An investigation into what dental hygienists and dental therapists would discover if they attempted to stop consuming added-sugar for 28 days.
Peer reviewed and originally published in the Annual Clinical Journal of Dental Health 2021
Timothy Ives MA Med Ed, BSc (Hons), Dip Dent Hyg, FHEA.
To observe what an international group of dental hygienists and dental therapists would discover if they attempted to stop consuming added-sugar for 28 days.
This action research project is presented as a qualitative case study involving a group of 41 dental hygienists and dental therapists from the UK, USA, Canada, Switzerland and Czech Republic. Following a 28-day no-added-sugar-challenge, participants answered questions via email
or video recordings and then took part in four semi-structured group online interviews which were recorded and transcribed.
Seventeen (n=41; 41%) participants completed the 28-day challenge giving positive feedback, commitment, support, planning and adopting strategies as key reasons for ‘success’. Twenty-four (n=41; 59%) participants failed to complete the 28 days giving: addiction; temptation; stress; boredom; planning; expense and hidden sugar as reasons for ‘failure’. However, all participants generated new knowledge relating to both success and failure.
Guiding a patient to stop consuming added-sugar is a highly complex task and should be approached like any other addiction. Clinicians should attempt this challenge as the new knowledge gained from this experience will benefit their approach to health behaviour change.
Action research, sugar, added-sugar, dental hygienist, dental therapist, behaviour change.
Sugar, although widely enjoyed by dental professionals, tends to feature in discussions with patients as something to be avoided. This contradictory behaviour may be one of the reasons that the dental profession is so unsuccessful in persuading patients to stop consuming so much sugar.
Dental hygienists and dental therapists are skilled in psychology and behavioural change, since much of their practice involves persuading patients to adopt different behaviours.1 Requesting this group of professionals to attempt what they are asking their patients to achieve, would provide an opportunity for them to create their own new knowledge base.
Sugar consumption plays a significant role in oral and systemic disease. Numerous systematic reviews have all agreed that there is a positive association between sugar consumption and dental caries.2 There is increasing evidence for the role of added sugars in periodontal disease, independent of traditional risk factors.3 When Cochrane systematically examined dietary interventions taking place within a dental environment they confirmed that the advice was being given but the evidence that sugar consumption in patients was reducing was weak.4 In 2018/2019 in England alone, over 59 thousand children were admitted to hospital to have carious teeth removed under general anaesthesia. More than 13 thousand of these children were aged 0-5 years.5
In 2018/2019 there were 3.9 million people diagnosed with diabetes in the UK and the projected figure for 2025, if the current trend continues, is 5 million people.6 This equates to nearly 8% of the population. There is now good evidence for the bi-directional relationship between periodontal disease and diabetes.7
Obesity is a major public health problem and is associated with premature death, diabetes, cardiovascular disease and some cancers.8 In 2018, 28% of the adult UK population was obese and 20% of children aged between 10-11 years were obese. This has increased by 3% since 2006/07.9 In order to reduce childhood obesity (and hopefully tooth decay rates) the UK government introduced a sugar tax from 6th April 2018.10 Companies have to pay £0.24 if a drink contains 8g per 100 mls or £0.18 for 5-8g per 100 mls. As a result, over 50% of manufacturers reformulated their drinks. Two key parts of the 2016 Government Childhood Obesity Plan was to remove 20% of sugar from products by 2020 and for clearer food labelling.11 In the latest government report published in October 2020, the average overall sugar reduction across all food categories stood at 3%, missing their target by 17%. Dr Alison Tedstone, Chief Nutritionist at Public Health England, with regard to this report stated, “Overall progress remains slow. Fast and more robust action is needed to help us consume less sugar, which will help us become healthier and lower the economic burden of obesity and preventable pressure on the NHS.”12
There is also evidence that obesity increases the risk of periodontitis onset and its progression.13
In 1972 Professor John Yudkin, the founding Professor of the Department of Nutrition at Queen Elizabeth College, London, warned that sugar was killing people, specifically through cardiovascular disease (CVD). Despite his warnings, the rate of CVD increased and the government advised a low-fat diet, which led to even higher sugar intake. CVD continues to rise along with obesity and sugar consumption.14,15
The debate continues about the role of fats and carbohydrates
in disease. According to the government, reducing saturated fat lowers cholesterol and CVD.13 In contrast, a 2017 study published in The Lancet described an 18-country study from five continents involving 135,335 people and assessed the association of carbohydrates and fats with CVD and total mortality. The conclusion of the study was: “A high carbohydrate intake was associated with a higher risk of mortality, whereas total fat and individual types of fat were related to lower mortality. Total fat and types of fat were not associated with CVD, myocardial infarction, or CVD disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings.”16
In 2018, the British Nutrition Foundation published research indicating 43% of adults could not find reliable nutritional information and 61% blamed ‘experts’ for the confusion.17 Based on historical evidence, the sugar industry itself and government advisory committees may be responsible for some of this confusion. In the 1960s and 1970s the Sugar Research Foundation (SRF) sponsored a research programme that laid the blame for CVD on dietary fats and completely ignored the role of sucrose. Government policy making committees based their health advice on these literature reviews that focused on fats causing heart disease and obesity, not sugar. These studies were published in The New England Journal of Medicine by a team of Harvard University researchers, who were individually paid the equivalent of $50,000 by a top sugar industry executive.18
To generate new knowledge from the study of an international group of dental hygienists and dental therapists who had been invited to stop consuming added sugar for a period of 28 days.
This action research (AR) study is a form of inquiry that enables clinicians to improve their own practice whilst influencing the learning of others.19 Ethical approval was obtained from O’Hehir University Ethics Committee (31/03/2020/1) and, due to the nature of AR and the requirement to continually change and adapt, the committee requested a continuing dialogue throughout the process, which was maintained. Approval was granted for the September semi-structured group interviews. Informed consent was obtained from research participants and confidentiality and privacy of the research participants was met throughout the process.
Invitations to participate in a 28-day-no-added-sugar-challenge were sent via email to all members of the British Society of Dental Hygiene and Therapy (BSDHT) and posted on international, closed social media discussion groups. For the purpose of this study, added sugar was defined as any of the sugars ending in ‘ose,’ or varieties thereof, that were not naturally present in food or drinks. Inclusion in this part of the research required participants to have a qualification in dental hygiene and/or dental therapy.
Participants were given a three-month window between 1st April and 30th June 2020 to attempt to complete 28 consecutive days without consuming added sugar. Participants were asked to inform of their start and end dates and upon completion, to answer the following questions either via email or sent as a video recording:
1. How many days did you complete?
2. Why do you think you completed this much?
3. What did you learn that you think may benefit your patients?
4. Do you have any additional comments?
After examining the data, several interesting themes were developing, and it was decided to explore this further via four semi-structured online group interviews using Zoom software on an iMac, which was recorded and transcribed. For security, the recordings were stored in a cloud using Dropbox, to which only the researcher had access. The interviews were undertaken during September 2020 and involved 18 clinicians fairly evenly split into four groups. Each interview took approximately one hour and selection criteria was based purely on availability. A semi-structured interview format was used as this format allows for the exploration of the perceptions of the participants within a conversational atmosphere.20 To validate the qualitative data, triangulation was used by asking similar open-ended questions to each group and participants were also ‘cross-pollinated’ with information from previous groups in order to better understand each theme.21 Participants were then invited to view the data and to edit comments that were made.
A total of 46 research participants from five countries – UK, USA, Canada, Australia, Czech Republic and Switzerland - agreed to take part in the challenge. Five participants failed to send in their data. Data were received from 41 participants: UK (25); USA (12); Canada (2); Czech Republic (1); and Switzerland (1). All of the participants were dental hygienists and 10 were dual-qualified dental hygienists and dental therapists.
Seventeen (n=41; 41%) participants completed 28 consecutive days without consuming added sugars. Various reasons were given for ‘success’ that could be grouped into the following:
• Received positive feedback and noticed a positive difference
• Made a commitment to the research organiser
• Various different support mechanisms and groups
• Changed shopping and cooking strategies
• Already eating a low sugar diet
• Planned very carefully
Twenty-four (59%) participants failed to complete the full 28 consecutive days without consuming added-sugar, but the majority considered their own partial achievement a big success. Various reasons were given for ‘failure’ that could be grouped into the following:
• Addicted to sugar
• Children, friends or family of participants tempted them with sugary treats
• Stress or boredom
• Required too much planning
• Too expensive
• Became aware of eating sugar after the event
Analysis and discussion
The themes that developed from the initial results were specific food related discoveries, health related changes, behaviour change and oral health strategies. Groups are numbered 1 to 4 and each participant is identified with a letter.
Theme 1: Specific food related discoveries
All participants believed sugar was addictive and the vast majority considered it to be more closely related to a drug than a food because of nil-health benefits and potential dangers to health. The diseases mentioned were tooth decay, heart disease, cancer, obesity and diabetes. All participants agreed that the dental profession does not take sugar seriously enough. Many commented on the availability of sugar within a dental practice setting.
1d stated: “Our staff-room is full of sugar. Dentists are as bad as nurses as they can’t go a day without a sugar treat. The staff room table is always being replenished with chocolate and it’s part of the routine.”
1c agreed: “I have been eating less sugar since I stopped practising.”
1b added: “I have never worked in a practice where someone went out and brought fruit. We don’t practice what we preach! Even when on a ‘health kick,’ staff come in consuming low-fat products loaded with sugar.”
1b continued: “Sugar indirectly kills more people than smoking with its links to obesity, diabetes, heart disease and cancer.”
1d replied: “But we don’t put sugar in the same category as smoking do we?”
Many of the participants found sugar in ‘foods’ they did not expect. Common examples were: stock cubes, seasonings, curry pastes, pesto and bread. Many participants were surprised at the sugar content of what they had previously considered to be healthy foods.
1a said: “Vegetarian foods are loaded with sugar. I had to make everything myself.”
1d added: “It never occurred to me that sausages and bacon would contain sugar and a gluten-free product has three times more sugar than its gluten counterpart. Many people assume gluten-free is healthier.”
1b replied: “It is unfair that people on vegetarian and gluten-free diets have to suffer without realising.”
Many of the participants had to cook completely from scratch and all had to adapt their cooking and baking habits: 1a made her own condiments and baked cakes containing erythritol and xylitol; 4d baked many cakes containing xylitol; and 1d baked with erythritol and none of her family noticed. Substituting sugar with xylitol and erythritol was generally popular for many participants and many considered this a good way to ‘wean’ someone off sugar.
1a said: “My (adult) children are now consuming xylitol without realizing. I had previously asked patients to use it in tea and coffee but now I am asking them to introduce it more widely.”
Theme 2: Health related changes
Some participants noticed very little change in their mental
and physical health and some noticed extreme changes. Many went through an initial sugar withdrawal with symptoms such as headaches, feeling sick and anxiety: 1d was so ill she was convinced she had COVID-19.
Following these withdrawal symptoms many participants noticed an improvement in different aspects of their health: 4a was less foggy; 4d had more energy; 4e was less grumpy; 3a had more energy, better concentration and not so hungry; 3b noticed her muscles ached less; 2b who suffers idiopathic inflammation, noticed her muscles ached less; 2e who was suffering myalgia and fatigue from COVID-19 noticed an improvement in these symptoms; 2b noticed her symptoms for dysmenorrhea were a lot less.
1d linked her anxiety to sugar: “I had a lot of anxiety linked to workload and different pressures but what I found coming off sugar, was when I went back to work, I realised it was the sugar. I had lots of anger issues and anxiety and a short fuse. Now I feel Zen, tranquil and calm.”
Many participants noticed weight loss to varying degrees. Some were disappointed that they had not lost more and some were astounded with the loss from just stopping sugar.
Many of the participants who completed the 28 days noticed significant taste related changes and agreed that following the research they had a better appreciation of taste.
1d said: “I can’t now tolerate fruit as it is too sweet.”
When discussing the effect of sugar on health, 1d said: “I thought I knew a lot about sugar but I didn’t. The general public really don’t know what impact it is having on our bodies and how bad it is. We need to take the same approach as we take with smoking.”
Some of the participants are still ‘added-sugar-free,’ several months later and 1d highlighted how being over-weight is becoming the norm: “I had all my bloods taken as my GP couldn’t believe my weight loss of 70 lbs (32 kg) was due to me quitting sugar. I guess the cross section of the public that GP’s see is not healthy.”
Theme 3: Behaviour change
Many participants linked health related changes to behaviour change. The complex relationship of different mental health related issues such as depression, anxiety, stress, boredom and sugar consumption were mentioned by many participants.
1d indicated: “Giving up alcohol helped me give up sugar as having
a glass of wine kicked started something in me that snowballed everything and waking in the morning feeling not great encouraged sugar consumption.”
2b also mentioned this: “Abstaining from alcohol was the key to quitting sugar. Alcohol loosens your control and inhibitions. I have been through this with eating disorders and understand the mechanism that it has on somebody.”
Being organised and planning ahead with meals was commonly discussed as a reason for success. Many of the participants researched alternative meals and many commented that undertaking the challenge during the COVID-19 pandemic when they were at home gave them an advantage that they would not have had if they were working full time. There was one exception: 2b felt it was more difficult at home as she was more inclined to think about food when she was less busy.
Support from friends, family and colleagues was commonly discussed as being essential. One of the participants from part
1 set up a closed social media support group for all who were participating in the research. 3a said: “Knowing someone in the support group could have had a worse day than me was nice.”
It became apparent that some participants were unable to complete the challenge because family or ‘friends’ offered them sugar which they accepted. In some cases, the other person was unaware and in some cases they were aware. The latter was discussed in all four groups and many participants were shocked that someone would do this.
2d said: “In the past I have encountered people who tried to tempt
me into unhealthy eating. Is it a jealousy thing? They see you doing something good and they want to derail you. Maybe they feel like they are being left behind.”
2a replied: “Maybe they have tried it before and failed and didn’t want to see you do something they failed at.”
2b considered: “It’s an exertion of dominance. They are trying to exert their dominance over you and trying to exert the fact that they are in control and exerting that over you. It’s a control thing.”
Theme 4: Oral health education strategies
In the final topic participants discussed the impact the experiment had on their patient communication and what further changes should be made.
2b had changed her language and was now discussing sugar in relation to systemic inflammation and being more holistic in her approach. 1d had allotted extra time at every appointment for a discussion on sugar. 4a would now ask her patients to undertake
a similar challenge. 4c felt that being able to use the experience of the challenge really helped and 4d felt that she is now able to be more empathetic. All participants agreed that the experience was invaluable for better patient understanding.
Going forward, 3a, who is a tutor, believed that the undergraduate programme needed to change with much more emphasis on behaviour change techniques and nutritional counselling. Similar curriculum changes were also mentioned by several other clinicians.
Many of the participants expressed that more marketing campaigns promoting the dangers of sugar and food labels that are easier to understand would benefit the general public. 2c considered that diet campaigns commonly failed to mention sugar, and 2b believed that dietitians working within the NHS were aware of the science but were being forced to offer outdated advice.
Some participants expressed that the concept of sugar being defined as a treat needed to change and 4e considered that a treat is not something that is consumed in such large amounts.
A large group of highly knowledgeable, experienced clinicians with skills in behaviour change struggled to stop consuming added sugar: the majority did not succeed. How therefore can we expect our patients to effect a different result?
All of the participants who undertook this research now understand why this is such a difficult problem to solve. Some of them had to become aware of an addiction they did not know they had. Some of them had to attempt this challenge to try and overcome their addiction whilst constantly being tempted with sugary treats. 4b asked, “Would we do this to an alcoholic?”
They all learned that food manufacturers do their best to hide sugar from the most careful consumer, whilst adding it to specific foods in order to keep people addicted and therefore consuming it. ‘Healthy foods’ are not necessarily healthy. For those that managed to ‘kick their habit’, many had to suffer horrible side effects for several days and needed the support of family and friends to achieve this. At the same time, they had to devote extra time for planning and develop new cooking skills as they could not rely on any packaged food being sugar free.
All of the participants expressed frustration with the current status quo with regard to the general accessibility of sugar and the accuracy of the government sponsored promotional information presented to the general public, confirming the research of the Nutritional Foundation, conflicting scientific research and comments made by the Chief Nutritionist.11, 12, 15, 16, 17
Many felt that the undergraduate curriculum is outdated and
does not leave graduates armed with the appropriate nutritional counselling and behaviour change skills. Many are planning to, or already have, undertake postgraduate courses in these topics.
As well as representing dental professionals, this group also represented the general public in that they all had different levels of mental and physical health. Each person needed to adopt the challenge differently, highlighting the complexity of successful communication with our patients, the importance of getting to know the patient, the specific potential hurdles that they as an individual need to overcome and the various support mechanisms they might need. These behavioural change complexities might explain why Cochrane identified that information was being given to patients, but the effectiveness for change was unclear.4
The experience gained from this challenge should provide the participants with additional abilities to help their patients succeed. Many are aware of the numerous potential positive short and
long term health changes. Many are still ‘added-sugar-free,’ several months later. 1d summed it up really nicely when discussing how she now allows herself an occasional ‘added-sugar-treat:’ “Sugar used to control me but now I control sugar.”
The research participants will now be more creative in their approach to behaviour change: they now know what questions to ask; are aware of the pitfalls; will be far more empathetic and realistic with their expectations; and above all, now have a good idea where they may have knowledge gaps that need filling.
Our patients would definitely benefit if every dental professional attempted the same challenge. Guiding a patient to stop consuming added-sugar is a highly complex task and should be approached like any other addiction.
The experience gained from this challenge has provided all of the research participants with more knowledge to help their patients. Many participants became healthier.
“Information is not knowledge. The only source of knowledge is experience.” Albert Einstein.
As a bare minimum all dental professionals should attempt this challenge. There is no justifiable reason not to do this as the new knowledge gained from this experience will benefit their approach to health behaviour change. Everyone will learn something.
We should review the undergraduate curriculum and post-graduate opportunities for behaviour change, psychology and nutritional counselling. These are the tools required to help make a patient healthy.
All dental professionals should adopt the same attitude towards sugar as they do with smoking and alcohol. We need to make it clear to all dental staff and our patients that sugar is extremely dangerous to general health.
The dental profession and representative associations need
to become aligned with the various medical professions, their associations and the government with regard to nutritional advice about sugar. There is currently no consistency or clarity of message.
As a profession we need to be one step ahead of the sugar industry, not two steps behind. We need to monitor the new names
for sugar, where sugar is being added and the various tactics
and misinformation the sugar industry currently employs. This information should be regularly disseminated to our patients.
Utilising an action research approach to this study gave the researcher the option of continuing and/or amending the approach based on initial findings. This was a relatively small research study. Similar studies to compare and contrast to this one were not found. Larger research studies involving different dental and medical professionals with a role in sugar cessation and also our patients would be required to better understand the various findings uncovered in this research.
This research was self-funded.
I am grateful to the BSDHT for their support in this research and to O’Hehir University Ethics Committee for the research approval.
Special thanks go to all of the research participants for their support, commitment, time and passion. Additionally, all 41 dental hygienists/dental therapists participating in the research viewed the final paper which was accepted as an accurate account of
Timothy Ives MA Med Ed, FHEA, BSc (Hons), RDH Co-Founder and Tutor O’Hehir University Education Committee BSDHT
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Refereed paper: Accepted 26 January 2021
If you found this research interesting, please stay tuned for my latest project on the creation of a no-added-sugar-tribe. Now in the process of data collation and will be published in the Spring of 2022....
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