Características Generales del Sistema Registral

NMES is a classification referring to all free sugars other than those naturally present in milk and whole fruit and vegetables (Ruxton et al, 2010). Foods high in NMES are implicated as causative factors in the aetiology of dental caries, obesity and diabetes, as well as other health problems (Cowin et al, 2000; Palmer et al, 2010). There is concern that non-adherence to the recommendation that no more than 11% of food energy should be derived from NMES (Department of Health, 1991) begins at weaning and continues throughout life.

An important aim of the study was to investigate whether high quality data on the quantity and frequency of NMES intake could be collected for a young age group of children. It was deemed that sufficient quality data of dietary habits were collected by the diaries to assess daily intake of NMES-containing food/drinks. Detailed nutritional analysis of the diet diaries confirmed that the quantity of NMES in the diet increases with age, with a three-fold increase in NMES consumption from six months to 12 months of age, but then a seemingly stable period after 12 months to 18 months. This confers that NMES exposure and reliance as a diet constituent begins within the first year of life, and a window of opportunity exists to offer dietary advice before habitual behaviour develops. This echoes the literature, which suggest that early dietary education to mothers of weaning babies is important in promoting a healthy diet

throughout childhood (Addessi et al, 2005). This increase in quantity of NMES consumed per day was also observed as an increase in the percentage of food energy derived from NMES between six months and 12 months of age. Only one participant (2.7%) exceeded the recommendation that no more than 11% of food energy is derived from NMES, showing that in this study, the recommendation is largely adhered to in young age groups. There is concern however, that the proportion that NMES contributes to total food energy would increase beyond the participant age groups quickly as the weaning diet is replaced with normal foods, and a reduction in the amount of milk consumed may greatly affect the percentage of energy attributable to NMES. Thirty-one percent of the participants had between eight and 11% of total food energy derived from NMES sources, and so they are in the upper limits of the recommended level, which may mean that with increasing age, they could be at risk of exceeding the recommendation.

Ninety percent of all the children participating in the survey of sugar intake among children in Scotland reported a diet which exceeded the recommended NMES intake of no greater than 11% of food energy (Sheehy et al, 2008). This is seen to continue

throughout life as the National Diet and Nutrition Survey 2008/2009 reports that of adults aged 19 to 64 years of age, the mean amount of total food energy derived from NMES is 12.5% (Bates et al, 2010).

Results of the survey of sugar intake among children in Scotland show that children who consume a greater amount of NMES per day (reporting consumption of greater amounts of soft drinks, biscuits, cakes and confectionery) are more likely to report treatment for dental decay (Sheehy et al, 2008). In this study, the main sources of NMES appeared to be from biscuits, cakes and pastries, diluting juice and flavoured yoghurts/fromage frais. Eighty-six percent of participants were offered biscuits, cakes and pastries during the diary period, 44% were offered confectionery, and 47% were offered diluting juice, and 58% were offered flavoured yoghurts/fromage frais. The percentage of participants offered these items increased from six months to 18 months of age. The GUS

longitudinal study showed further increase in consumption of confectionery with age, as more than 43% of children aged 22 months had sweets or chocolate at least once a day, and 78% consumed these food types at least twice a week (Bradshaw et al, 2008).

Although none of the participants in this study reported soft drink consumption, the GUS study reported 12% of children aged 22 months had non-diet soft drinks at least once a day (Bradshaw et al, 2008), which suggests exposure to these drinks may happen in early childhood just beyond the ages investigated in this study.

Consumption of diluting juice was twice as prevalent in deprived areas (62% of participants in SIMD Q1 and Q2, compared to 31% in SIMD Q4 and Q5) whereas more flavoured yoghurt/fromage frais was consumed by participants in less deprived areas (69% of participants in SIMD Q4 and Q5 had two or more portions over the diary period, compared to 38% in SIMD Q1 and Q2). These results show that the sources of NMES in a baby and toddler diet are varied and widespread, but the type of sources offered to the child is influenced by socio-economic factors. The GUS study reported that frequency of consumption of sweets and chocolates is more prevalent amongst the socially

disadvantaged groups. Sixty-six percent of children whose mothers had no qualifications ate these foods once a day or more often, in contrast to 37% of children whose mothers had higher grades or above (Bradshaw et al, 2008). Similarly, around double the number of children in households in semi-routine and routine occupations, and in the lowest income group respectively, had sweets or chocolates once a day or more, compared with households in managerial and professional households and those in the highest income group (Bradshaw et al, 2008).

Of particular concern to dental health is the frequency of NMES intake, as discussed in section 2.4.5.The relationship between sugar quantity and dental caries appears to be

weaker than expected (Anderson et al, 2009; Ruxton et al, 2010), and has led to more focus on the importance of the timing and frequency of sugar intake in the aetiology of caries, rather than amount consumed (Harris et al, 2004). The number of

eating/drinking events containing NMES per day is of importance in the aetiology of caries. Repeated reduction in the pH of the oral cavity, by the fermentation of dietary carbohydrate by plaque bacteria, causes a net demineralisation of tooth enamel and can lead to dental caries (SIGN, 2000). Frequency of intake of NMES-containing foods and drinks is shown to be significantly associated with dental caries experience in children (Marshall, Eichenberger-Gilmore, Larson et al, 2007; Touger-Decker & Mobley, 2007; Palmer et al, 2010) and in young children, before the clinical signs of caries

appear, with colonisation of cariogenic bacteria (Wan et al, 2001; Habibian et al, 2002).

There was no clear association found between the SIMD quintile, education or NS-SEC of participants and the number of NMES episodes recorded per day of diary completion. When NMES derived from pureed fruit and fruit juice was excluded, 46% of participants residing in SIMD Q1 and Q2 gave more than four episodes of NMES per day, compared to 15% of participants residing in SIMD Q4 and Q5. Also 50% of participants with a standard education gave more than four episodes of NMES (excluding fruit sugars) compared to 17% of those with a higher education. It was concerning that the children having the most episodes of sugar intake per day were living with both their parents and

grandparents. The GUS study also highlighted the particularly important role of grandparents (38% of parents who mentioned difficulties in controlling the amount of sweets and sugary snacks given to their child, cited grandparents as giving their child these foods). This role depends on the level of involvement they have and may arise from generational differences in attitudes to healthy eating, giving a potential focus for intervention measures (Bradshaw et al, 2008).

When examining the proportion of total number of eating/drinking episodes during the diary period that comprised of or included NMES-containing foods/drinks, it was found that this figure increases with the age of the child. The mean frequency of consumption of NMES-containing foods/drinks accounted for 31, 58 and 65% of the mean total

eating/drinking episodes at six, 12 and 18 months respectively. These findings are slightly lower than but support the results of the comparable study discussed in section 2.6.3.2 which found NMES-containing foods/drinks accounted for 46, 60 and 67% of total eating/drinking events for six, 12 and 18-month old children (Habibian et al, 2002). This trend confers a risk of further increase in the daily frequency of consumption of NMES with age throughout childhood, which puts children at greater risk of developing dental caries (due to NMES intake) with age.