Deluged with soft drinks, our children are gaining weight and losing teeth in record numbers. Can public health solutions prevail?
By Jennifer Bowden and Catherine Woulfe.
For 22-year-old Matthew Taylor (not his real name), a recent visit to the dentist brought unwanted news – two fillings and one tooth so decayed it would have to be removed. This, following the seven fillings and two extractions he’d had in the past two years, had Taylor wondering why his teeth were causing him so much trouble.
His dentist wouldn’t have been surprised. Dentists are seeing more and more children and young adults with rotten, decaying teeth. Sometimes the decay is so widespread it’s not uncommon for two-year-old children to get general anaesthesia and have all 20 of their teeth removed. Although dental general anaesthesia is very efficient, it is considered a last resort due to the small but real risk any general anaesthesia poses to a patient’s health. There are also suggestions that general anaesthesia in early childhood may affect a child’s neuro-development.
About 5000 children younger than seven years receive a general anaesthetic each year to have decayed teeth removed. The cost to taxpayers runs to tens of millions of dollars. With more children and young adults being admitted to hospital due to dental decay, that cost is likely to increase.
Good oral health is crucial for good general health in children and adults. Dental caries can cause a significant amount of pain; in children this can interfere with their sleep, ability to eat, school performance and overall behaviour. Removing rotten teeth is often the only solution for dental decay, but it’s a less than ideal one. Children who have teeth removed can have difficulties eating, speaking and socialising. What’s more, if their molars (back teeth) are removed, their permanent adult teeth, which are yet to erupt, can move around, resulting in complex orthodontic problems that require expensive treatments many families simply cannot afford.
Around 34,000 children, aged one to 14 years, had one or more teeth removed due to decay, abscess or infection in 2012, according to the latest New Zealand Health Survey. That figure is likely to climb based on current trends. A 2012 report, Admissions to New Zealand Public Hospitals for Dental Care: A 20 Year Review, found children aged eight years and younger had the highest rates of admission to hospital for dental treatment, with children aged between three and four years the biggest users of hospital services for dental treatment.
Although hospital admissions for dental treatment have increased slightly across all age groups, the increases among children are truly staggering – between 1990 and 1994, children aged three to four years had fewer than eight admissions per 1000, but that had steadily climbed to 22 admissions per 1000 during 2005-2009, compared with adults, whose rate went from fewer than one admission per 1000 in the 1990s to fewer than two per 1000 in 2005-2009. Among all age groups, dental caries accounted for more than three-quarters of admissions for dental disease.
THE AGE OF DECAY
A portion of this increase in hospital admissions is due to changes in general anaesthetic standards, which has meant fewer general anaesthetics are administered in private dental practices. However, that doesn’t explain the explosion in admissions among young children. Rather it seems likely that changes in access to dental care in the community, a lack of primary prevention for children or an increase in dental disease is to blame.
Dr Rob Beaglehole, principal dental officer at the Nelson Marlborough District Health Board, strongly believes an increased intake of soft drinks and other sugar-sweetened beverages is to blame for the rising tide of dental decay in children and young adults.
This is disputed by the general manager of Coca-Cola Oceania Ltd, Paul Fitzgerald, who says “the consumption of sugar-sweetened beverages [SSBs] has actually declined over the last five to six years”.
Fitzgerald points out that his company and the other big player, Frucor, have introduced numerous low and no-sugar options, and that according to its data, in New Zealand today “one in three soft drinks sold [by Coca-Cola ] doesn’t contain sugar”. The data also show that the amount of sugar sold into the Kiwi diet via its drinks has dropped by 15% since 2008.
However, even if people brush their teeth carefully and have regular dental check-ups, it doesn’t take long for a diet high in sugary drinks to damage a set of healthy teeth irreversibly, explains Beaglehole. “I had a 16-year-old girl come to see me. I took X-rays, gave her a thorough check-up and she had nothing wrong with her [teeth]. A year later she turned up and I took more X-rays, gave her another check-up, and she needed 14 fillings and two extractions.”
So what had happened in one short year that could possibly cause so much dental damage? It turned out she had got a job at McDonalds and was now drinking far more high-sugar soft drink.
Such incidents are increasingly common, with dentists regularly extracting rotten, decayed teeth from teenagers, who will then need to think about a denture or an implant at a later date, says Beaglehole. Although dentures have advanced considerably in the past few generations, the fact is dentures will never fit perfectly, may be uncomfortable and can cause problems with pronunciation for some people.
Add to that the ongoing maintenance and care required to keep well-functioning dentures and it’s clear prevention is far preferable to cure.
But, it isn’t only teenagers. Beaglehole regularly sees children as young as two years old who must get a general anaesthetic to have their decayed and eroded teeth removed. “These weren’t accidents; they were decay or dental abscesses. And the abscess happens after the tooth has decayed so much that it dies off and you get an infection. The only thing that’s causing that is a diet high in sugar. No amount of brushing your teeth can protect against that huge intake of sugary drinks. Water fluoridation is a positive thing, but all it does is reduce the incidence of tooth decay. It won’t prevent it totally.”
In most cases, when Beaglehole asks parents why their child’s teeth are in such poor condition, soft drinks are mentioned.
Beaglehole stresses he doesn’t have anything personally against Coca-Cola. It’s just that it is the biggest seller in New Zealand supermarkets.
Fitzgerald says Coca-Cola believes that what Beaglehole sees is “a tragedy. We totally empathise with what he has to deal with.”
But Fitzgerald says “emotive discussions” are taking precedence over co-operation and helpful dialogue that can bring about change.
“More effort, more focus on educating people how to look after their teeth, would have a much more profound and long-lasting effect than just picking on SSBs, when you’re not changing any of the environment that these people are operating in.”
SUGAR IN, MILK OUT
We should have seen this coming. Back in 2000, an Italian study, published in the Journal of Public Health Dentistry, noted the high prevalence of “rampant, early-childhood dental decay” seen in Italian pre-schoolers was associated with the use of baby bottles filled with sweetened beverages, and inversely associated with milk and yoghurt intake. In 2003, US researchers published in Pediatrics a longitudinal study that recorded the dietary intake and dental health of more than 640 children aged from one to seven years. They found children who had higher intakes of soft drinks and sugar-sweetened beverages made from powder were more likely to have dental caries, as were children who had lower intakes of milk at two and three years.
SSBs such as soft drinks and energy drinks are particularly damaging to teeth for two reasons. Firstly, they have a high sugar content, and sugar feeds the bacteria on teeth (known as plaque), which in turn produce acid that causes the tooth to decay, resulting in dental caries.
The greater the quantity and frequency of sugar consumed, the greater the chance of caries. And SSBs in particular, as a major source of added sugar, have been found to significantly increase the risk of tooth decay in children and adults.
SSBs also tend to be acidic. On the pH scale, which measures acidity, seven is defined as neutral and lower numbers indicate a greater acidity. Coca-Cola has a pH of 2.9, for example – close to lemon juice and vinegar, and above stomach acid, which has a pH of about two. Acidic drinks such as SSBs can cause dental erosion, causing teeth to dissolve (although Coca-Cola points out that drinks don’t need chewing and therefore have less contact with teeth than most foods. Healthier drinks, such as water and milk, have relatively neutral pHs of seven and 6.8 respectively.
At Beaglehole’s presentation about dental decay at the recent Fighting Sugar in Soft Drinks (FIZZ) symposium at the University of Auckland, his images of young patients having numerous rotten, decayed teeth removed surprised the well-seasoned audience from the health sector.
Fitzgerald gave a speech too, outlining the initiatives his company has taken in tackling the obesity problem.
“We had five minutes at a two-day symposium on anti-sugar,” he says wryly. “We attended the whole thing.”
The FIZZ symposium also provided a forum for the New Zealand Beverage Guidance Panel (NZBGP) to present their recommendations. The panel was established by researchers at the University of Auckland and includes members from other academic institutions and health organisations. It aims to raise awareness about the relative risks and health benefits of different drinks.
Beaglehole believes teeth are a warning sign of the harm SSBs are doing to children’s general health. They contribute 26% of the sugar consumed by children and 17% of that consumed by adults. And we’re consuming far too much sugar to start with – it contributes 25% of total energy to children’s diets, and around 20% to adults’ diets.
A WORLD OF KNOWLEDGE
In March, the World Health Organisation published a draft document, for public comment, updating recommendations on intake of added sugars. The WHO suggests added sugars should contribute no more than 10% of total energy. It notes there are also benefits in reducing total added-sugar intake to less than 5% of total energy.
Among children, intake of added sugar from SSBs alone exceeds the WHO recommended 5%, even before all the other added sugars from processed foods and drinks are considered.
Clearly a vast chasm exists between our intake of added sugars and what is good for our health, and unsurprisingly that chasm is producing a raft of negative health consequences.
Some 29% of children consume four or more SSBs per week; those who consume one can of SSB per day have a 3.3kg higher mean weight, while those who consume two cans have a 5.3kg higher weight, according to the Obesity Prevention in Communities study.
This study, together with a plethora of other scientific evidence, strongly implicates the consumption of SSBs in unwanted weight gain. SSBs also increase the risk of dental caries, type 2 diabetes mellitus, cardiovascular disease and gout.
Accumulating evidence also suggests SSBs may increase cancer risk and impair cognitive development in children.
It’s for these reasons the NZBGP has created a six-point policy brief, presented at the FIZZ symposium, on options to reduce SSB consumption in New Zealand.
Explains NZBGP member Boyd Swinburn, professor of population nutrition and global health at the University of Auckland: “What we desperately need is a government-led, systems-based approach around reducing SSBs and unhealthy food in general in New Zealand. SSBs are a particular focus, because it’s low-hanging fruit. In other words, it’s the thing that is pretty obvious as a major contributor [to ill health] and adds no nutritional value or other value to the diet.”
The NZBGP recommends the Government: introduce a 20% excise tax on SSBs with all funding to be used for health promotion; strengthen the National Administration Guidelines, so schools only provide foods and beverages that meet dietary guidelines; implement campaigns to encourage healthy beverage choices; and restrict marketing to children of unhealthy foods and beverages, including SSBs.
Schools, health organisations, advocacy groups, workplaces and community groups are all ready to make changes, says Swinburn, they’re just waiting for some leadership from the Government.
“Industry obviously does not particularly want all this action to happen around SSBs, so they will, I’m sure, spend their time lobbying heavily against it.”
Not so, insists Fitzgerald. “We don’t do much lobbying at all, we’re spending all our time, effort, marketing and more and more resources on following up on the [obesity-tackling] commitments that we made last year.
“When you look at the weight of lobbying of industry versus the public health arena – and not all the public health arena by the way, it’s just a portion of them – I would say we are way outweighed in terms of lobby resources and lobby focus.”
It’s unfortunate, Fitzgerald says, that “extreme” views such as those of Beaglehole and Swinburn are dominating the public discussion. “If we could start from where we’re in agreement rather than from where we’re different, we would get a whole lot more done.”
Asked to pick actions that Coca-Cola would be most opposed to, Fitzgerald highlights taxation and marketing restrictions.
Taxation is “a really blunt tool”, he says, “that has never been proven to be effective, and leads to unintended consequences”. Such as? Dairies suffering because they can’t compete on price points, he says. Consumers moving to house brands or to cordials or powdered mixes, which could lead to an increase in sugar consumption. And those in the lower socio-economic brackets being worse affected.
Fitzgerald says Coca-Cola already has “very strict” policies around marketing to children, and these are ingrained in the company psyche.
If he made a decision to “overtly go after the children that we’re accused of going after”, that would be quickly rifled out by those higher up and “I would lose my job in a nanosecond”.
“We agree that there are issues in society and that there are lots of different causes for that, and as a leader in the food industry there are things that we need to do differently and do better. And we’ve stood up and we’ve taken a stance and we’re doing things differently.”
But Fitzgerald argues that coming down hard on SSBs is no silver bullet. The fermentable carbohydrates that cause the problems are in many foods, not just these drinks.
Focusing on the SSBs translates to the public, he says, as “if I want to get on top of my health concerns, I just have to stop consuming that single product or that single beverage. And it’s a much more complex issue than that.”
IT’S THE ENVIRONMENT
Considerable changes to our food supply and lifestyle in the past few decades have resulted in what researchers refer to as an obesogenic environment – that is, an environment that promotes unwanted weight gain and is not conducive to losing weight. “I don’t think there’s any serious people doing research in this area that don’t doubt that it’s the obesogenic environment, which has changed over the last 30 odd years, which has driven the obesity epidemic,” says Swinburn. “It’s the only way you can explain how obesity has taken off in all corners of the world all at the same time; that it’s related to major changes within the global food supply, the type of food, the amount of food and so on.”
Although genetic differences and, to a far lesser degree, factors such as nutrition knowledge may explain some of the differences between individuals in responding to this obesogenic environment, the fact remains that a growing proportion of the global population is struggling to maintain a healthy diet and body weight.
Industry and, to a degree, the Government hold to the view that the obesity epidemic and other health problems related to SSB intake are due to increasingly poor choices by individuals, says Swinburn.
The evidence suggests quite the opposite has happened, he maintains. “Personal responsibility has in general increased enormously around the world. People are far more careful than they ever were about safe sex, workplace health, household health, health in cars, smoking – almost every other area of health and safety, you can see that personal responsibility has increased.”
Yet copious pages of published clinical trials show time and again that humans eat more when portion sizes are bigger, and food is cheaper and more accessible. If we are surrounded by cheap high-energy food that is easily accessible 24 hours a day, we will eat it, despite our heightened sense of personal responsibility. It makes sense if we are trying to ensure our long-term survival and prevent starvation. But in our current obesogenic environment, that is not something we have to worry about.
“[Scientific] evidence should play a much larger role in policy making than it does,” says Swinburn. Indeed, a 2013 report by chief scientific adviser Sir Peter Gluckman noted that there was a high degree of variability across the New Zealand public service in respect to the understanding of “robust evidence for policy formation and the evaluation of policy implementation”.
Says Swinburn, “In general if commercial lobby groups are pitted against health lobby groups, I’m afraid recent evidence would suggest the health advocates or the health position loses out and the status quo is kept in place. And the status quo is clearly heavily pro-commercial interests, to the detriment of the health of the population, like obesity. It’s obviously not all of it, but there is a lot of inaction that is allowing the status quo to happen, which is continuing to drive up our obesity rates, particularly our childhood obesity rates.” Hence many industry and government-sponsored solutions continue to focus on educating people to make better food and lifestyle choices, rather than looking to change or influence the environment.
Some societal changes, Fitzgerald acknowledges, came about because of regulations. But others, such as the shift in our attitude to safe sex, happened “through education, and people were able to make a choice, there was no regulation [around] that”.
“Similarly, when you look at sun care and the Slip, Slop, Slap campaign … there’s no regulation in place there, that was done through public education and getting the message out.”
Which is exactly what his company is trying to do, he reiterates. “You need to make holistic changes to your life, not just look for the silver bullet, which these guys are.”
THE PRICE IS NOT RIGHT
Matthew Taylor is a prime example of a young man drinking significant quantities of high-sugar energy drinks and suffering with poor dental health as a result. So what would Taylor think if more information was provided to him about the sugar content of his energy drink? “Fourteen teaspoons of sugar [in a 500ml can] doesn’t really bother me. I know it’s a lot but I’d still drink the drink. After having so many fillings, that puts you off more.” Taylor reckons if cans had information about health harms he would be less likely to drink up to 1.5 litres in a day. Price too would affect his choice. Energy drinks are cheaper than bottled water at the moment, says Taylor, so he’s always going to pick the cheaper, less healthy option.
Indeed, cost was found to be the single most important factor in influencing food-purchasing decisions, according to a 2011 study led by Professor Cliona Ni Mhurchu’s University of Auckland research team. The food industry knows this, as they use pricing alterations very effectively as part of sales promotions. For example, “buy one, get one free” campaigns can increase sales by up to 3000%.
The good news for health campaigners is that soft-drink pricing is highly elastic. This means consumers are very sensitive to pricing. A 10% tax on soft drinks could lead to a 13% decrease in population purchases within New Zealand, according to a recent study. Hence, the 20% excise tax on SSBs, recommended by the NZBGP, could conceivably reduce New Zealanders’ soft drink intake by even more. It’s also estimated that a 20% tax on soft drinks would avert 67 deaths from cardiovascular disease, diabetes and diet-related cancers annually, according to a 2014 study in the New Zealand Medical Journal.
But, would the general public want an excise tax on soft drinks? Market research conducted in January 2014 found some 44% of people would welcome an excise tax on SSBs. “Those are very high levels of public support,” says Swinburn. “When we brought in taxation for tobacco, levels of support were only in the 30s or 40s. I think politicians need to be aware of that. Obviously there would be a lot of support for it if they’re brave enough to come out and take the flak that the industry would be firing at them.”
Meanwhile, professionals, such as dentist Rob Beaglehole, continue to deal with the reality of SSBs. The day we phoned him to arrange our interview, he’d just finished pulling several teeth out of a 19-year-old man who had arrived at the clinic with a 1.5-litre bottle of Coke. Apparently that was his normal daily intake.
Says Beaglehole, “I’m continually shocked when people turn up to the dental department with their sugary drinks in their hands. I guess what it highlights is that the right-wing bloggers, the National Government, they still think the best way is to try and educate the population about the dangers of drinking these drinks. But it’s very difficult to educate people in that sense when we live in an unhealthy environment and they’re not provided with enough information. That’s the ironic thing about it.” If the government wants to educate people, then they need to regulate and ensure the industry provides appropriate information on the packaging of products, says Beaglehole, who’d also like to see widespread public health campaigns to highlight the fact that a typical 600ml bottle of soft drink can contain 16 teaspoons of sugar.
“I think the hardest thing for policy makers to comprehend is that, generally speaking, we’re middle-class, we’ve got an income, but there’s a big proportion of the population out there that don’t have jobs, or have low-paying jobs, their education levels are not high and they just need healthier choices. And it’s very confusing when the All Blacks are associated with an unhealthy product.” Coca-Cola is one of the All Blacks’ sponsors.
PRACTICE AND PREACHING
Recently, after spending a morning pulling rotten teeth out of children’s mouths, Beaglehole was resting by the window at the Nelson Hospital when he noticed a truck with Coca-Cola advertising on its sides delivering drinks to the back of the hospital. “I was actually so shocked that it galvanised me into action. So I spoke to the chief executive [of the Nelson Marlborough District Health Board] and I said it was quite ironic that in the morning I’d been taking out teeth and here we are, we have an SSB company delivering their products to the hospital. I said I’d highly recommend we have a policy on SSBs.”
Chief executive Chris Fleming agreed, so Beaglehole wrote a policy recommending that all sugar-sweetened beverages, such as soft drinks, energy drinks, sports drinks and juices with added sugar, be removed from sale on board premises. Fleming championed the policy with the executive team and an overwhelming vote in favour of the policy led to its introduction on March 1; cafes and shops in board facilities have until March 31 to sell off old stock and comply with the new policy.
Nelson Marlborough is thought to be the first DHB in the country to have an SSB policy. Beaglehole hopes this standard will soon extend to the Nelson City Council. He’s paid them a visit with an empty bottle of Coke containing 40 teaspoons of sugar and a pile of rotten and decayed teeth, to demonstrate graphically the sugar content and harms of SSBs. While there was much debate within the council chamber, ultimately Beaglehole’s proposal to ban SSBs from council premises and events hit a stalemate, with the vote split 5-5. But Beaglehole hasn’t given up, he plans to keep lobbying for change in the hope that the Nelson City Council will become the first SSB-free council.
Something needs to change soon, because the clock is ticking. Says Swinburn, “The number of adults and children in New Zealand who are overweight or obese is increasing. In many countries the rates in children have been levelling off but not in New Zealand. We’re third in the OECD countries in terms of overweight and obesity, behind the US and Mexico. We’ve got the statistics to show that what we are currently doing is not working.”
But, Swinburn thinks there is hope. “I do think this current Government is starting to take it seriously. They have realised that the approach that they have been taking, which is a hands-off approach, and dismantling things that were there under Labour, has been detrimental to the health of children, because obesity rates are much higher than they are in Australia, for example. And they’re going up in New Zealand, whereas in many countries they’re flattening off. I think they have seen the statistics on childhood obesity and they’re not heading in the right direction.”
“New Zealand is a small, rich, smart country and should be doing way better on the obesity epidemic than it is. We should be world leaders, not laggards. The essential ingredient that is missing is political leadership, to lead the charge on community programmes and policies and to be a champion for the issue. If we can get that it will be amazing how many people will respond.”
Coca-Cola & Frucor: helping kids choose less sugar
• Eight years ago both companies signed voluntary agreements with the Government to stop selling full-sugar fizzy drinks or energy drinks to schools. Both have stuck to their promise, and Frucor estimates the move has cut 52.8kg of sugar from the diet of every child “who might otherwise have had one can of soft drink a day at school”.
• Frucor has rolled out 47 low- or zero-sugar drink options, while Coca-Cola now has more than 50. Coca-Cola says one in three of its soft drinks bought in New Zealand is sugar-free. The low- and zero-sugar options cost the same as the full-sugar versions.
• Coca-Cola has made more products available in smaller packages, with new 300ml pocket packs and 250ml mini cans now sold in more than 3500 New Zealand stores (about 35-40% of all its vendors).
• Frucor has replaced its original range of h2go flavoured waters with sugar-free variants, and estimates this move alone cut 55 tonnes of sugar from Kiwi diets.
• Both companies display at-a-glance nutritional information on panels on the front of packaging, as well as ingredient labels on the back.
• Frucor, which makes Just Juice, has developed juice dilution guidelines for children and displays these on packs.
• Coca-Cola has set an explicit goal to get 100,000 Kiwi teens exercising for 60 minutes a day by 2020. The company has partnered with Bike NZ and the Foundation for Youth Development to “form a community of young people that is built around cycling and movement and motivating teens to do more”.
• Frucor is a long-term partner of the Life Education Trust, which owns the giraffe vans that visit schools, teaching kids about their health and wellbeing.