The ASA supports the WHO focus on improving nutrition and food security throughout the world and the need to reduce non-communicable diseases such as cardiovascular diseases, obesity, diabetes and some types of cancer. We recognize that obesity and dental health are serious and complex health problems that require the collective efforts of everyone to solve. We firmly believe that it is important that health policy is based on strong evidence-based research.
The World Health Organisation’s (WHO) final 10% guideline on free sugars intake continues to be based on evidence related to tooth decay, not overweight or obesity. The WHO has clarified that this is “based on moderate quality evidence from observational studies of dental caries”1.
ASA is disappointed that the WHO has added a conditional recommendation suggesting “a further reduction of the intake of free sugars to below 5% of total energy intake”, as it is based on evidence that was judged to be “very low scientific quality” by the WHO-commissioned researchers. In fact, the recommendation is based solely on low level evidence from three studies related to dental caries in a specific population (Japanese children with low fluoride exposure)1.
It is well recognised that the frequency of consumption of sugars is more important than the quantity consumed with respect to risk of dental caries2. In the absence of good oral hygiene, especially the use of fluoridated toothpaste, bacteria on the teeth can breakdown fermentable carbohydrates to produce acid. This acid can eventually lead to dental decay or caries.3, 4
The WHO review did not find evidence to support a specific level of free sugars intake that would prevent overweight or obesity5. The WHO guidelines should not be applied as recommendations to prevent obesity or other non-communicable diseases.
ASA recommends focusing on what the WHO has clearly defined as the primary cause of obesity: an imbalance between calories in (those consumed from all foods and beverages) and calories out (those burned through physical activity and keeping your body’s metabolism going)7.
ASA also recommends continuing to support and communicate healthy lifestyle guidelines that are developed for and relevant to Australians. The recently revised Australian Dietary Guidelines8provides the best advice: to achieve and maintain a healthy weight, be physically active and choose amounts of nutritious food and drinks to meet your energy needs. In relation to sugar intake, the guidelines recommend we limit intake of foods and drinks containing added sugars like confectionary, soft drinks and biscuits.
For further information please contact Katie Ayling at (02) 9235 8915.
In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of total energy intake
WHO suggests a further reduction of the intake of free sugars to below 5% of total energy intake (conditional
The recommendation to limit free sugars intake to less than 10% of total energy intake is based on moderate quality
evidence from observational studies of dental caries.
The recommendation to further limit free sugars intake to less than 5% of total energy intake is based on very low quality
evidence from ecological studies in which a positive dose- response relationship between free sugars intake and dental
caries was observed at free sugars intake of less than 5% of total energy intake.
Strong recommendations indicate that “the desirable effects of adherence to the recommendation outweigh the
undesirable consequences”. This means that “the recommendation can be adopted as policy in most situations”.
Conditional recommendations are made when there is less certainty “about the balance between the benefits and harms or
disadvantages of implementing a recommendation”. This means that “policy-making will require substantial debate and
involvement of various stakeholders” for translating them into action.
2. Anderson et al (2009) Sucrose and dental caries: a review of the evidence. Obesity reviews, 10, suppl1, 41-54
3. Fitch C, Keim KS. Position of the Academy of Nutrition and Dietetics: use of nutritive and non-nutritive sweeteners. J Acad. Nutr Diet. May
4. Van Loveren C, Duggal MS. The role of diet in caries prevention. In Dent J. 2001;51(6 Suppl 1): 399-406
5. Te Morenga et al (2012) Dietary sugars and body weight: a systematic review and meta-analysis of randomised clinical trials and cohort
studies BMJ 2012;345:e7492
6. NHMRC Systematic Review 2011 Section 14. SUGARS (S1.1) p 520.
7. World Health Organization (WHO). Fact Sheet on Overweight and Obesity. Accessed 5 March 2015.
8. NHMRC (2013) Eat for Health. Australian Dietary Guidelines. Providing the scientific evidence for healthier Australian diets