Faculty of Dental Surgery at the Royal College of Surgeons – Written evidence (FPO0010)

About the Faculty

The Faculty of Dental Surgery at the Royal College of Surgeons is the professional body which supports hospital-based and specialist dentists, who deal with the consequences of poor oral health on a daily basis. We represent around 5,000 members, many of whom work in NHS primary, secondary and community care and public health settings.

The Faculty also campaigns on a number of public policy issues relevant to dentistry, including children’s oral health. We recently published a new position statement on this issue which highlighted that since 2015 there have been over 100,000 hospital admissions for children under the age of 10 as a result of preventable tooth decay.[1] Diet is a major factor in this problem, as excessive sugar consumption is the main cause of tooth decay. In this submission we set out the measures we believe are necessary to address this issue, and have focused our evidence on questions 2, 7, 12 and 15 of the Committee’s call for evidence.

Summary

Child tooth decay is a significant public health issue affecting nearly a quarter of children, and is also a major source of health inequality. Diet is a crucial determinant of children’s oral health, as excessive sugar consumption is the main cause of tooth decay. Reducing children’s sugar intake is therefore key to improving their oral health, as well as addressing other challenges such as childhood obesity.

The Faculty welcomed the introduction of the soft drinks industry levy in April 2018, and evaluations indicate this has been effective in reducing sugar consumption. We believe it is vital that the new administration maintains the levy, and would like to see it extended to cover sugary dairy drinks. We also believe there is a case for using some of the revenue to fund oral health improvement programmes.

The Government has also been working with the food and drinks industry on a voluntary sugar reformulation programme, although evaluations suggest that progress has been more limited than hoped. Further action may be necessary if the aim of achieving a 20% reduction in sugar content is to be achieved.

The previous administration also made a number of other commitments around reducing sugar consumption, including introducing new restrictions on advertising and promotions for high sugar products (which are underpinned by a strong evidence base), updating the School Food Standards and reducing the content of commercial baby food. Taken together these represent an ambitious package of measures for reducing sugar consumption and we believe it is essential the new administration takes them forward, otherwise an enormous opportunity to deliver significant improvements in child health will be lost.

The Faculty also views improving education and information around healthy eating as an essential part of improving children’s oral health, and that the new administration should seek to build on successful public health campaigns such as Change 4 Life and Sugar Smart. In addition, we believe that all schools should be encouraged to become sugar free, and as part of this would support the introduction of nutritional guidelines for packed lunches.

Question 2: What are some of the key ways in which diet (including food insecurity) impacts on public health? Has sufficient progress been made on tackling childhood obesity and, if not, why not?

Diet is a crucial determinant of children’s oral health, as excessive sugar consumption is the main cause of tooth decay. This represents a major public health issue. Nearly a quarter (23.3%) of five year olds in England have tooth decay,[2] and it is also the leading cause of hospital admissions for five to nine year olds by some distance (there were 26,111 such admissions in 2017-18).[3] This is despite the fact that tooth decay is nearly entirely preventable.

Research also indicates that poor oral health is a major source of health inequality. Analysis by Public Health England has shown that 33.7% of five year olds in the most deprived parts of England have tooth decay, compared to just 13.6% of five year olds in the least deprived areas.[4]

From a clinical perspective, sugar facilitates acid formation by oral bacteria within dental plaque, which can demineralise and create cavities in tooth enamel leading to rapid decay. Some estimates suggest that the average five year old consumes their own body weight in sugar each year, posing a significant risk to oral health.

Given the central role that sugar consumption plays in causing both tooth decay and child obesity, the two issues can be tackled together. The Faculty believes that some important steps have been taken in our efforts to address these problems in recent years, but it is important that the new administration maintains a focus on this and looks to build on what has been achieved so far.

The Faculty welcomed the introduction of the soft drinks industry levy in April 2018, which has proven to be an effective intervention. An evaluation of the policy published by Public Health England last year found that there has been a reduction in the sugar content of products covered by the levy as manufacturers have reformulated. The levy was also found to have helped drive a shift in sales towards products with a lower sugar content.[5]

We are aware that there is currently some doubt over the future of the levy. In July the Secretary of State for Health and Social Care suggested in oral evidence to the Commons Health and Social Care Committee that the policy would be subject to a review by the Chief Medical Officer, as part of work she is undertaking to examine how the Government can meet its target of halving child obesity by 2030.[6]

The Faculty is clear in its view that the soft drinks levy has been effective and should be maintained. We also support the extension of the levy to sugar sweetened dairy drinks, something proposed in Chapter 3 of the Child Obesity Plan which was included in the Prevention Green Paper.[7] Furthermore, given the significant role that sugar plays in causing tooth decay we believe there is a case for using some of the revenue raised to fund oral health improvement programmes, particularly in deprived areas.

In addition to the soft drinks industry levy, the Government is also working with food and drink manufacturers on a wider sugar reformulation programme. This aims to achieve a 20% reduction in the sugar content of products which are most commonly consumed by children by 2020. However, these targets are voluntary and there have been concerns that they may not be met.

Initial assessments of the programme suggest that progress has been limited. The target for the first year of the programme was to achieve a 5% reduction in sugar content, but Public Health England’s evaluation indicated that across 8 of the 10 food categories in the scope of the programme retailers and manufacturers only achieved a 2% reduction.[8]

The Faculty is fully supportive of the aims of the reformulation programme, but recognises that further action may be necessary in order to achieve them. One approach could be to extend the soft drinks industry levy to other products which do not achieve the reformulation targets.

As well as policies that have already been introduced to reduce children’s sugar consumption, the previous administration also made a number of further commitments which have yet to be implemented. These included pledges in Chapter 2 of the Child Obesity Plan to tighten restrictions around promotions and advertising for high sugar products (these measures were the subject of public consultations earlier this year and we say more about them in our response to Question 7), and update the School Food Standards in order to reduce sugar consumption (we will comment further on this in our response to Question 15). Chapter 3 of the Child Obesity Plan also included proposals to work with the commercial baby food industry to reduce the sugar content of their products.

Taken together these commitments represent an ambitious package of measures for reducing sugar consumption and addressing associated problems such as child tooth decay and obesity. However, with a new administration having taken office there is now inevitable uncertainty about whether these will ultimately be introduced. We believe that it is essential that the new administration follows through on its predecessors’ commitments, otherwise an enormous opportunity to deliver significant improvements in child health will be lost.

Question 7: What impact do food outlets (including supermarkets, delivery services, or fast food outlets) have on the average UK diet? How important are factors such as advertising, packaging, or product placement in influencing consumer choice, particularly for those in lower income groups?

Evidence indicates that advertising and price and location promotions do have an impact on consumer behaviour and can drive increased consumption of high sugar products.

In terms of advertising, systematic research published in the American Journal of Clinical Nutrition in 2016 found that, in children, exposure to food advertising led to statistically significant increases in food intake. The researchers concluded their findings “provide evidence that acute exposure to unhealthy food advertisements increases food intake in children” and argued that “recommendations for enacting environmental strategies and policy options to reduce children’s exposure to food advertising are evidence based and warranted”.[9]

Furthermore, a 2017 report by the Obesity Health Alliance (of which the Faculty is a member) highlighted that 59% of food and drink advertisements shown during family TV programmes such as “The Voice” were for products high in salt, sugar and fat. Due to loopholes in existing regulations, these programmes are not subject to the same level of advertising restrictions as those explicitly aimed at children.[10] Separate research by the Obesity Health Alliance has found that 72% of people support the introduction of a 9pm watershed on junk food adverts during popular family TV shows, and 70% support a similar watershed on online advertisements.[11]

With respect to promotions, Public Health England has examined the impact of price promotions on consumer behaviour and found that they can increase purchasing of high sugar products. Analysis undertaken in 2015 showed that around one fifth (22%) of food and drink volumes brought on promotion could be considered incremental to expected levels of purchasing, and that high sugar products were both more likely to be promoted and more deeply promoted. Ultimately Public Health England concluded that eliminating price promotions on high sugar products altogether would lead to a 6.1% reduction in sugar volumes purchased by consumers, equating to around 7.4 grams of sugar per individual per day.[12]

There is also evidence to suggest that product placement and location promotions can make consumption of unhealthy products more likely. A local study conducted in Sheffield in 2014, which researchers believed was possibly the first to analyse the display of unhealthy foodstuffs to children in the checkout area, found that “on average 89.5% of food products on display to children in convenience supermarkets were unhealthy, and that in most cases foodstuffs on display were at the upper end of the spectrum of unhealthy foodstuffs”.[13]

As set out in our response to Question 2, measures to tighten restrictions around advertising and promotions for high sugar products were proposed in Chapter 2 of the Child Obesity Plan and were subject to public consultation earlier this year. We believe it is vital that the new administration now takes these forward.

Question 12: A Public Health England report has concluded that “considerable and largely unprecedented” dietary shifts are required to meet Government guidance on healthy diets. What policy approaches (for example, fiscal or regulatory measures, voluntary guidelines, or attempts to change individual or population behaviour through information and education) would most effectively enable this? What role could public procurement play in improving dietary behaviours?

From the perspective of driving a reduction in sugar consumption, we believe that the Government’s sugar reformulation programme is a key component of driving a shift towards healthier diets.

As set out in our response to Question 2, there have been concerns over whether the voluntary nature of the programme will deliver the 20% reduction in sugar content initially promised. Further action may therefore be necessary to achieve this, potentially including fiscal and regulatory measures.

The Faculty also believes that improving public information and education around healthy eating will be crucial. Existing public health campaigns such as Change 4 Life and Sugar Smart are successful examples of these sorts of initiatives, and the new administration should seek to build on them moving forward.

Question 15: Are there any additional changes at a national policy level that would help to ensure efforts to improve food insecurity and poor diet, and its impact on public health and the environment, are effectively coordinated, implemented and monitored?

One further policy measure that the Faculty believes could make an important impact to reducing sugar consumption for all schools to become “sugar free”.

The original Child Obesity Plan contained a number of proposals aimed at reducing the availability of sugary food and drinks in schools. These included updating the School Food Standards (which still allow desserts, cakes and biscuits to be served at school lunchtimes) to reduce sugar consumption, and requiring all free schools and academies (some of which are exempt from the Standards) to sign up to them.[14] As we understand it these commitments have not yet been fully implemented despite having been made three years ago, and the Faculty believes they should therefore be completed as a matter of urgency.

However, we would also like to see the Government go further and encourage all schools to become completely sugar free. A recent report by the London Assembly Health Committee highlighted that this approach has been implemented successfully in some London schools, and the Faculty believes it should be adopted nationwide.[15] As part of this we would support the publication of nutritional guidelines for packed lunches, something which has previously been advocated by the House of Commons Health Committee and the APPG on School Food.[16] Furthermore, the Faculty notes that London’s Child Obesity Taskforce has recently recommended increasing the number of “water only” schools, in which only water and plain reduced fat milk are served, and would be supportive of introducing this more widely.[17]

9 September 2019

[3] Figures taken from NHS Digital Hospital Admitted Patient Care Activity Diagnosis dataset for 2017-18. Acute tonsillitis caused the second most hospital admissions for five to nine year olds in 2017-18 – 12,143 – but this was less than half the number caused by tooth decay during the period.