Unhealthy cannot be sugar-coated

13 June 2018 Congress

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FDI, the NCD Alliance, and the World Health Organization are organizing a joint session at the World Dental Congress in Buenos Aires later this year to highlight the need for common preventative interventions. Featuring four expert speakers, the session, titled ‘Curbing the Sugar Rush’, will focus on how to tackle oral diseases and other NCDs through a unified approach. We interviewed:

Portrait of Dr Fiona Adshead

Dr Fiona Adshead, Deputy CEO and Director of Strategy and Partnerships, NCD Alliance

Portrait of Dr Stefan Listl

Dr Stefan Listl, Professor in Quality and Safety of Oral Healthcare, Radboud University

Portrait of Dr Esperanza Cerón

Dr Esperanza Cerón, Executive Director, Educar Consumidores

Portrait of Dr Benoit Varenne

Dr Benoit Varenne, Oral Health Programme Officer, NCD Prevention, World Health Organization

As moderator of the session, what’s the strategy behind choosing to tackle oral diseases and other noncommunicable diseases (NCDs) through a unified approach focused on sugar?

Portrait of Dr Fiona Adshead

The NCD Alliance believes that oral health and noncommunicable diseases (NCDs) do not exist in isolation from one another.

"Our joint session with FDI is designed to raise awareness of the links between our communities, by focusing on one shared risk factor – sugar – it demonstrates the benefits of working together by integrating oral health into NCD strategies."
Dr Fiona Adshead

Oral diseases affect 3.9 billion people worldwide, with dental caries being the most widespread NCD. Excessive sugar intake from snacks, processed foods, and beverages is a common risk factor for cardiovascular diseases, cancer and diabetes, and is the leading risk factor for tooth decay. Surging levels of global sugar consumption thus represents a significant oral health and NCD challenge. Without targeted investment in widespread preventative interventions the burden of oral diseases and other NCDs will continue to accelerate.

Global action by governments and other stakeholders is therefore urgently needed to reduce levels of sugar consumption. The speakers in this session will illustrate how the oral health and NCD community can engage, collaborate and advance cost-effective interventions focused on lowering daily levels of sugar intake, including imposing higher taxation on sugar-rich foods and beverages, adopting transparent food and nutrition labelling, and implementing public health education campaigns.

Sugar has major economic and social impacts on oral diseases and NCDs. What’s your view on the methods to address sugar consumption, such as taxation or transparent labelling for health promotion?

Portrait of Dr Stefan Listl

Various noncommunicable diseases (including oral diseases) share sugar as a common risk factor. Potential interventions to reduce sugar consumption include sugar taxation, food labelling, social marketing and sponsorship bans on sugary foods and drinks, as well as nutrition standards including the lowest possible sugar levels for foods and drinks consumed in public institutions (such as schools and kindergartens).

Sugar-sweetened beverage (SSB) taxation has been a matter of recent debate. Quasi-experimental evidence suggests that consumers are responsive to changes in SSB prices, so several countries have implemented such a tax. Overall, however, there is still relatively little empirical evidence on the (oral) health impacts of SSB taxation in the longer run.

With regard to the impact of food labelling, the empirical evidence is mixed. Some studies suggest that nutrition labels may help consumers in choosing healthier foods and drinks. Other studies indicate that consumers may have problems to understand the information provided on food labels and consequently fail to meet the intended recommendations.

"Hence, the emerging evidence on sugar taxation and food labelling should be carefully considered while staying cognizant of the relevance of other factors which are also conducive for the promotion of good (oral) health."
Dr Stefan Listl

In Buenos Aires, you will address the importance of educating consumers on sugar consumption and ‘overcoming industry interference.’ Whose role is it to raise public awareness and can industry be part of the conversation?

Portrait of Dr Esperanza Cerón

The World Health Organization recognizes the impact of the growing consumption of sugars and ultra-processed products in the development of the obesity epidemic, chronic diseases, and oral diseases. Health has been recognized as a fundamental autonomous human right in Colombia. This means that the government is responsible for ensuring the development of public policies that guarantee healthy foods and such policies must be free of conflicts of interest.

The food industry interferes by giving misleading information about the safety of its products; hiring professionals and conducting studies that minimize the harm from consumption; and buying decision makers, for example by financing their political campaigns and attacking organizations that promote information to consumers.

In our case in Colombia (as well as in Mexico), there were personal threats and a legal attempt to censor the information to consumers.

"Health professionals must influence governments so that health is made a priority in public policies, over conflicts with industry, as the growing costs for health systems to treat these diseases are not a minor problem."
Dr Esperanza Cerón 

In Colombia, you had to face the industry directly after the release of a Public Service Announcement on the harms of sugary drinks. Can you tell us how things have changed – or remained the same – since the story went public?

Portrait of Dr Esperanza Cerón

The sugar-sweetened beverage (SSB) industry sued Educar Consumidores, a nongovernmental organization that promoted a pedagogical video alerting the population about the excessive consumption of SSB, alleging misleading advertising. The lawsuit was presented to the Superintendence of Industry and Commerce who – without following the due process – immediately ordered the media to take down the video and forbade Educar Consumidores to mention the subject publicly unless it passed through prior approval.

After two failed appeals, we had to appeal to the Constitutional Court who finally ruled in favour of consumers’ right to be truthfully informed – especially regarding relevant information to protect people’s health. The Court also recognized that no prior censorship could be exercised, thus protecting the right to freedom of expression.

Yet, things have not changed in Colombia which is proof of the growing weight of industry interference in public policy. Two years ago, a bill was passed to put pedagogical labeling indicating if the products have excess sugars or fats. Parliamentarians, however, oppose the bill alleging the enormous damage to industry and the fact that jobs would be lost. That is, they deny the right to consumer information behind fallacious arguments.

"In our opinion, and in accordance with the Inter-American Commission on Human Rights, health must prevail over industry interests."
Dr Esperanza Cerón 

From a global health perspective, what are the gains and challenges of setting and implementing policy measures promoting reduced sugar consumption and how do they link to oral health?

Portrait of Dr Benoit Varenne

Firstly, it is important to remember that free sugars are the essential dietary factor in the development of dental caries – because dental caries does not occur in the absence of dietary sugars. In many countries, sugar-sweetened beverages (SSB) – including fruit- and milk-based sweetened drinks as well as 100% fruit juices – are a primary source of free sugars. In addition, confectionery, biscuits, sweetened cereals, sweet desserts, sucrose, honey, and preserves are also common sources of free sugars.

This is why the World Health Organization calls for limiting free sugars intake to less than 10% of total energy intake – and ideally even further to less than 5% – to minimize the risk of dental caries throughout the life course (based on the guideline ‘sugars intake for adults and children’ published in 2015). Implementing population-wide strategies such as taxation of SSB, clear nutrition labelling, regulating advertising of foods and drinks high in free sugars, and removing all SSB for sale and service from hospitals, schools and public workplaces are some examples of effective ways to address the burden and impact of dental caries globally.

"Public health solutions for the prevention of dental caries are most effective when integrated with the prevention and control of other noncommunicable diseases, based on the principles of addressing common risks and the wider shared determinants of health."
Dr Benoit Varenne 


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