Journal of Dental Research2015, Vol. 94(10) 1338 –1340© International & American Associations for Dental Research 2015Reprints and permissions: sagepub.com/journalsPermissions.navDOI: 10.1177/0022034515598958jdr.sagepub.com

Perspective

Billions of dollars each year are allocated to research with the goal of improving the health of a population. Despite this, many health policies in place do not reflect the current science. Often, findings from basic, clinical, and health services research fail to be translated to policies and practice that may improve health. Scientists play a critical role in explaining their findings as part of the health policy process. For proper dissemination, implementation, and adoption, scientists must not only conduct rigorous science but also be able to commu-nicate their work to the appropriate bodies to improve policy outcomes as well as population health.

The most-touted success story of translation of science to pol-icy implementation is community water fluoridation. Although it has been met with some challenges, international and domes-tic policies have embraced community water fluoridation. The U.S. Centers for Disease Control and Prevention (2015) has listed “fluoridation of drinking water to prevent dental caries” among the “achievements in public health, 1900–1999.” Many communities have implemented water fluoridation programs, and dental caries rates have declined (American Dental Association 2005).

Recently, the role of sugar in the dental caries process has garnered much attention. The association of diet, namely sugar intake, on the development of dental disease has been estab-lished, but what remains to be seen is how these findings will be translated to widespread policies to reduce intake.

The Science: Sugar and Dental CariesIn a systematic review commissioned by the World Health Organization (WHO), Moynihan and Kelly (2014) reported that a moderate level of evidence exists for the relationship between sugar intake and dental caries, particularly in children. The investigators examined >50 studies using the Grading of Recommendations Assessment, Development, and Evaluation system for the review. They included multiple studies that found that those who consumed free sugars >10% of total energy intake had increased levels of dental caries when com-pared with those who had <10% free sugar intake. Nearly all the studies included reported a positive association between sugar intake and dental caries experience. The evidence of this association became apparent in the early 1950s and has been substantiated for >50 y in >20 countries.

The dental caries process is dynamic and fluid by nature. Featherstone (2004) describes it as a “balance between patho-logical factors that lead to demineralization and protective fac-tors that lead to remineralization.” Pathological factors mentioned are bacteria and ingestion of fermentable carbohy-drates (sugars); protective factors include salivary flow and fluoride exposure. Caries reduction attributable to water fluori-dation ranges from 8% to 37% among adolescents (Newbrun 1989). Topical fluoride therapies also have been shown to reduce caries by nearly 25% when compared with no fluoride therapy (Marinho et al. 2004).

Despite the widespread use of home and professional fluo-rides and community water fluoridation, dental caries continues to be a problem. Sheiham and James (2015) make the case for sugar being the primary and necessary factor of the dental car-ies process, emphasizing the cumulative effect of sugar con-sumption over a lifetime as it relates to dental caries. In a large longitudinal population study following children from birth to age 10, Ruottinen and colleagues (2004) compared caries status in children with high sugar consumption exceeding 10% of energy intake with those below. They reported that those chil-dren in the low-sugar-intake group had on average 50% less disease experience (as measured by DMFT/dmft) than children in the high-sugar-intake group. Reducing sugar intake requires behavior change. Although much is known about the associa-tion of sugar intake and dental caries, there have been few long-term randomized clinical trials targeting behavioral changes to decrease sugar intake to date (Ebbeling et al. 2006). A system-atic review examining sugar intake and weight gain/obesity concluded that there was “moderate level evidence” but stressed that many of the randomized control trials addressing sugar and obesity in children suffered from poor compliance, which led to a finding of no effect (Te Morenga et al. 2013). This illustrates the difficulty in conducting research to elicit behavior change.

598958 JDRXXX10.1177/0022034515598958Journal of Dental ResearchSugar, Dental Caries, and Health Policyresearch-article2015

1Department of Pediatric Dentistry, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA2Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA

Corresponding Author:J.Y. Lee, UNC School of Dentistry, 228 Brauer Hall, Campus Box 7450, Chapel Hill, NC 27599, USA. Email: jessica_lee@unc.edu

The Confluence of Sugar, Dental Caries, and Health Policy

B.D. Meyer1,2 and J.Y. Lee1,2

Keywords: health services research, translational science, diet, dental public health, implementation science, dissemination practice

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Sugar, Dental Caries, and Health Policy 1339

The Policies: Limiting Sugar Intake

Policies to promote behavior change can be categorized into 4 primary strategies: 1) provide information about the behav-ior, 2) increase/decrease opportunities for behavior, 3) provide incentives/ disincentives for behavior, and/or 4) require/prohibit behavior (Dunton et al. 2010). All 4 approaches have been applied, with variable success, in attempts to reduce sugar intake. The WHO (2015) recently published guide-lines calling for restricted sugar intake based on evidence relating sugar to higher risks of noncommunicable dis-eases—namely. unhealthy weight gain and dental caries. The guidelines were created to set recommendations for policy makers looking to reduce the risk of these 2 noncommunicable diseases in adults and children. The new WHO guidelines include 1) a strong recommendation to reduce free sugar intake over the course of a lifetime, 2) a strong recommendation to limit free sugar intake to <10% of total energy (calories) consumed, and 3) a conditional recommendation to reduce the free sugar intake to <5% of total energy intake.

The recommendations developed by WHO are in place to protect the health of populations while understanding that indi-vidual differences may exist. In light of this, it suggests that these guidelines should not apply to those in need of specific therapeutic diets but rather be used by policy makers to develop policies consistent with national nutritional guidelines and cul-tural norms. The WHO recommendations are by no means calling for a zero-tolerance policy on sugar intake; rather, they are simply calling for a reduction in sugar intake that could improve the health of populations.

Policy recommendations to limit sugar intake are certainly not new. In 2010, the U.S. Department of Agriculture and the U.S. Department of Health and Human Services jointly released the revised dietary guidelines. In it, they report that “added sugars contribute an average of 16 percent of the total calories in American diets,” and they make a recommendation that the total amount of added fats and sugars consumed be reduced to 9% to 15% (depending on total caloric intake) for an average adult. The 2015 guidelines are currently being developed and have been open for public comment. The draft guidelines include a reduction in added sugar intake to no more than 10% of daily energy. It also supports labeling and educa-tional approaches, including added sugar labeling (U.S. Department of Agriculture and U.S. Department of Health and Human Services 2015). The American Dental Association (2015) was among many organizations that provided public comment in support of the dietary restrictions on added sugar intake.

Other health policy approaches have been implemented to reduce sugar intake (Figure). In efforts to educate the public

about nutritional content in packaged foods, the U.S. Congress passed the 1990 Nutrition Labeling and Education Act, which authorized the U.S. Food and Drug Administration to require that all packaged foods label the amount of nutrients, including sugars. In 2014, the U.S. Food and Drug Administration pro-posed a rule change to require a declaration of “added sugars.”

Collectively, the recent policy changes should have some impact on sugar intake, but awareness raising and recommen-dations for intake restrictions are not often enough to prompt behavior change. More attention is needed to address the accessibility of sugary products (i.e., access to vending machines) and disincentives for behavior (i.e., sugar tax).

The Challenges: Translating Science to PolicyDespite the existing scientific evidence showing that increased intake of sugar is associated with dental caries, very little action has taken place to address these issues at the policy level. Research has identified several factors that may hinder the trans-lation of research into health policy. Factors include the per-ceived need of researchers to be objective and their balancing objectivity with advocacy and an ability to communicate research findings to stakeholders and policy makers (Brownson et al. 2009). Sommer (2001) argues that “standing by the side-lines pursuing other interests and expecting published data to ‘speak for itself’ is leaving a good deal to chance.” Scientists can and should be very useful to policy makers.

Other major barriers to implementation may involve out-side parties with special interests. Kearns and colleagues (2015) gave historical context to the discussion surrounding sugar intake and dental caries. In their investigation, the authors reviewed the sugar research organizations’ efforts to influence not only public awareness but also research agendas and policy decisions dating back to the early 1950s. A case study by Parascandola (2005) reviewed the relationship among science, industry, and policy related to tobacco harm reduction and found that tobacco interest groups were primarily focused

Figure. Timeline showing relationship among research, industry, and policy. AAPD, American Academy of Pediatric Dentistry; NIDR, National Institute of Dentofacial Research; SRF, Sugar Research Foundation; USDA, U.S. Department of Agriculture; WHO, World Health Organization.

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on protecting their interests and assets rather than contributing to a growing knowledge base. Clearly, opposition to translating science to public health policy is not new. In the early 1950s, the first opposition to water fluoridation arose, and some still continues today (Richmond 1985). A major challenge in health policy making is creating policy that satisfies key stakeholders while being true to the research and promoting population health.

The FutureAs the policies surrounding limiting sugar intake continue to evolve, attention must be given on how to best put these polices into practice to produce positive behavior change, which ulti-mately should lead to improved oral health outcomes. Future research need not focus on the specifics of the restriction but instead on the behavioral changes required to adhere with the recommendations. Moving forward, perhaps policy makers could be courageous enough to develop policies restricting sugar intake consistent with national and WHO guidelines, and maybe researchers can begin to uncover the behavioral keys necessary for the successful implementation of these policies. In 2005, the National Institute of Dental and Craniofacial Research awarded 3 major grants that establish regional “prac-tice-based” research networks to investigate with greater sci-entific rigor everyday issues in the delivery of oral health care. Recently this has been transformed into a National Dental Practice–Based Research Network. This may provide a forum to conduct behavior research on sugar intake. In 2006, the National Institutes of Health launched the Clinical and Translational Science Award (CTSA) program. The goal of the CTSA is to accelerate “the process of translating laboratory discoveries into treatments for patients, training a new genera-tion of clinical and translational researchers, and engaging communities in clinical research efforts.” The CTSA could also be a mechanism to test policies on sugar intake.

There has been increasing attention on how to reduce the research, evidence-practice, and policy gaps. Translational research traditionally describes how basic biomedical sciences can be incorporated into clinical practice, but the additional step of translation of clinical science into improved health must also occur. This requires engagement of stakeholders (policy mak-ers, insurance companies, private sector, etc.) who are in the appropriate positions to use the evidence to make informed policy decisions to improve the health of a population.

Author Contributions

B.D. Meyer, contributed to design, drafted and critically revised the manuscript; J.Y. Lee, contributed to conception, design, data acquisition, analysis, and interpretation, drafted and critically revised the manuscript. Both authors gave final approval and agree to be accountable for all aspects of the work.

Acknowledgments

The authors received no financial support and declare no potential conflicts of interest with respect to the authorship and/or publica-tion of this article.

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