Health Impacts of Hidden Sugars

Oral Disease

A collective term representing tooth decay, gingivitis, periodontal disease, tooth loss, and oral cancer affect 3.5 million people worldwide.¹ The World Health Organization (WHO), Global Health Status Report of 2022 states oral disease is greater than the combined global prevalence of the five major non-communicable diseases (NCD) (Neurodegenerative, Type 2 Diabetes, Cardiovascular Disease, Chronic Respiratory Disease, and Cancer).² High sugar consumption, along with tobacco and alcohol misuse are key modifiable risk factors for preventing oral disease.

Severe periodontal disease has a global prevalence of 19%.¹ There is mounting research that a high-sugar diet consisting of ultra processed foods (UPF), especially sugar sweetened beverages (SSB), increases the risk of periodontal inflammation.¹ The inflammation stems from dysbiosis of the periodontal microbiota, leading to a loss of supporting structures.

The most diverse microbiome in the human body is in the oral cavity, containing over seven hundred different species of bacteria. Higher free sugar intake along with high glycemic foods, decrease the diversity of healthy bacteria, increase streptococcus species leading to caries risk as well as dysbiosis of the oral microbiome.¹

The initiation, development and progression of periodontal inflammation caused by dysbiosis of biofilm, the host response to inflammation causing tissue damage, and other mitigating systemic factors in the body, can exaggerate the role excessive free sugars play in the diet.

Oral disease in the form of early childhood caries (ECC) links with other diseases of childhood, primarily due to risk factors shared by other noncommunicable diseases (NCDs).²⁰ Early Childhood Caries (ECC) is characterized by microbiome dysbiosis with increased cariogenic bacterial load. The frequency and high consumption of sugar intake correlates with obesity, diabetes, and nonalcoholic fatty liver disease with the incidence growing in pediatric patients. In addition, dental caries can lead to abscesses and dental pain, which may compromise the ability to eat, sleep and may restrict life activity of children. Severe dental caries is associated with poor growth.²⁰ Moreover, ECC is an economic burden to the family and society.²⁰ ECC is the most common NCD among children around the globe.²

Obesity

According to the World Health Organization (WHO), in 2022, 1 in 8 people are living with obesity, while worldwide the rate of obesity has doubled since 1990.³ In adolescent, the rate has quadrupled.³ In most cases, obesity is multifactorial due to obesogenic environments, psychosocial factors, and genetic variants.³ For example, access to sustainable food at affordable prices, a lack of safety, and physical location barriers, contributes to obesogenic environments, especially in economically challenged populations. At the same time, the overwhelmed healthcare system, lacks preventive measures in initial stages to reduce progression of the disease, with a projected financial burden of $3 trillion dollars by 2030 globally.³ Childhood and adolescent obesity have adverse psychological consequences including poor school performance, quality of life, and discrimination and bullying. It is common to find obesity co-existing within the same communities. Children in low-income households are more vulnerable to inadequate prenatal care and exposed to high-fat, high sugar diets that are lower in nutrient quality. The diet patterns, in conjunction with inactivity, results in a sharp increase to childhood obesity. The evidence of diet and obesity appears strongest when investigating the impacts of sugar sweetened beverages (SSB) marketed to adolescents, specifically sucrose and high fructose corn syrup, given the unique way they are metabolized by the body.² Added sugars during processing and preparation, such as bakery products and ice cream are key contributors to obesity.

The recommendation suggests no more than 10% of total calorie intake from added sugars. The current dietary and physical patterns are often the result of environmental and societal conditions that constrain personal choice. The rise in obesity demands a multisectoral action.

Inflammatory Conditions

Consumption of a diet high in added sugars are linked to several non-communicable diseases, causing systemic inflammation, gut dysbiosis, and metabolic syndrome. For example, dietary factors associated the consumption of a Western dietary are important determinates of gut microbiota diversity, and often are the precursor leading to poor health outcomes.

Inflammation is a protective host response to outside stimuli. Unregulated chronic inflammation can lead to pathology within the body, specifically cardiovascular disease, diabetes, neurodegenerative diseases, cancer, and metabolic syndrome.¹ Poor lifestyle choices, an ultra processed diet, and microbiome dysbiosis are major contributors to systemic chronic inflammation. Current evidence indicates that excessive dietary sugars can induce inflammation through several mechanisms.¹

Consuming excess sugars increase intestinal permeability leading to inflammation and gut barrier dysfunction.¹ An increased intestinal mucosal lining disrupts homeostasis and leads to the transfer of bacteria into the host, causing systemic inflammation. When the gut microbiota are disrupted, an increase in gram negative bacteria release pro inflammatory cytokines, transferring the endotoxins to the liver, which increases the incidence of both nonalcoholic fatty liver disease (NAFLD) as well as insulin resistance.¹

Diabetes & Insulin Resistance

Diabetes, mostly in the form of Type 2, is strongly related to diet and lifecycle factors. The disease affects 13% of the population, a decline in glycemic control from a decade ago.⁵ Diabetes is associated with sugar consumption, specifically sugar sweetened beverages (SSB). ² Carbohydrates (fructose) from fruit, vegetables, and whole grains, are protective factors for diabetes risk. Insulin resistance, a precursor to Type 2 diabetes, is a condition when the body’s cells become less responsive to the hormone insulin. When cells are resistant to insulin, glucose builds up in the blood, leading to higher blood glucose levels. Studies indicate a plant-based diet may improve insulin sensitivity and better glycemic control.

The Glycemic Index (GI) is a rating system from 0 to 100 that measures how a carbohydrate raises blood sugar levels. Proteins and fats are zero GI foods. Most whole fruits and vegetables are considered low (55 or lower) to medium (56-69) glycemic-index foods apart from dates, kiwi, watermelon, potatoes, rutabaga, parsnips, and pumpkin, which are consider high-glycemic index foods (70 or higher). Ultra processed foods (UPF) and refined carbohydrates are considered high GI foods.¹³ Studies demonstrate that a low glycemic index diet reduced levels of the inflammatory biomarker C-reactive protein whereas diets in high-glycemic foods increased inflammation. ¹³

Here are key recommendations from the American Diabetes Association’s 2023 Standards of Care.¹⁴ Healthcare providers can utilize the “Standards of Care” as a guideline for patient education.

Non-Alcoholic Fatty Liver Disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) is a silent public health problem worldwide. Most individuals are asymptomatic and unaware of their risk, typically associated with obesity and an unhealthy lifestyle. Diets high in glycemic load and sugar sweetened beverages (SSB) are associated with NAFLD. High fructose corn syrup in SSB increase adiposity, insulin resistance, inflammation, and impaired gut permeability together with bacterial overgrowth, causing changes in the gut-liver access.⁸ In addition, artificial sweeteners may result in gut microbiome dysbiosis, leaky gut, and the release of proinflammatory mediators, enhancing the effects of NAFLD.⁶

The diagram below demonstrates the intercorrelation between diets high in sugars and non communicable diseases. (NCD).

Figure 1. Periodontal Inflammation Overview

Periodontal health is inextricably linked to systemic health including several lifestyle factors (see Figure 1).¹ More than one million adults will die from diet-related disease in the US every year.¹⁶ Addressing these issues requires a multifaceted approach, including better nutrition education, policy change, and increased access to healthy foods.

Pediatric & Adolescent Health

Research has linked declining pediatric and adolescent health to high sugar consumption, problems with sleep, learning, and worsening emotional health, as well as an increase in diabetes, obesity, and non-alcoholic fatty liver disease. (NAFLD)¹⁸ The type of sugar, in the form of high fructose corn syrup found in sugar sweetened beverages (SSB) such as soda, energy drinks, and juice may also play a role in inflammatory conditions such as asthma as well as digestive disorders and gut dysbiosis.¹⁸ As sugar has become embedded in ultra processed foods (UPF) and beverages, the over consumption of sugars in children and adolescent diets have promoted studies on the correlation between diet and long-term cognitive processes and hyperactivity disorders. The American Academy on Pediatrics recommends limits of less than 10% of total calorie intake of added sugars per day or less than 6 teaspoons. More than 70% of adolescent, in the form of SSB exceed the limit.¹⁸ Key interventions to consider include regulate marketing of ultra processed foods and drinks to children and adolescents and introduce taxation policies on foods and drinks high in free sugars.²⁰