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On average, Americans eat 66 pounds of added sugar in their diets annually.1 What is not so sweet is the possible impact on oral and systemic health overconsumption of sucrose poses. While it is an established fact that excess sugar consumption has detrimental effects on oral health and caries prevention, the harmful systemic effects of over-consumption of sucrose are still being elucidated. Linking excessive sugar ingestion with systemic disorders continues to be debated—often pitting the sugar industry against consumer groups advocating for limitations on sweeteners added to dietary products. Clarification is clearly needed on the topic. This article will update readers on current research findings involving added sweeteners used in today’s diet.
Dietary Sugars and Sweeteners
Dietary sweeteners are classified as either “nutritive” or “non-nutritive.” Nutritive sweeteners provide the body with calories in the form of carbohydrates, while non-nutritive sweeteners have little if any caloric value. While much of the sweetness in today’s food and beverage items results from “added sugars” (sweetening agents added prior to consumption, during preparation, or in processing), some “sugars” are found naturally in foods. A notable example is the fructose in fresh fruits. When whole fruit is ingested, the body receives not only the sugar, but the benefits from associated fiber, vitamins, minerals, and phytonutrients.
However, that is not the case when sweeteners are added to food and beverage items prior to consumption. Added sweeteners—whether nutritive or non-nutritive—are primarily included in ingestible products to enhance flavor. While certain additive sweetening agents may also be utilized in products to prolong shelf life, these ingredients are not included to enhance nutritive benefits.
Sucrose (Table Sugar)
Classified as a disaccharide, sucrose is made up of one glucose and one fructose bonded together and is generally derived from sugar cane or beets. Sugar is a popular food and beverage sweetener, with Americans consuming an estimated average of 30 teaspoons of added sucrose each day. This amount represents two to three times more than what the body needs. How this over-consumption is affecting lives is extraordinary.
In the early part of the twentieth century, researchers such as Haven Emerson from Columbia University noted a significant increase in deaths from diabetes between 1900 and 1920, which corresponded to an increase of sugar consumption during that period. In the 1960s, a noted British nutritionist, John Yudkin, conducted a series of experiments on animals and humans that showed high amounts of sugar in the diet led to high levels of fat and insulin in the blood—risk factors for heart disease and diabetes.2 Unfortunately, Yudkin’s research was overshadowed by critics who suggested that the rising rates of obesity and heart disease were instead a function of overconsumption of saturated fat. As a result, Americans decreased dietary fat in their diets. Yet obesity rates and cardiovascular disease continued to rise.
Further study convinced experts that sucrose—especially the fructose component—was indeed to be blamed for the rise in obesity and cardiovascular disease. While glucose (the other component of the disaccharide sucrose) is metabolized by cells throughout the body, fructose is processed primarily in the liver. When fructose is consumed in quickly digested forms such as sucrose or high fructose corn syrup, the liver metabolizes the sugar, producing triglycerides and very low density lipoproteins (VLDL) in the process. While some of these fatty metabolites remain in the liver where they can negatively affect structure and function of the organ, most of the fatty metabolites are deposited into the blood. Excess triglycerides and VLDL blood levels result in hypertension and insulin resistance. The pancreas responds to these conditions by secreting more insulin. Over time, a condition known as “metabolic syndrome” develops, characterized by obesity (especially around the waist), hypertension and increased triglyceride levels, lowered high density lipoprotein blood levels, and high fasting glucose levels. If the conditions of metabolic syndrome are not addressed, type 2 diabetes can result.2
In addition to metabolic syndrome, cardiovascular health risks associated with consumption of added dietary sweeteners continue to be studied. In 2010, investigators from the Centers for Disease Control and Prevention (CDC) interviewed more than 6,000 American adults about their eating habits. The study team found that the more added sugars participants ate, the lower their blood levels of high-density lipoprotein, and the higher their levels of triglyceride and low-density lipoprotein. Then in 2014, it was reported that CDC researchers found a significant link between the amount of sugar consumed and heart risk after analyzing the diets of tens of thousands of Americans.3
Other investigative studies found that people who consumed 25% or more of their daily calories from refined sugar tripled their risk of dying from cardiovascular disease.3 Of special interest were the findings from the Nurses’ Health Study (conducted by researchers at Harvard School of Public Health and Brigham and Women’s Hospital in Boston). Among the 88,520 women enrolled in the study, participants who consumed more than two sweetened beverages daily were 35% more likely to develop heart disease than women who drank fewer than one a day.4
According to the CDC, sugar-sweetened beverages (SSBs) are the leading sources of added sugars; in 2010, they were the single largest source of calories from added sugar in the American diet. These beverages include any liquids that are sweetened with various forms of added sugars, such as brown sugar, corn sweetener, corn syrup, dextrose, fructose, glucose, high-fructose corn syrup, honey, lactose, malt syrup, maltose, molasses, raw sugar, and sucrose. Frequently drinking SSBs is not only associated with heightened cardiovascular risk, but also with weight gain/obesity, type 2 diabetes, kidney diseases, non-alcoholic liver disease, and gout.5-8 In 2013, it was reported that 25,000 people a year in the United States die from obesity-related diseases that result from drinking sweetened beverages—and the number worldwide is an astronomical 180,000.9
In response to these and other concerns regarding SSBs, the World Health Organization issued a lengthy report concerning the need to reduce consumption of sweetened beverages in order to fight health issues like obesity, diabetes and dental caries.10
Given research demonstrating the harmful effects of sugar consumption, the American Heart Association (AHA) began setting healthy limits on sucrose ingestion. To that end, the AHA currently recommends reducing the amount of added sugars to no more than half of daily discretionary calorie allowance. This is no more than 100 calories (six teaspoons) per day for most women, and 150 calories (nine teaspoons) per day for men.4 Additionally, children aged 2 to 18 should eat or drink fewer than six teaspoons of added sugars daily.11 It should be noted that, for example, a 12 ounce can of sweetened soda typically contains around 10 teaspoons of sugar.2
SSB consumption varies by age, sex, race/ethnicity, geography, and socioeconomic status. In 2011-2014, 6 in 10 youth (63%) and 5 in 10 adults (49%) drank an SSB on a given day. On average, US youth consume 143 calories from SSBs, while adults take in 145 calories on a given day.12 In 2013, beverage companies produced enough sugary drinks (eg, sodas, fruit drinks, sports drinks, sweetened teas and coffees, and energy drinks) to provide an average of 38 gallons per American annually.
Artificial Sweeteners
Although non-caloric artificial sweeteners (such as sucralose, acesulfame K, aspartame, and saccharin) have long been recommended as a healthier alternative to sugar, over-use of these ingredients is a concern, as they, too, have associated detrimental health issues—especially as an aid to weight loss. In particular, a number of studies in recent years have challenged the diet benefits of “diet soda” consumption.
Published in 2005 by the Journal of the American College of Nutrition, results of a two-year study found overweight children who gained weight drank more diet sodas than the normal-weight children in the study.13 A 2010 review of the literature published in the Yale Journal of Biology and Medicine concluded that “research studies suggest that artificial sweeteners may contribute to weight gain.”14 Another 2010 review published in the International Journal of Pediatric Obesity found that large epidemiological studies “support the existence of an association between artificially sweetened beverage consumption and weight gain in children.”15
In addition, Growing Up Today—a nationwide study of more than 10,000 children aged nine to fourteen—found that, for the boys in the study, intakes of diet soda “were significantly associated with weight gains.” These analyses are questioning the validity of marketing artificially sweetened products as “diet.”16
Conclusion
As a component of comprehensive care, nutritional counseling provided in the dental and dental hygiene settings benefits dental patients greatly. It is the author’s considered opinion that the use of added sweeteners—whether artificial or natural; nutritive or non-nutritive—dramatically impacts the dietary choices made by the American public. Disseminating information in the dental setting concerning dietary sweeteners and their impact on health should be included in any patient discussion of nutritional concerns.
1. University of California San Francisco. How much is too much? The growing concern over too much added sugar in our diets. http://sugarscience.ucsf.edu/the-growing-concern-of-overconsumption/#.WW5P5dMrLBJ. Accessed July 18, 2017.
2. Cohen R. Sugar love: A not so sweet story. National Geographic. August 2013.
3. Yang Q, Zhang Z, Gregg EW, et al. Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Intern Med. 2014;174(4):516-524.
4. Fung TT, Malik V, Rexrode KM, et al. Sweetened beverage consumption and risk of coronary heart disease in women. Am J Clin Nutr. 2009;89(4):1037-1042.
5. Malik V, Popkin B, Bray G, Desprs J-P, Hu F. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation. 2010;121(11):1356-1364.
6. Malik VS, Hu FB. Fructose and cardiometabolic health: What the evidence from sugar-sweetened beverages tells us. J Am Coll Cardiol. 2015;66(14):1615-1624.
7. Bomback AS, Derebail VK, Shoham DA, et al. Sugar-sweetened soda consumption, hyperuricemia, and kidney disease. Kidney Int. 2010;77(7):609-616.
8. Bernabe E, Vehkalahti MM, Sheiham A, et al. Sugar-sweetened beverages and dental caries in adults: a 4-year prospective study. J Dent. 2014;42(8):952-958.
9. CTVNews. Sugary drinks linked to staggering 180,000 deaths each year: study. March 19, 2013. http://www.ctvnews.ca/health/health-headlines/sugary-drinks-linked-to-staggering-180-000-deaths-each-year-study-1.1202272. Accessed July 18, 2017.
10. World Health Organization. Guideline: Sugars intake for adults and children. 2015.
11. Vos MB, et al. Added sugars and cardiovascular disease risk in children: A scientific statement from the American Heart Association. Circulation. 2017;135(19):e1017-e1034.
12. Centers for Disease Control and Prevention. Get the facts: Sugar-sweetened beverages and consumption. https://www.cdc.gov/nutrition/data-statistics/sugar-sweetened-beverages-intake.html. Accessed 6 June 6, 2017.
13. Blum JW, Jacobsen DJ, Donnelly JE. Beverage consumption patterns in elementary school aged children across a two-year period. J Am Coll Nutr. 2005;24(2):93-98.
14. Yang Q. Gain weight by “going diet?” Artificial sweeteners and the neurobiology of sugar cravings. Yale J Biol Med. 2010;83(2):101–108.
15. Brown RJ, De Banate MA, Rother KI. Artificial Sweeteners: A systematic review of metabolic effects in youth. Int J Pediatr Obes. 2010;5(4):305–312.
16. Gordon G. Soda shouldn’t be called ‘diet,’ advocacy group says. McClatchy DC Bureau. April 9 2015