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11 Nov 2016
No more sugar coating!
AIIMS Global symposium advocates a cut down in sugar intake to reduce burden of early childhood caries
The International Symposium on Sugar, “Is Sugar the New Tobacco- Oral health Perspectives” was held on the 11th of November 2016 at the India Habitat Centre. It was organised by the Centre for Dental Education and Research, AIIMS New Delhi.
The event was attended by more than 150 delegates, many from various far-flung places like Puducherry, Chennai, Bangalore, Daman, Kannur and Kolkata. A good number of students from the NCR Region, Chandigarh and Jaipur were also present. There was a wide representation of faculty and residents from the streams of Public Health Dentistry, Community Medicine, Pedodontics and Preventive Dentistry, Nutrition and Dietetics, Endodontics and General Dentistry. There was also a representation from the sugar industry, a surprise from the Indian Sugar Mills Association, the WHO, Indian Dietetics Association and the media representatives.
Widely researched and studied since coon’s age, Sugar is aptly termed the prime mover of dental decay. Proven Cause-Effect relationships exist between sugar consumption and decay. Added sugars include sweet, sticky food and sugar sweetened beverages. In this epoch of increased availability and consumption of ready to eat and highly refined food, sugar could turn bitter!
Seemly, it was about time the professionals cut out for discussing this aspect and generate substantial evidence. It was also reported that sugar could be the ‘Next Tobacco’. The theme of the Symposium is thus: “Is Sugar the New Tobacco?” The topic is of enormous relevance to the dental fraternity addressing the effects of sugar on not just teeth and gums, but systemic health as well, which is not taken notice of. The symposium was proposed to address this relatively unexplored yet significant offshoot.
Seeking to demystify the evidence on sugar consumption reaching levels of addiction, akin to tobacco, the symposium witnessed a multifarious audience, with some observations being loudly articulated with substantial evidence. The speakers were from diverse disciplines and their presentations gave many unanswered questions some explicit clarifications.
Representing the WHO, Dr Jayasurya Kumari Navaratne said, the topic Sugar, is very current and it needs to be discussed in both developed and developing countries alike; one to control the ongoing menace and the other to prevent a spill over of the harm caused by excessive consumption. Opining at the inaugural, she also specified that the alternatives suggested by WHO need to be considered in word and spirit, the most singular aspect being taxation of Sugar Sweetened Beverages (SSBs)
The Director AIIMS, Prof. M C Misra said, we need to do away with sugars, fizzy drinks and refined food before sugar related elements reach epidemic proportions in India, particularly childhood obesity, diabetes and of course dental decay. Only when there is a tab over portion size and a control over aerated drink consumption that is loaded with sugar, can India and other developing nations think of achieving a regulation he said. He suggested that we do away with elaborate meals and focus on what is a definite requirement of the body in terms of carbohydrates and other necessary nutrients.
Prof. OP Kharbanda delivered the welcome address. He gave a brief overview on the history of sugar and how India has leapfrogged from a modest 2 Kilograms per year to a staggering 20Kg per capita per year consumption. He suggested that one should moderate sugar consumption right from childhood and this contributes to habit formation. This he said is also a way towards prevention of early childhood caries, a condition that’s escalating in India.
Paula Moynihan and Cynthia Pine, renowned professors from New Castle University and the Queen Mary University of London respectively were the international speakers at the symposium. Their core areas of work are dental caries prevention, control of sugar consumption and patterns of consumption.
The pre lunch session was focussed on academia, with research works and presentations on Non Communicable Disease Burden, the impact of sugar, the comparison of the sugar related caries versus caries caused by non sugar origin.
1. Dr Anand Krishnan, Professor CCM, AIIMS
Dr Anand Krishnan a leading researcher on NCDs from the Centre for Community Medicine, AIIMS deciphered about the current scenario of sugar consumption in India, the changing trends of sugar being an occasional treat during festivities to it being a regular component of everyday diet particularly in the form of free sugars.
Dr Anand also construed that the portion size has increased considerably and so has the frequency of eating. He illustrated a global picture of how sugar travelled from Polynesia in New Guinea to various places across the world and how the food plate changed thereafter.
He said 52% are affected by NCDs in India and there is a definite nexus between salt, oil and sugar consumption. Cardio vascular diseases, obesity, diabetes are all hooked up to one another and can be addressed by simple changes in diet.
2. Prof Paula Moynihan, Director WHO-CC on Nutrition and Oral Health, New Castle
Recalling her research on sugars and dental caries that informed the update of the WHO Guideline on sugars, Prof Paula emphasized the role of free sugars in dental caries causation. Her evidence synthesis showed a consistent relationship between amount of free sugars consumed and risk of dental caries, which indicated ideally that intake of free sugars (added sugars, honey, syrups and fruit juices), should be as low as 5% of calorie intake. She presented data to show that current intakes were far in excess of this level. She emphasized that sugars reduction would not be achieved by advising people to eat less sugar alone: summarizing strategies to lower sugars consumption she stated that national policy, sugar tax, reformation of foods and drinks to lower the sugars content, restrictions on advertising and better training and education were all needed to help people lower their sugar intake.
3. Prof Sonali Jhanjhee, Department of Psychiatry, AIIMS New Delhi
One of the most edifying presentations of the symposium was “Drawing parallels between sugar and tobacco: industry, science and policy” Beginning with some of the basics on addiction theories, Prof Sonali, an expert in tobacco cessation counselling detailed the pathways of addiction where in reward hormones like dopamine play a pivotal role. She suggested that once high sugar substances are consumed, they continue to excite the child tempting him to eat even more following a synergistic effect of dopamine and insulin. She also presented some preclinical studies done on rats where it was proven that leptin pathway is also a key mover in sugar addiction.
She said, industrial marketing motives always are aimed at neutralising the outcomes of many public health programmes and the extensive advertising and magnetic marketing strategies where children often seem to be the target groups are responsible for the proclivity for these high sugar products. These foods vivify and stimulate the hedonic desires of continuously munching one after the other, owing to the hyper palatability of sugary foods. Industry plays a hidden hand in modifying the diet patterns of children, she added.
Inclining on the message that was being sent across, the break between academic sessions was allocated for a 10 minute activity that involved stretches, breathing exercises and twists. The audience seemed to enjoy this on the sidelines of the ongoing academic sessions. It was insisted that instead of taking in cookies and tea or coffee in between meals, it would be a great idea to do a little of physical activity which might as well lead to a better activity of the intellectual faculties! Healthy Living – Healthy Eating was the take home message. Using stairs instead of elevators and eating fibre rich fruits and raw veggies instead of canned juices and cooked stuff was emphasised.
4. Ms Rachita Gupta, National professional Officer, WHO Country Office-India
With a very crisp presentation on the fact file, the National Professional Officer on Nutrition from the WHO Country Office SEARO India, Rachita Gupta underlined the significance of curtailing sugar intake particularly in the developing countries. She presented the current trends of consumption among various groups in India. She suggested alternative strategies to control sugar menace which include supple of safe drinking water, school fruit programme. She also spoke on the tricky triad of salt, oil and sugar that needs to be targeted together. Aerated drinks should be carrying food labels on high sugar present in them she added.
5. Prof Cynthia Pine, Dental Public Health Specialist, Queen Mary University, London
Talking on Food Prints, the impact of Sugar on Oral Health, Prof Cynthia Pine highlighted that sugar is the prime mover when it comes to dental caries causation and opined that socio economic status has a definite link with sugar consumption. She presented her research work in which a study done in London to prove the cause effect relationship between sugar consumption frequency, public health services and caries proved that there is a dynamic relation between sugar and decay. She also suggested that for improved oral health outcomes, a definite multipronged strategy to curb sale and advertising of high sugar products is the need of the hour. She also added that nutrition labelling is the key to achieving a control on the consumption trends, an adoption form the USFDA.
6. Prof Nikhil Tandon, Head Endocrinology
Speaking on the metabolic perspectives, Prof Tandon gave an overview on the profile of Indian population as outlined in a survey that he performed called CARRS. He said, it is important to take note of the form of food we consume, even if that is fruit. An apple consumed as a whole is definitely better than the juice since the latter leads to a spike in the sugar levels in blood, inducing the dopamine release and quicker urge to consume more. He also said, a direct relationship exists between sugar and oil intake, both complementing each other. Habituals early in life tend to continue consuming high sugar diet. He also said the concept of artificial sweeteners and zero sugar foods needs to be researched further. Zero sugar doesn’t mean zero calories, the rest of the contents definitely add up to empty calories he added.
7. Panel Discussion
In the quest to bring up an incremental paradigm, the symposium was concluded with a panel discussion. Coordinated by the Chief, CDER, Prof OP Kharbanda, the Panel Discussion was the most interesting segment of the symposium. With all the 6 speakers and a representative from the Indian Sugar Mills Association on the panel, a wide assortment of questions was posed by the enthusiastic audience.
These ranged from the role of non-sugar sweeteners in sugars reduction, the outputs of the sugar industry, the economics of sugar control, the concept of hyper palatability, the relevance of urban rural divide and varied diet patterns, the significance of the nutrition and food labelling patterns, the agricultural adjustments needed to combat the effects of refined food consumption – which indicated the need for broad consideration for changes in policy and practice to facilitate reduced sugar availability and for example, mitigate any undesirable economic impacts. How the dentist is pivotal to all these interactions was also raised.
A framework is in the making for advocacy on rationalising sugar intake among children as well as adults. This framework is being prepared in consultation with the resource persons, the experts in the fields of public health dentistry, community medicine, preventive dentistry, nutrition and psychiatry as well as those from the food industry, FSSAI and all the relevant stakeholders.