Country level ecological analysis of per capita sugar and alcohol consumption and their association with dental caries prevalence in South Asian countries

Country level ecological analysis of per capita sugar and alcohol consumption and their association with dental caries prevalence in South Asian countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Country level ecological analysis of per capita sugar and alcohol consumption and their association with dental caries prevalence in South Asian countries Hindol Das This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8310665/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Dental caries remains a significant public health concern globally. Dental caries is highly prevalent in South Asia, but the contribution of population-level dietary exposures remains unclear. Dietary sugar is a well-established risk factor, while alcohol consumption may influence oral health outcomes in adults. This study examined the ecological associations between per capita refined sugar availability, adult alcohol consumption, and the prevalence of untreated dental caries in South Asian countries. Methods Country-level data for seven South Asian countries (Afghanistan, Bangladesh, India, Iran, Maldives, Pakistan, and Sri Lanka) were obtained from the WHO Global Health Observatory. Variables included per capita refined sugar availability, adult per capita alcohol consumption, and prevalence of untreated dental caries in children (1–9 years) and adults (≥ 5 years). Simple linear regressions assessed ecological associations between dietary variables and caries prevalence. Results Sugar availability showed negligible associations with caries in both children (R² = 0.052) and adults (R² = 0.031). Adult alcohol consumption demonstrated a modest negative association with adult caries prevalence (R² = 0.222). These ecological associations likely reflect country-level confounding factors such as oral health infrastructure, socioeconomic status, and diet patterns rather than causal relationships. Conclusion Ecological analysis of South Asian countries showed limited correlation between sugar and alcohol consumption and dental caries prevalence. These findings highlight the multifactorial nature of caries and the influence of population-level health system and socioeconomic factors in oral health research. Ecological correlations were weak, indicating that national dental caries burdens in South Asia are influenced more by oral health systems and social determinants than by population-level sugar availability or alcohol exposure. Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Oral diseases remain a major global public health challenge, affecting an estimated 3.5 billion people worldwide and disproportionately impacting low- and middle-income countries.( 1 , 2 ) Among these conditions, dental caries is the most prevalent, contributing to pain, infection, impaired quality of life, and substantial economic burden.( 3 , 4 ) The Global Burden of Disease (GBD) shows untreated dental caries in permanent teeth is the most common health condition globally.( 5 ) South Asia, home to nearly a quarter of the world’s population, continues to face a high burden of dental caries in children, with recent global reports identifying the region as having the highest prevalence of caries in primary teeth.( 6 , 7 ) Dietary sugar is one of the most consistently identified modifiable risk factors for dental caries. The biological mechanism is well established: fermentable carbohydrates promote acid production by cariogenic bacteria, leading to demineralization of dental enamel.( 8 , 9 ) As such, population-level sugar availability is often used as an indicator of dietary exposure in ecological public health analyses.( 10 ) Several global reports have highlighted rising sugar consumption in developing economies, but the relationship between country-level sugar availability and oral disease burden in South Asia remains poorly understood.( 11 ) Alcohol consumption, on the other hand, is primarily studied in relation to oral cancer and periodontal disease.( 12 – 14 ) However, alcohol may indirectly influence dental caries risk through multiple pathways, including reduced salivary flow, high sugar content in certain alcoholic beverages, and associated lifestyle factors such as tobacco use.( 15 , 16 ) Despite these theoretical links, ecological evidence on alcohol consumption and dental caries prevalence is limited, particularly in the South Asian context where alcohol use varies dramatically between countries due to cultural, legal, and religious factors. The World Health Organization’s (WHO) Global Health Observatory recently released updated oral health profiles for all member states, providing standardized indicators for dental caries and associated risk factors.( 17 ) These data offer a unique opportunity to explore regional trends and generate hypotheses regarding population-level determinants of oral diseases. Given this context, the present study aims to examine ecological associations between per capita refined sugar availability, per capita alcohol consumption, and the prevalence of untreated dental caries in both children and adults across seven South Asian countries. By analysing population-level patterns, this ecological approach provides valuable insights into broader trends, helping to inform future public health strategies, research priorities, and oral health policy development in the region.( 18 ) METHODS Study Design and Setting This study employed an ecological cross-sectional design using publicly available country-level data from the World Health Organization (WHO) Global Health Observatory (GHO) oral health database.(17) The analysis focused on seven South Asian countries for which complete data were available: Afghanistan, Bangladesh, India, Iran, Maldives, Pakistan, and Sri Lanka. These countries were selected as they represent the South Asian region as defined by WHO and possess comparable socio-demographic profiles, with varying dietary patterns and oral health outcomes. Data Sources All variables included in this analysis were extracted from the WHO Global Oral Health Database (GHO, 2025 update), which compiles standardized national statistics derived from surveys, health system reporting, and population-level monitoring initiatives. The following indicators were collected: Per capita availability of refined sugar (g/day) – Derived from national food balance sheets and represents average availability of refined sugar within the population. Alcohol consumption, per capita (litres of pure alcohol/year, 15+ years) – A three-year average indicator aligned with SDG 3.5.2; includes recorded and unrecorded consumption. Prevalence of untreated dental caries: Deciduous teeth in children aged 1–9 years (%) Permanent teeth in people aged ≥5 years (%) These indicators were available for all seven countries in the most recent reporting period. Data Preparation and Management Data from each variable were compiled into a unified spreadsheet (Microsoft Excel 365). Because alcohol consumption data for some countries (e.g., Afghanistan, Bangladesh) were reported as ranges (e.g., 0.0 [0.0–0.1]), the lower bound value (0.0) was used for analysis to avoid upward bias. No imputation or transformations were applied due to the small dataset and the interpretability of raw values in ecological research. Statistical Analysis All analyses were conducted in Microsoft Excel using built-in statistical tools. The primary objective was to examine country-level associations between: Per capita sugar availability and caries in children (deciduous dentition) Per capita sugar availability and caries in adults (permanent dentition) Per capita alcohol consumption and caries in adults Given the sample size of countries (n=7), simple linear regression was selected as the most appropriate method for exploratory ecological analysis. Scatter plots were generated for each pair of variables, and Excel’s “Add Trendline” function was used to obtain: Regression equation (slope and intercept) Coefficient of determination (R²) Visualization of fitted regression line No multivariable modelling was performed due to sample size constraints and risk of model overfitting. Ethical Considerations The study used publicly accessible, de-identified, aggregated data from WHO databases. As no human participants were involved and no identifiable information was used, ethical approval was not required. RESULTS Descriptive Data Data from seven South Asian countries were analysed. Per capita refined sugar availability ranged from 16.9 g/day in Bangladesh to 75.6 g/day in Sri Lanka. Alcohol consumption among adults (15 + years) showed wide variation, from 0.0 L per capita in Afghanistan and Bangladesh to 4.5 L per capita in India. The prevalence of untreated dental caries in children (deciduous teeth) ranged from 43.0% to 46.7%, whereas prevalence in adults (permanent teeth) ranged from 27.0% to 36.8% across the region. A summary of country-level data is presented in Table 1 . Table 1 Per capita sugar and alcohol consumption and prevalence of untreated dental caries in children and adults across South Asian countries Country Per capita availability of refined sugar (g/day) Prevalence of untreated caries of deciduous teeth in children 1–9 years (%) Prevalence of untreated caries of permanent teeth in people 5 + years (%) Alcohol, total per capita (15+) consumption (in litres of pure alcohol) (SDG Indicator 3.5.2), three-year average Afghanistan 46.8 45.8 36.8 0.0 Bangladesh 16.9 43.5 30.4 0.0 India 53.8 43.3 28.8 4.5 Iran 74.6 46.7 33.6 0.1 Maldives 62.8 44.0 28.0 1.6 Pakistan 57.7 45.7 27.0 0.1 Sri Lanka 75.6 43.0 27.4 2.7 Association Between Sugar Availability and Dental Caries in Children A simple linear regression was performed between per capita sugar availability and the prevalence of untreated caries in children aged 1–9 years as given in Fig. 1 . The fitted regression equation was: y = 0.0168x + 43.641 with a coefficient of determination: R² = 0.0524 The scatter plot of per-capita refined sugar availability and the prevalence of untreated caries in children (1–9 years) shows a very weak positive association (R² = 0.052). The regression equation (y = 0.0168x + 43.641) indicates, that for every 1 g/day increase in sugar availability, caries prevalence increases by only 0.0168%. However, sugar availability explains only 5.2% of the variation in caries across the seven countries, suggesting that sugar alone is not a major determinant of caries in this south asian countries. Other factors such as fluoride exposure, oral hygiene behavior, socioeconomic status, and access to dental care likely play a much larger role. Association Between Sugar Availability and Dental Caries in Adults Regression analysis between per capita sugar availability and prevalence of untreated caries in adults aged ≥ 5 years as given in Fig. 2 . The fitted regression equation was: y = − 0.0322x + 32.072 with a coefficient of determination: R² = 0.0311 This also reflects a very weak association, accounting for only 3.1% of the variability in adult caries prevalence. The linear regression analysis for untreated dental caries in permanent teeth among individuals aged 5 + years revealed a very weak and negative association with per capita sugar availability (y = -0.0322x + 32.072, R² = 0.0311). The regression equation indicates, for every 1 g/day increase in sugar availability, the prevalence of untreated caries in permanent teeth decreases by 0.0322%. Sugar availability explains only about 3.1% of the variation in adult caries prevalence - essentially no meaningful relationship. This suggests that sugar availability alone does not explain the variation in adult caries prevalence in these South Asian countries. The negative slope indicates a slight decrease in caries prevalence with increasing sugar, but this effect is negligible and likely not biologically meaningful. Association Between Alcohol Consumption and Dental Caries in Adults Linear regression between alcohol consumption and and prevalence of untreated caries in adults aged ≥ 5 years as given in Fig. 3 . The fitted regression equation was y = − 0.2267x + 8.1507 with a coefficient of determination: R² = 0.2216 This model explained that higher alcohol consumption is associated with slightly lower adult caries prevalence across South Asian countries, although the effect is small and explains only ~ 22% of the variation. Regression analysis between adult per capita alcohol consumption and untreated dental caries in adults (5 + years) revealed a weak negative association (y = -0.2267x + 8.1507, R² = 0.222). The regression equation indicates, for every 1 litre increase in per capita alcohol consumption, adult caries prevalence decreases by ~ 0.23%. Alcohol explains only 22% of the variation in adult caries prevalence across these 7 countries - modest at best. This ecological relationship likely reflects country-level confounding factors such as oral health care access, diet, or socioeconomic status rather than a protective effect of alcohol. Summary of Regression Findings Sugar availability showed minimal correlation with dental caries in both children and adults. Alcohol consumption was negatively associated with adult caries prevalence, although this association remained modest and ecological in nature. All regression plots with trendlines, R² values, and equations were generated using Microsoft Excel and are available as Figs. 1 – 3 . Interpretation Sugar availability showed weak or negligible correlations with dental caries in both children and adults. Adult alcohol consumption was inversely associated with adult caries prevalence at the country level, but this likely reflects confounding by socioeconomic or health system factors rather than a protective effect of alcohol. DISCUSSION This ecological analysis examined the association of per capita refined sugar availability and adult alcohol consumption with the prevalence of untreated dental caries across seven South Asian countries. Contrary to the well-established individual-level evidence linking dietary sugar to caries development, the present study found minimal ecological correlation between sugar availability and untreated dental caries in both children and adults.( 9 , 11 ) Alcohol consumption demonstrated a modest negative association with adult caries prevalence, though this is likely attributable to contextual and health-system differences rather than a direct protective effect. The weak associations observed for sugar may be explained by several factors. First, per capita sugar availability does not equate to individual sugar intake, as food availability metrics may mask variation in actual consumption due to household distribution patterns, socioeconomic disparities, food insecurity, and cultural dietary preferences.( 19 ) Second, dental caries is strongly influenced by oral hygiene behaviors, fluoride exposure, and access to preventive dental care-factors that vary considerably across South Asian countries and may overshadow dietary contributions in ecological analyses.( 3 ) Third, as an aggregate measure, prevalence of untreated caries does not account for restorative care access; countries with more dental services may report lower prevalence, independent of sugar intake.( 9 ) The inverse association between alcohol consumption and adult dental caries should be interpreted with caution. Alcohol intake is shaped by cultural and religious norms in South Asia, resulting in pronounced differences between countries such as India, and Sri Lanka compared with Afghanistan or Bangladesh. Higher alcohol-consuming countries may also have greater urbanization, higher socioeconomic status, or better oral healthcare infrastructure, which could independently reduce caries prevalence.( 20 , 21 ) Therefore, the observed negative association likely reflects confounding by structural and socio-behavioral factors, rather than any causal effect of alcohol on caries risk. Furthermore, alcohol is known to contribute to oral cancer and periodontal disease, and high consumption often correlates with tobacco use-reinforcing that alcohol is not protective for oral health. The findings align with broader evidence emphasizing the multifactorial nature of dental caries, particularly in low- and middle-income regions where preventive systems are unevenly distributed. The results indicate that diet alone cannot explain national patterns of untreated caries without considering oral health service delivery, fluoride programs, health literacy, and broader social determinants. ( 22 ) Strengths and Limitations A key strength of this study is the use of standardized WHO GHO data, allowing for cross-country comparability. Additionally, this is one of the few analyses exploring sugar–caries ecological relationships specifically within the South Asian region. However, limitations must be acknowledged. The small number of countries (n = 7) restricts statistical power, and ecological designs cannot account for within-country variability or individual-level risk factors, giving rise to potential ecological fallacy. The alcohol consumption values represent population averages and may not reflect actual exposure patterns relevant to oral health. Finally, other important influences on dental caries-such as fluoride use, oral hygiene practices, socioeconomic gradients, and dietary diversity-were not considered in this study. Implications and Future Directions These findings highlight the need for country-level oral health surveillance that captures behavioral, environmental, and systemic determinants. Future research should incorporate individual-level datasets, include multivariable models, and explore additional risk factors such as tobacco use, sugar-sweetened beverages, fluoride programs, and access to dental services. Policymakers should prioritize comprehensive oral health strategies that extend beyond dietary interventions to address preventive care access, public awareness, and early detection. Recent evidence supports integrating oral health education in school curricula and highlights a broad range of social, behavioral, and system‑level factors influencing oral disease beyond diet and sugar exposure.( 23 , 24 ) CONCLUSION This ecological study of seven South Asian countries found limited associations between per capita refined sugar availability and the prevalence of untreated dental caries in both children and adults. Although alcohol consumption showed a modest inverse association with adult caries prevalence, this pattern is likely driven by broader socioeconomic and health-system differences rather than any biological protective effect. Taken together, the findings highlights the complexity of dental caries as a public health issue and demonstrate that national-level oral disease patterns cannot be explained by dietary factors alone. The findings indicate the multifactorial etiology of caries and the importance of country-level oral health policies, preventive programs, and health system factors in mitigating oral disease burden. Policy responses should prioritize oral health system strengthening and prevention programs rather than focusing narrowly on dietary factors alone. Declarations Ethical approval Not applicable. The study utilized publicly accessible, aggregated country-level data and did not involve human subjects or personal health information. Consent to participate Not applicable. Consent to publish Not applicable. Clinical trial number Not applicable Funding None Author Contribution H.D. conceived the study, collected and analyzed the data, prepared all figures and tables, and wrote the manuscript. H.D. reviewed and approved the final version of the manuscript. Data Availability All data used in this study are publicly available through the World Health Organization Global Health Observatory (GHO) oral health database. The dataset can be accessed by searching the oral health indicators within the GHO portal. No proprietary or restricted data were used. References Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al. Oral diseases: a global public health challenge. Lancet. 2019;394(10194):249–60. Global oral health. status report: towards universal health coverage for oral health by 2030 [Internet]. [cited 2025 Dec 9]. Available from: https://www.who.int/publications/i/item/9789240061484 Oral health [Internet]. [cited 2025 Dec 9]. Available from: https://www.who.int/news-room/fact-sheets/detail/oral-health Giacaman RA, Fernández CE, Muñoz-Sandoval C, León S, García-Manríquez N, Echeverría C, et al. Understanding dental caries as a non-communicable and behavioral disease: Management implications. Front Oral Health. 2022;3:764479. Bernabe E, Marcenes W, Abdulkader RS, Abreu LG, Afzal S, Alhalaiqa FN, et al. Trends in the global, regional, and national burden of oral conditions from 1990 to 2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2025;405(10482):897–910. Das H, Janakiram C, Ramanarayanan V, Karuveettil V, Kumar V, Balachandran P, et al. Effectiveness of an oral health curriculum in reducing dental caries increment and improving oral hygiene behaviour among schoolchildren of Ernakulam district in Kerala, India: study protocol for a cluster randomised trial. BMJ Open. 2023;13(2):e069877. Chen X, Jia L, Wang Q, Wang JJ, Tian Y, Zhang Z, et al. Global, regional, and national burden of caries in primary teeth from 1990 to 2021: results from the global burden of disease study 2021. BMC Oral Health. 2025;25(1):1381. The Role of Sugars in the Caries Process. | Integrative Journal of Medical Sciences [Internet]. [cited 2025 Dec 9]. Available from: https://mbmj.org/index.php/ijms/article/view/519?utm_source=chatgpt.com Sugars. and dental caries [Internet]. [cited 2025 Dec 9]. Available from: https://www.who.int/news-room/fact-sheets/detail/sugars-and-dental-caries Woodward M, Walker AR. Sugar consumption and dental caries: evidence from 90 countries. Br Dent J. 1994;176(8):297–302. Moynihan PJ, Kelly SA. Effect on caries of restricting sugars intake: systematic review to inform WHO guidelines. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] [Internet]. Centre for Reviews and Dissemination (UK); 2014 [cited 2025 Dec 9]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK179817/ Das H, Motghare S. India as The Oral Cancer Capital of the World: The Rising Burden of Oral Malignancies across the Nation. Int J Sci Healthc Res. 2021;6:99–107. Gandhi UH, Benjamin A, Gajjar S, Hirani T, Desai K, Suhagia BB, et al. Alcohol Periodontal Disease: Narrative Rev Cureus. 2024;16(6):e62270. Mashberg A, Garfinkel L, Harris S. Alcohol as a primary risk factor in oral squamous carcinoma. CA Cancer J Clin. 1981;31(3):146–55. Kaner EF, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Drugs and Alcohol Group, editor. Cochrane Database of Systematic Reviews [Internet]. 2018 Feb 24 [cited 2025 Dec 9];2018(6). Available from: http://doi.wiley.com/10.1002/14651858.CD004148.pub4 Fan X, Peters BA, Jacobs EJ, Gapstur SM, Purdue MP, Freedman ND, et al. Drinking alcohol is associated with variation in the human oral microbiome in a large study of American adults. Microbiome. 2018;6(1):59. Oral health data portal [Internet]. [cited 2025 Dec 9]. Available from: https://www.who.int/data/gho/data/themes/oral-health-data-portal Morgenstern H. Ecologic Studies in Epidemiology: Concepts, Principles, and Methods. Annual Review of Public Health. 1995;16(Volume 16, 1995):61–81. Socioeconomic factors in. relation to dental caries among children aged 5–14 years: a cross-national comparative study using secondary data analyses | BMC Oral Health [Internet]. [cited 2025 Dec 9]. Available from: https://link.springer.com/article/ 10.1186/s12903-025-06959-3?utm_source=chatgpt.com Cook WK, Caetano R. Ethnic Drinking Cultures, Gender, and Socioeconomic Status in Asian American and Latino Drinking. Alcohol Clin Exp Res. 2014;38(12):3043–51. Sudhinaraset M, Wigglesworth C, Takeuchi DT. Social and Cultural Contexts of Alcohol Use. Alcohol Res. 2016;38(1):35–45. Das H, Janakiram C, Karuveettil SVK. Effectiveness of school-based oral health education interventions on oral health status and oral hygiene behaviors among schoolchildren: an umbrella review. Evid Based Dent. 2025;26(2):110–1. Das DH, Janakiram DC, Ramanarayanan DV, Karuveettil DV, Kumar DV, Balachandran DP, et al. Oral health curriculum to reduce dental caries increment in schoolchildren. Int Dent J. 2023;73:S36. Das H, Janakiram C. Integrating Oral Health Curriculum into Indian Schools: Evidence-Based Perspectives and Policy Recommendations for National Implementation from a trial in Kerala, India [Internet]. Research Square; 2025 [cited 2025 Dec 9]. Available from: https://www.researchsquare.com/article/rs-8186678/v1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8310665","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":596780219,"identity":"fb02f3b0-974b-46da-b02e-074b7979219a","order_by":0,"name":"Hindol 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2","display":"","copyAsset":false,"role":"figure","size":71522,"visible":true,"origin":"","legend":"\u003cp\u003eAssociation between per capita sugar availability and prevalence of untreated caries in adults (≥5 years) across South Asian countries\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8310665/v1/7cebd31ad79a285cfed0230a.png"},{"id":103563107,"identity":"2cea85fc-5c06-4a43-b715-19ad721da8d8","added_by":"auto","created_at":"2026-02-27 06:28:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":66527,"visible":true,"origin":"","legend":"\u003cp\u003eAssociation between adult per capita alcohol consumption and prevalence of untreated caries in adults (≥5 years) across South Asian 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worldwide and disproportionately impacting low- and middle-income countries.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Among these conditions, dental caries is the most prevalent, contributing to pain, infection, impaired quality of life, and substantial economic burden.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) The Global Burden of Disease (GBD) shows untreated dental caries in permanent teeth is the most common health condition globally.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) South Asia, home to nearly a quarter of the world\u0026rsquo;s population, continues to face a high burden of dental caries in children, with recent global reports identifying the region as having the highest prevalence of caries in primary teeth.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDietary sugar is one of the most consistently identified modifiable risk factors for dental caries. The biological mechanism is well established: fermentable carbohydrates promote acid production by cariogenic bacteria, leading to demineralization of dental enamel.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) As such, population-level sugar availability is often used as an indicator of dietary exposure in ecological public health analyses.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Several global reports have highlighted rising sugar consumption in developing economies, but the relationship between country-level sugar availability and oral disease burden in South Asia remains poorly understood.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAlcohol consumption, on the other hand, is primarily studied in relation to oral cancer and periodontal disease.(\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) However, alcohol may indirectly influence dental caries risk through multiple pathways, including reduced salivary flow, high sugar content in certain alcoholic beverages, and associated lifestyle factors such as tobacco use.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Despite these theoretical links, ecological evidence on alcohol consumption and dental caries prevalence is limited, particularly in the South Asian context where alcohol use varies dramatically between countries due to cultural, legal, and religious factors.\u003c/p\u003e \u003cp\u003eThe World Health Organization\u0026rsquo;s (WHO) Global Health Observatory recently released updated oral health profiles for all member states, providing standardized indicators for dental caries and associated risk factors.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) These data offer a unique opportunity to explore regional trends and generate hypotheses regarding population-level determinants of oral diseases.\u003c/p\u003e \u003cp\u003eGiven this context, the present study aims to examine ecological associations between per capita refined sugar availability, per capita alcohol consumption, and the prevalence of untreated dental caries in both children and adults across seven South Asian countries. By analysing population-level patterns, this ecological approach provides valuable insights into broader trends, helping to inform future public health strategies, research priorities, and oral health policy development in the region.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed an ecological cross-sectional design using publicly available country-level data from the World Health Organization (WHO) Global Health Observatory (GHO) oral health database.(17) \u0026nbsp;The analysis focused on seven South Asian countries for which complete data were available: Afghanistan, Bangladesh, India, Iran, Maldives, Pakistan, and Sri Lanka. These countries were selected as they represent the South Asian region as defined by WHO and possess comparable socio-demographic profiles, with varying dietary patterns and oral health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll variables included in this analysis were extracted from the WHO Global Oral Health Database (GHO, 2025 update), which compiles standardized national statistics derived from surveys, health system reporting, and population-level monitoring initiatives. The following indicators were collected:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003ePer capita availability of refined sugar (g/day)\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;– Derived from national food balance sheets and represents average availability of refined sugar within the population.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAlcohol consumption, per capita (litres of pure alcohol/year, 15+ years)\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;– A three-year average indicator aligned with SDG 3.5.2; includes recorded and unrecorded consumption.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePrevalence of untreated dental caries:\u003c/strong\u003e\n \u003cul type=\"circle\"\u003e\n \u003cli\u003eDeciduous teeth in children aged 1–9 years (%)\u003c/li\u003e\n \u003cli\u003ePermanent teeth in people aged ≥5 years (%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThese indicators were available for all seven countries in the most recent reporting period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Preparation and Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from each variable were compiled into a unified spreadsheet (Microsoft Excel 365). Because alcohol consumption data for some countries (e.g., Afghanistan, Bangladesh) were reported as ranges (e.g., 0.0 [0.0–0.1]), the lower bound value (0.0) was used for analysis to avoid upward bias. No imputation or transformations were applied due to the small dataset and the interpretability of raw values in ecological research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll analyses were conducted in Microsoft Excel using built-in statistical tools. The primary objective was to examine country-level associations between:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003ePer capita sugar availability and caries in children (deciduous dentition)\u003c/li\u003e\n \u003cli\u003ePer capita sugar availability and caries in adults (permanent dentition)\u003c/li\u003e\n \u003cli\u003ePer capita alcohol consumption and caries in adults\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eGiven the sample size of countries (n=7), simple linear regression was selected as the most appropriate method for exploratory ecological analysis. Scatter plots were generated for each pair of variables, and Excel’s “Add Trendline” function was used to obtain:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eRegression equation (slope and intercept)\u003c/li\u003e\n \u003cli\u003eCoefficient of determination (R²)\u003c/li\u003e\n \u003cli\u003eVisualization of fitted regression line\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNo multivariable modelling was performed due to sample size constraints and risk of model overfitting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study used publicly accessible, de-identified, aggregated data from WHO databases. As no human participants were involved and no identifiable information was used, ethical approval was not required.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive Data\u003c/h2\u003e \u003cp\u003eData from seven South Asian countries were analysed. Per capita refined sugar availability ranged from 16.9 g/day in Bangladesh to 75.6 g/day in Sri Lanka. Alcohol consumption among adults (15\u0026thinsp;+\u0026thinsp;years) showed wide variation, from 0.0 L per capita in Afghanistan and Bangladesh to 4.5 L per capita in India.\u003c/p\u003e \u003cp\u003eThe prevalence of untreated dental caries in children (deciduous teeth) ranged from 43.0% to 46.7%, whereas prevalence in adults (permanent teeth) ranged from 27.0% to 36.8% across the region.\u003c/p\u003e \u003cp\u003eA summary of country-level data is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePer capita sugar and alcohol consumption and prevalence of untreated dental caries in children and adults across South Asian countries\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePer capita availability of refined sugar (g/day)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrevalence of untreated caries of deciduous teeth in children 1\u0026ndash;9 years (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrevalence of untreated caries of permanent teeth in people 5\u0026thinsp;+\u0026thinsp;years (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAlcohol, total per capita (15+) consumption (in litres of pure alcohol) (SDG Indicator 3.5.2), three-year average\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfghanistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIran\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaldives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSri Lanka\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAssociation Between Sugar Availability and Dental Caries in Children\u003c/h2\u003e \u003cp\u003eA simple linear regression was performed between per capita sugar availability and the prevalence of untreated caries in children aged 1\u0026ndash;9 years as given in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe fitted regression equation was: y\u0026thinsp;=\u0026thinsp;0.0168x\u0026thinsp;+\u0026thinsp;43.641\u003c/p\u003e \u003cp\u003ewith a coefficient of determination: R\u0026sup2; = 0.0524\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe scatter plot of per-capita refined sugar availability and the prevalence of untreated caries in children (1\u0026ndash;9 years) shows a very weak positive association (R\u0026sup2; = 0.052). The regression equation (y\u0026thinsp;=\u0026thinsp;0.0168x\u0026thinsp;+\u0026thinsp;43.641) indicates, that for every 1 g/day increase in sugar availability, caries prevalence increases by only 0.0168%. However, sugar availability explains only 5.2% of the variation in caries across the seven countries, suggesting that sugar alone is not a major determinant of caries in this south asian countries. Other factors such as fluoride exposure, oral hygiene behavior, socioeconomic status, and access to dental care likely play a much larger role.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAssociation Between Sugar Availability and Dental Caries in Adults\u003c/h2\u003e \u003cp\u003eRegression analysis between per capita sugar availability and prevalence of untreated caries in adults aged\u0026thinsp;\u0026ge;\u0026thinsp;5 years as given in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe fitted regression equation was: y = \u0026minus;\u0026thinsp;0.0322x\u0026thinsp;+\u0026thinsp;32.072\u003c/p\u003e \u003cp\u003ewith a coefficient of determination: R\u0026sup2; = 0.0311\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis also reflects a very weak association, accounting for only 3.1% of the variability in adult caries prevalence.\u003c/p\u003e \u003cp\u003eThe linear regression analysis for untreated dental caries in permanent teeth among individuals aged 5\u0026thinsp;+\u0026thinsp;years revealed a very weak and negative association with per capita sugar availability (y = -0.0322x\u0026thinsp;+\u0026thinsp;32.072, R\u0026sup2; = 0.0311). The regression equation indicates, for every 1 g/day increase in sugar availability, the prevalence of untreated caries in permanent teeth \u003cem\u003edecreases\u003c/em\u003e by 0.0322%. Sugar availability explains only about 3.1% of the variation in adult caries prevalence - essentially no meaningful relationship. This suggests that sugar availability alone does not explain the variation in adult caries prevalence in these South Asian countries. The negative slope indicates a slight decrease in caries prevalence with increasing sugar, but this effect is negligible and likely not biologically meaningful.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAssociation Between Alcohol Consumption and Dental Caries in Adults\u003c/h2\u003e \u003cp\u003eLinear regression between alcohol consumption and and prevalence of untreated caries in adults aged\u0026thinsp;\u0026ge;\u0026thinsp;5 years as given in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe fitted regression equation was y = \u0026minus;\u0026thinsp;0.2267x\u0026thinsp;+\u0026thinsp;8.1507\u003c/p\u003e \u003cp\u003ewith a coefficient of determination: R\u0026sup2; = 0.2216\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis model explained that higher alcohol consumption is associated with slightly lower adult caries prevalence across South Asian countries, although the effect is small and explains only\u0026thinsp;~\u0026thinsp;22% of the variation.\u003c/p\u003e \u003cp\u003eRegression analysis between adult per capita alcohol consumption and untreated dental caries in adults (5\u0026thinsp;+\u0026thinsp;years) revealed a weak negative association (y = -0.2267x\u0026thinsp;+\u0026thinsp;8.1507, R\u0026sup2; = 0.222). The regression equation indicates, for every 1 litre increase in per capita alcohol consumption, adult caries prevalence decreases by ~\u0026thinsp;0.23%. Alcohol explains only 22% of the variation in adult caries prevalence across these 7 countries - modest at best. This ecological relationship likely reflects country-level confounding factors such as oral health care access, diet, or socioeconomic status rather than a protective effect of alcohol.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSummary of Regression Findings\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSugar availability showed minimal correlation with dental caries in both children and adults.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAlcohol consumption was negatively associated with adult caries prevalence, although this association remained modest and ecological in nature.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAll regression plots with trendlines, R\u0026sup2; values, and equations were generated using Microsoft Excel and are available as Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation\u003c/h2\u003e \u003cp\u003eSugar availability showed weak or negligible correlations with dental caries in both children and adults. Adult alcohol consumption was inversely associated with adult caries prevalence at the country level, but this likely reflects confounding by socioeconomic or health system factors rather than a protective effect of alcohol.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis ecological analysis examined the association of per capita refined sugar availability and adult alcohol consumption with the prevalence of untreated dental caries across seven South Asian countries. Contrary to the well-established individual-level evidence linking dietary sugar to caries development, the present study found minimal ecological correlation between sugar availability and untreated dental caries in both children and adults.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Alcohol consumption demonstrated a modest negative association with adult caries prevalence, though this is likely attributable to contextual and health-system differences rather than a direct protective effect.\u003c/p\u003e \u003cp\u003eThe weak associations observed for sugar may be explained by several factors. First, per capita sugar availability does not equate to individual sugar intake, as food availability metrics may mask variation in actual consumption due to household distribution patterns, socioeconomic disparities, food insecurity, and cultural dietary preferences.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Second, dental caries is strongly influenced by oral hygiene behaviors, fluoride exposure, and access to preventive dental care-factors that vary considerably across South Asian countries and may overshadow dietary contributions in ecological analyses.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Third, as an aggregate measure, prevalence of untreated caries does not account for restorative care access; countries with more dental services may report lower prevalence, independent of sugar intake.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe inverse association between alcohol consumption and adult dental caries should be interpreted with caution. Alcohol intake is shaped by cultural and religious norms in South Asia, resulting in pronounced differences between countries such as India, and Sri Lanka compared with Afghanistan or Bangladesh. Higher alcohol-consuming countries may also have greater urbanization, higher socioeconomic status, or better oral healthcare infrastructure, which could independently reduce caries prevalence.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) Therefore, the observed negative association likely reflects confounding by structural and socio-behavioral factors, rather than any causal effect of alcohol on caries risk. Furthermore, alcohol is known to contribute to oral cancer and periodontal disease, and high consumption often correlates with tobacco use-reinforcing that alcohol is not protective for oral health.\u003c/p\u003e \u003cp\u003eThe findings align with broader evidence emphasizing the multifactorial nature of dental caries, particularly in low- and middle-income regions where preventive systems are unevenly distributed. The results indicate that diet alone cannot explain national patterns of untreated caries without considering oral health service delivery, fluoride programs, health literacy, and broader social determinants. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eA key strength of this study is the use of standardized WHO GHO data, allowing for cross-country comparability. Additionally, this is one of the few analyses exploring sugar\u0026ndash;caries ecological relationships specifically within the South Asian region.\u003c/p\u003e \u003cp\u003eHowever, limitations must be acknowledged. The small number of countries (n\u0026thinsp;=\u0026thinsp;7) restricts statistical power, and ecological designs cannot account for within-country variability or individual-level risk factors, giving rise to potential ecological fallacy. The alcohol consumption values represent population averages and may not reflect actual exposure patterns relevant to oral health. Finally, other important influences on dental caries-such as fluoride use, oral hygiene practices, socioeconomic gradients, and dietary diversity-were not considered in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eImplications and Future Directions\u003c/h2\u003e \u003cp\u003eThese findings highlight the need for country-level oral health surveillance that captures behavioral, environmental, and systemic determinants. Future research should incorporate individual-level datasets, include multivariable models, and explore additional risk factors such as tobacco use, sugar-sweetened beverages, fluoride programs, and access to dental services. Policymakers should prioritize comprehensive oral health strategies that extend beyond dietary interventions to address preventive care access, public awareness, and early detection. Recent evidence supports integrating oral health education in school curricula and highlights a broad range of social, behavioral, and system‑level factors influencing oral disease beyond diet and sugar exposure.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis ecological study of seven South Asian countries found limited associations between per capita refined sugar availability and the prevalence of untreated dental caries in both children and adults. Although alcohol consumption showed a modest inverse association with adult caries prevalence, this pattern is likely driven by broader socioeconomic and health-system differences rather than any biological protective effect. Taken together, the findings highlights the complexity of dental caries as a public health issue and demonstrate that national-level oral disease patterns cannot be explained by dietary factors alone. The findings indicate the multifactorial etiology of caries and the importance of country-level oral health policies, preventive programs, and health system factors in mitigating oral disease burden. Policy responses should prioritize oral health system strengthening and prevention programs rather than focusing narrowly on dietary factors alone.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003eNot applicable. The study utilized publicly accessible, aggregated country-level data and did not involve human subjects or personal health information.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eH.D. conceived the study, collected and analyzed the data, prepared all figures and tables, and wrote the manuscript. H.D. reviewed and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data used in this study are publicly available through the World Health Organization Global Health Observatory (GHO) oral health database. The dataset can be accessed by searching the oral health indicators within the GHO portal. No proprietary or restricted data were used.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePeres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al. Oral diseases: a global public health challenge. Lancet. 2019;394(10194):249\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlobal oral health. status report: towards universal health coverage for oral health by 2030 [Internet]. [cited 2025 Dec 9]. 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Alcohol Res. 2016;38(1):35\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas H, Janakiram C, Karuveettil SVK. Effectiveness of school-based oral health education interventions on oral health status and oral hygiene behaviors among schoolchildren: an umbrella review. Evid Based Dent. 2025;26(2):110\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas DH, Janakiram DC, Ramanarayanan DV, Karuveettil DV, Kumar DV, Balachandran DP, et al. Oral health curriculum to reduce dental caries increment in schoolchildren. Int Dent J. 2023;73:S36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas H, Janakiram C. Integrating Oral Health Curriculum into Indian Schools: Evidence-Based Perspectives and Policy Recommendations for National Implementation from a trial in Kerala, India [Internet]. Research Square; 2025 [cited 2025 Dec 9]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchsquare.com/article/rs-8186678/v1\u003c/span\u003e\u003cspan address=\"https://www.researchsquare.com/article/rs-8186678/v1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8310665/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8310665/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDental caries remains a significant public health concern globally. Dental caries is highly prevalent in South Asia, but the contribution of population-level dietary exposures remains unclear. Dietary sugar is a well-established risk factor, while alcohol consumption may influence oral health outcomes in adults. This study examined the ecological associations between per capita refined sugar availability, adult alcohol consumption, and the prevalence of untreated dental caries in South Asian countries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCountry-level data for seven South Asian countries (Afghanistan, Bangladesh, India, Iran, Maldives, Pakistan, and Sri Lanka) were obtained from the WHO Global Health Observatory. Variables included per capita refined sugar availability, adult per capita alcohol consumption, and prevalence of untreated dental caries in children (1\u0026ndash;9 years) and adults (\u0026ge;\u0026thinsp;5 years). Simple linear regressions assessed ecological associations between dietary variables and caries prevalence.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSugar availability showed negligible associations with caries in both children (R\u0026sup2; = 0.052) and adults (R\u0026sup2; = 0.031). Adult alcohol consumption demonstrated a modest negative association with adult caries prevalence (R\u0026sup2; = 0.222). These ecological associations likely reflect country-level confounding factors such as oral health infrastructure, socioeconomic status, and diet patterns rather than causal relationships.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eEcological analysis of South Asian countries showed limited correlation between sugar and alcohol consumption and dental caries prevalence. These findings highlight the multifactorial nature of caries and the influence of population-level health system and socioeconomic factors in oral health research. Ecological correlations were weak, indicating that national dental caries burdens in South Asia are influenced more by oral health systems and social determinants than by population-level sugar availability or alcohol exposure.\u003c/p\u003e","manuscriptTitle":"Country level ecological analysis of per capita sugar and alcohol consumption and their association with dental caries prevalence in South Asian countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 06:28:36","doi":"10.21203/rs.3.rs-8310665/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"08d06948-60c5-44f9-86c2-3967d7505769","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T06:28:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 06:28:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8310665","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8310665","identity":"rs-8310665","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}