Bhisol is a small village on the outskirts of Thane district in Maharashtra. Everyone knows everybody here. When we visited Bhisol as part of a public health team whose objective was to screen and identify children at risk of oral diseases, we decided to set up our camp at the government school since we were told that all the village children would be found there. A little over 100 children attend this school, and a mere three teachers cater to their education needs.

A small clearing in front of a modest one-story school building acts as the assembly ground. Once the assembly is over, one of the teachers calls out the names of the children celebrating their ‘Vadh-diwas’ or birthday (there are two birthdays that day). As is customary in Indian schools, students celebrating their birthday attend school in any outfit of their liking and distribute sweets to their schoolmates as a celebration for the same. The day progresses, and we find that a couple of students have distributed toffees to celebrate the Vadh-diwas of their grandparents, and one is celebrating the birth of his younger sibling. What a wholesome day – each student pockets almost 10 toffees!

Figure 1: Government school at Bhisol, Thane dist (Source: author)

Figure 2: A school classroom with a birthday girl (Source: author)

Like Bhisol, we visited six such village schools from 2023-2024. Around 80-100 children were enrolled in each. Every new school had more people to celebrate and more toffees. Our team interacted with the children (aged between 4-14 years) and screened them for oral diseases such as dental caries, gingivitis, periodontitis, and other oral infections. We also educated them on oral hygiene habits and encouraged the caregivers of those children with pressing oral health problems to get treated as part of the public health initiative sponsored by the CSR wing of a prominent corporate group based in the district.

Our work with children from these rural communities revealed that a vast number were suffering from dental caries. For some medical context- dental caries occurs when the bacteria in our mouth break down tooth structure by releasing acid using the sugars from our diet. The more sugar we consume and the less oral hygiene we maintain, the more the teeth decay. Tooth decay leads to pain, infection and long-term issues like malnutrition. While the occurrence of dental caries isn’t uncommon amongst children with mixed dentition (the phase between 6- 13 years of age, when milk teeth are falling off and being replaced by permanent teeth), the high prevalence of caries in village children is a cause for concern.

Figure 3: A dental checkup camp in progress (Source: author)

The Observed Problem

One would assume that rural communities like these, living on a primarily fibrous diet (vegetables, meat and millets) with natural sugars (sugarcane, jaggery) and limited free sugars (sugar added manually to food), wouldn’t have as many dental issues as their urban contemporaries. However, we found that these children were consuming excessive free sugars in the form of packaged sweets (toffees, chocolates) and processed foods (cakes, biscuits and aerated drinks). The ‘processed food diet’ has seeped so deeply into their lifestyle that they are taking in a lot more than the recommended limit of 24-30 grams or 6-7 spoons per day (one toffee contains 4-5 grams of sugar on average). (1)

This is a cause for concern because sugar not only determines oral health but also affects the body in several other ways. A child growing up on excessive sugar has already been dealt a bad hand, with issues such as obesity, diabetes, cardiovascular diseases, cognition and mental health disorders such as attention deficit syndrome (2) on the cards. Moreover, from a sociological standpoint, rural children’s access to healthcare services remains limited, making them vulnerable targets for disease and illness.

Observation #1

There is a difference in how fast processed foods are reaching our villages versus how basic healthcare services are not. These are small villages that are self-sustaining in terms of food. The roads connecting them to the nearest city, Thane, are at best ridden with potholes and, at worst, non-existent. With one sub-health centre in the village and one Ayush doctor who visits for 3-4 hours per day, health services in these villages are not very advanced. But agents of modern-day lifestyle diseases (processed foods in this case) have reached these places and are already fast at work. Why has processed food penetrated the rural diet, but access to comprehensive healthcare has fallen behind?

The fact that corporations manufacturing these processed foods incorporate differing levels of sugar in different markets adds to the disparities in social determinants of health. A recent investigation into the sugar content of baby food and cereal by the International Baby Food Action Network revealed that corporate giants like Nestle add additional sugar (3 grams per portion in India, 5 grams in Ethiopia and 6 grams in Thailand) into their products sold in Low- and Middle-income Countries (LMICs), while the products sold in European markets are devoid this. (3) The diet of Indian children (and possibly those from other LMICs) has been completely altered right from infancy.

Observation #2

While children will always be attracted to sugar confectionaries, the onus for teaching them better dietary habits and regulation of sugar intake falls on the adults in their lives. According to the latest Household Consumption Expenditure Survey (HCES) released by the Ministry of Statistics and Programme Implementation (MoSPI), rural households spent more monthly income on processed foods and beverages rather than on cereals, vegetables and other natural food. Expenditure on processed food items for 2022-23 rose to 9.62% as opposed to 7.90% in 2011-12. (4)

Parents/ primary caregivers of children who had decayed teeth were invited to seek treatment at our town clinic. Here, we interviewed the primary caregivers (mostly mothers) on the eating and oral hygiene habits of the children. Most mothers faced the dilemma of joint family decision-making- their major complaints being that grandparents, older relatives and neighbours were often the ‘suppliers’ of sweets for the children. The Marathi word ‘Kautuk’ best describes this situation- when you’re so fond/proud of somebody that you cannot help but spoil them. From rewarding children for minor accomplishments to giving them change money to buy sweets, to taking them along to the local shops, adults around these children are unable to say ‘no’ or ‘enough’. The result is unlimited processed food and sugar intake and health issues that follow such habits.

Figure 4: A child out to buy sweets with her grandmother (Source: author)

Addressing These Observations

As is commonly said, it takes a village to raise a child. Teachers, friends, neighbours, relatives—so many people influence a child’s health and well-being. For children, the household is the first place where eating habits may develop, so adults in villages must be educated on the ill effects of excess sugar and processed food consumption. Awareness campaigns using audio-visual educational aids in the local languages can help address some of the complexities of child upbringing in the rural joint-family system.

Children in urban spaces aren’t better off in terms of disease prevalence, but they do have better access to specialised healthcare services (subject to their caregiver’s economic capacity). The skewed dentist-to-population ratio in urban India (1:10,000), as opposed to that in rural India (1:150,000), indicates that we need urgent policy changes directed at increasing specialised medical aid in our villages. Perhaps a different medical specialist visiting the village sub-health centre every day of the week can go a long way in tackling specific rural health issues.

In 2020, a study on the relationships between globalization, health services, obesity, sugar consumption, and dental caries found that the prevalence of dental caries had risen significantly after the new millennium, particularly in LMICs. (5) While access to urban goods and products has made life easier, it acts as a double-edged sword by altering dietary habits that may have long-term implications on the population’s well-being. Stricter regulation of food products and sugar trade and holding corporations accountable for their manufacturing malpractices will reduce some of the public health consequences of globalization and reform dietary habits.

The WHO recommends taxing beverages based on sugar content, and several countries have imposed a ‘sugar tax’ on sweetened beverages and foods. Research from Mexico, the UK and South Africa has shown that this has reduced consumption and caused companies to reformulate their products to reduce sugar levels of sugar. (6) India, however, is yet to implement this method, as it imposes higher taxation based on aeration/carbonation but not on sugar levels of the product. (7) The NITI Aayog also recommends imposing health taxes on sugary foods and beverages to address their overconsumption, leading to obesity and related diseases. (8) Nipping the problem in the bud will be the best way to prevent the larger, more complex problem of widespread health issues from multiplying.

References:

Sugar: The Facts. National Health Services, UK. https://www.nhs.uk/live-well/eat-well/foodtypes/how-does-sugar-in-our-diet-affect-our-health/#:~:text=This%20means%3A,day%20(5%20sugar%20cubes)

Gillespie, Kerri M., Kemps Eva, Melanie J. White, Selena E. Bartlett. (2023). The Impact of Free Sugar on Human Health-A Narrative Review. Nutrients. 10;15(4):889.

The Economic Times. (2024). Nestle Adds Sugar to Baby Cereal Sold in India But Not in Europe & UK, Study Reveals. The Economic Times. 18 April 2024.  https://economictimes.indiatimes.com/industry/cons-products/food/nestle-adds-sugar-to-baby-cereal-sold-in-india-but-not-in-europe-uk-study-reveals/articleshow/109387730.cms?from=mdr 

Aggarwal, Raghav. (2024). Rural Indians Are Now Spending More on Processed Food, Drinks Than Cereals. Business Standard. https://www.business-standard.com/economy/news/rural-indians-are-now-spending-more-on-processed-food-drinks-than-cereals-household-consumption-expenditure-survey-124022600142_1.html

Alsuraim, Bakr Salem and Han, Dong-Hun. (2020). Effect of Globalization on Global Dental Caries Trend. Medicine. 99(35): e21767.

Countries That Have Taxes on Sugar-sweetened Beverages (SSBs). Obesity Evidence Hub. https://www.obesityevidencehub.org.au/collections/prevention/countries-that-have-implemented-taxes-on-sugar-sweetened-beverages-ssbs 

Joseph, John. (2023). Sugar-sweetened Beverages Tax: The Way Forward in India. The Times of India. 14 July 2023. https://timesofindia.indiatimes.com/blogs/voices/sugar-sweetened-beverages-tax-the-way-forward-in-india/

Porecha, Maitri. (2023). Levy 20-30% Health Tax on Food High in Sugar, Salt, Fat: Study. The Hindu. 30 December 2023. https://www.thehindu.com/sci-tech/science/levy-20-30-health-tax-on-food-high-in-sugar-salt-fat-study/article67687274.ece

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Agrima Thakur is a Pune-based orthodontist, medical researcher, and writer who is interested in gender and science. Her work has been published in several medical journals and she has also been featured on platforms such as Boomlive.in, Young Feminist Europe and Science Reporter, amongst others.