al., 2005). A first attempt at explaining the unique characteristics of oral diseases comes from epidemiological information available in WHO databanks. If only dental diseases are considered, analysis of current data shows that nearly 100% of the population in the majority of countries is affected by dental caries, and severe periodontitis is found in 5-
To explore a possible relationship between the caries experience and pattern in the primary dentition at 5 years of age and the permanent dentition at 10 years of age. Further, to examine the possibility of predicting children in a caries-risk group at 5 years verified at 10 years of age.
A sample of 186 children (90 males) were clinically examined as 5-year-olds and re-examined as 10-year-olds by calibrated dentists. A five-graded diagnostic system including enamel caries was used. Bitewing radiographs were taken. A true risk group of children at 10 years were defined as those with at least one dentin or filled lesion on the mesial surface of 6-year molars, and/or on incisors, and/or total DMFS (decayed, missing, and filled surfaces) more than 1 SD above the mean. The prediction was measured in terms of OR (odds ratio), sensitivity/specificity, and receiver operating characteristic curves.
Statistically significant correlations (r=0.5) were found between the caries experience in the two dentitions as well as between the primary second molars at baseline and the permanent teeth at 10 years. 'Primary second molars' and 'all primary molars' were the most powerful predictors for allocation into the risk group (24% of the sample). The highest achieved sum of sensitivity and specificity, 148%, was attained at a cut-off point above two carious surfaces in enamel and/or dentin in primary second molars.
Statistically significant relationship in disease between the dentitions was found. More than two surfaces with caries experience in primary second molars are suggested as a clinically useful predictor at 5 years of age for being at high risk at age 10.