key: cord-0064031-a07tjokv authors: Westgarth, David title: Are we finally winning the war on unhealthy foods? date: 2021-06-07 journal: BDJ In Pract DOI: 10.1038/s41404-021-0794-4 sha: 24a8f71cc65ac03969b3503f5e24ff356970335e doc_id: 64031 cord_uid: a07tjokv nan Growing up, my sister and I loved watching Gladiators. Ulrika Jonsson, John Fashanu (and his legendary Awooga catchphrase), Wolf and the suspiciously brutal Shadow were the highlight of our Saturday nights. As any child does, you obviously have to recreate some of the games in the home, much to our parent's dismay, including running a gauntlet through the house to the finish line outside. Halcyon days. The running of the gauntlet using sofa cushions and pillows may be a distant, amusing memory, but there's one arena in which it feels like it's replicated. In my mind, doing the weekly shopping in a supermarket and trying to get to the checkout avoiding the numerous 'special offers' feels like a gauntlet. Even online it's 'have you forgot this' or 'you may be interested in that' . In the main, these offers aren't for healthy, nutritious foods either. For families with small children, it must feel like an obstacle course to get to the checkout without having a small human tug on your coat and ask for the chocolate bar they've snaffled into the trolley. And yet so much progress has been made in the 'war' against sugar. Is it one of the bright spots in dentistry's fight to improve the oral health of the nation? In any war there are a series of battles. Some are more important to win than others, but the more wins you chalk up, the greater the chance of coming out on top. So it is worth assessing how many of these mini battles are being won. The traffic light system on food packaging. The government introduced a Soft Drinks Industry Levy (SDIL). Supermarkets in England are to be barred from displaying unhealthy food and drinks at checkouts or using them in buy one, get one free offers. Advertising of foods high in fat, sugar and salt (HFSS) is to be restricted from April 2022. Kelloggs dropped all of its advertising from Joe Wicks' Body Coach YouTube channel after a complaint to the Advertising Standards Authority. While these may sound small and somewhat insignificant, there are clear signs legislation rather than challenges and voluntary efforts work. In Public Health England's progress report on the sugar COVER FEATURE reduction programme between 2015 and 2018, 1 they stated sugar levels in drinks covered by the levy reduced ten times faster than in foods such as biscuits, cakes, sweets and puddings, a discrepancy they say is due to the 'voluntary challenge' made to companies to reduce levels of sugar, not through legislation. Voluntary measures secured reductions of just 3%, against a 20% target over five years, with only breakfast cereals and yoghurts on track. Soft drinks meanwhile saw a 29% fall in sugar content, as businesses attempted to reduce their exposure to the Sugar Levy. The report also highlighted the sugar content of yoghurt has fallen by 10.3%, in breakfast cereals by 8.5%, in cakes by 4.8% and in sweet spreads and sauces by 4.6%. In their more recent report of last October, these data show the food industry has cut barely 3% of sugar from products bought in shops and supermarkets over the last four years. Yoghurt and fromage saw a 12.9% decrease, breakfast cereals by 13.3% and sweet spread and sauces by 5.6%. 2 Specific to the SDIL, for retailers and manufacturer branded products, there was a 43.7% reduction in the total sugar content per 100ml between 2015 and 2019 for the drinks subject to the levy. Overall sales (in litres) of drinks subject to the levy have increased by 14.9%, but the total sugar sales from the soft drinks decreased by 35.4%. Critically, the report also stated: The percentage decreases from the SDIL are much greater than those seen for the food categories included in the voluntary sugar reduction programme. ' While the Levy was forecast -pre-COVID-19 -to raise £340 million in 2020-21, the British Dental Association expressed concerns. They said that the related Spending Round failed to make any commitment to ring-fence revenue for spending on preventive programmes in ' Supermarkets in England are to be barred from displaying unhealthy food and drinks at checkouts or using them in buy one, get one free offers. Advertising of foods high in fat, sugar and salt (HFSS) is to be restricted from April 2022.' children, their concern perhaps reflective of what happened in Northern Ireland, where at the time owing to a lack of functioning government, the £12.3 million raised from the SDIL disappeared into a black hole. In fact, The Northern Ireland Department of Finance has previously confirmed that the 2018-19 funding was 'not ring-fenced for any particular purpose' . They went on to express their support to expand the levy to include milkbased drinks and other products both to encourage reformulation, and encourage behaviour change among consumers. For some brands -IrnBru springs to mind -this involved reassuring customers it would not taste any different after completing their reformulation process. For brands like Coke Classic and Original Pepsi, they chose to either absorb the tax or pass it on to consumers. The tax puts a charge of 24p on drinks containing 8g of sugar per 100ml and 18p a litre on those with 5-8g of sugar per 100ml -so whichever way you cut it, the price went up. A more recent victory came in December 2020 when the government announced promotions on food and drinks high in fat, salt or sugar (HFSS) in retailers will be restricted in stores and online from April 2022. The new rules, designed to support the nation to make healthier choices, will prohibit retailers from offering multibuy promotions such as 'buy one get one free' or '3 for 2' offers on these products. Unhealthy promotions will also no longer be featured in key locations, such as at checkouts, store entrances, aisle ends and their online equivalents. Free refills of sugary soft drinks will also be prohibited in the eating-out sector. When announcing the measures, Public Health Minister Jo Churchill said: 'We know families want to be presented with healthier choices. This is why we are restricting promotions and introducing a range of measures to make sure the healthy choice is the easy choice. ' It is when you dig a little under the surface of such comments when you realise there is significant work left to do. 'Choice' is just that; behaviour change is a huge and complex issue, and while a choice is available, unhealthy choices will still be made. It was also fascinating to see the reactionagain -of the advertising industry, who have expressed their 'dismay' at the UK government's announcement. Ad industry chiefs expressed disappointment because they had raised questions during the consultation about the evidence to show that advertising restrictions, particularly if they were imposed in isolation without other measures, would reduce childhood obesity. Phil Smith, director-general of ISBA, representing UK brand advertisers, said: ' As their own evidence demonstrated, a blanket ban does next-to-nothing to tackle obesity whilst damaging business, risking jobs and restricting adult freedom of choice. 'If, after months of engagement, government has chosen to ignore more sophisticated, better targeted, cheaper and more proportionate ways to protect children online, then business will be forgiven for thinking that this government cares less for serious policy than it does cheap headlines. ' Advertising Association chief executive Stephen Woodford said: 'We are dismayed at the government's decision that it is going to press ahead with a 9pm watershed and total online ban on HFSS advertising. 'The government's own evidence shows that such measures will be ineffective in tackling obesity. The country needs balanced, consistent and well-evidenced policy interventions that will make a positive difference. The 9pm watershed and online ban will not reduce obesity levels, but will damage business and innovation and put jobs at risk. ' Jon Mew, chief executive at IAB UK, said: 'We strongly disagree with the ban and the government's rationale for it. We recognise that childhood obesity is a significant challenge that must be addressed, and our view remains that an online ad ban is not the solution for this complex problem. ' In other news, after the untimely demise of several theme park guests, T-Rex blames customers for buying tickets to dinosaur park in first place and absolves itself of any wrongdoing. ' A more recent victory came in December 2020 when the government announced promotions on food and drinks high in fat, salt or sugar (HFSS) in retailers will be restricted in stores and online from April 2022.' Back in the real world, commenting on the announcement, British Society of Paediatric Dentistry spokesperson Claire Stevens said: 'I am delighted that the Government has listened to all the organisations that have been campaigning for advertising of junk food and drink to be restricted. April 2022 cannot arrive soon enough. 'Frequent snacking of foods which are high in sugar leads to children and young people being at high risk of dental decay. Currently there are too many products which are marketed at children claiming to be good for growing children because they have 'no added sugar' but are laden with hidden sugars as well as salt and fat. 'Our advice to parents and carers is to seek out products which contribute to a balanced diet and combine with plenty of fresh fruit and vegetables, while keeping any sugarcontaining food and drink to mealtimes. 'We would like a general reformulation of products to make the foods on shop shelves healthier as well as a complete overhaul of food labelling, so that it's easier for parents to assess which food products are the most nutritious. ' Along with Jamie Oliver, Public Health England, Sustain and a plethora of other organisations wanting to reduce obesity and dental decay in children, we have been at war on sugar for years. The sugar levy has had a positive impact, but more steps are needed. We would like to see greater incentivisation of healthy food and drink choices to protect our children's oral health. ' This dynamic of consumer vs manufacturer, regulation vs freedom of choice, upstream and downstream is perhaps a leading reason why the war rages on. While there is no general consensus on which of these singleentity approaches is the most appealing, there is little doubt in which is the most effective. You only need to look at the data to see giving the consumer freedom to make their own choices over regulation does not work. The SDIL and 'voluntary challenge' for foods is a relatively open and closed case. Intervene upstream, and the downstream salmon will reap the benefits. But is it as simple as that? I have previously written at length about necessary regulation vs nanny state interventions. 3 There is a fictitious line that cannot be crossed, where consumers will say enough is enough, we want our freedoms back. Where it lies is anyone's guess, but it exists and there will be a time when it is crossed. Will anything containing sugar be behind the counter, a-la cigarettes? What about naturallyoccurring sugars? How far up the ladder is oral health when making these decisions? Take the Prime Minister, for example. It is on record that he is not a fan of 'sin taxes' , but rather the freedom of choice. How can that be squared with every facet of the Department of Health and Social Care providing evidence to the contrary? The BDA has previously suggested some reports on the effectiveness of sin taxes have been delayed because they had irrefutable evidence to show how well they worked. So, who has the biggest slice of the pie when it comes to bringing about change: the consumer, the manufacturer or government regulation? If we think that is the consumer's role, chances are we're going to be waiting for a considerable time. It is well-documented that bringing about behaviour change is difficult. It is perhaps the most difficult thing one can do, yet it has the fewest barriers, as there is only one thing realistically in the way of changing behaviour; the individual. Yet you can only begin to change behaviour once the individual is ready to change. If you tell them to change, that is completely different than discussing why change is needed, how you can go about doing it. For some people being told what to do prompts rebellion -my because-I've-been-told-not-to-press-the-redbutton-I-really-want-to-press-the-red-button theory. Human nature says you want to know why you can't press the red button because you've been told not to, so you do it anyway to find out. Besides human nature, there is also a more fundamental reason the consumer should not take the majority of the burden, and that is knowledge. How much do they know? Do they want to know? If so, how good are their sources? If they know, do they do it anyway? Words like indulgent and treat are thrown into the mix to justify behaviour at odds with health and science, and it isn't going to go away any time soon. That's where manufacturers have a greater role to play. Not just with the product itself, but the marketing of it. I know this because I'm a marketer's dream. Show me an Instagram advert for a cat t-shirt and I'm all over it. I'm not alone in falling into this category either, which is why I believe the advertising sector was so dismayed. They know marketing junk food to children works. Stick a juicy Big Mac advert on during Britain's Got Talent, for example, and that will sit with you until it's time to have a takeaway, and guess what? That's what you'll order. While it is clear to see that a number of manufacturers have committed to reducing sugar levels in their soft drinks, the PHE data show the same cannot be said of foods. In 2020 an editorial in the BMJ made it clear that the authors believe the food industry shares the blame not only for the obesity pandemic, but also for the severity of COVID-19 disease and the devastating consequences of the outbreak. 4 The authors went on to call for governments to force the food industry to take out the huge and unnecessary amount of sugar, saturated fat, and salt they add to our food and drinks and only promote healthy foods, thus improving the diet of the entire population and bringing even greater benefits for those more socially deprived. In specifically digging out the food industry on this while simultaneously calling for the government -not the industry -to do something about it, speaks volumes as to how academics see the chances of them implementing change of their own volition. Rather like the advertising bodies, they also point to sugar reduction alone not being enough to curb obesity rates. Which it is why government regulation and intervention upstream is the only real way to bring about tangible change. Leaving people to make their own decisions hasn't worked out, and leaving it in the hands of the manufacturers to do the right thing is unlikely, so the bulk of the burden lies here. And it is why there is so much frustration that the challenge to reduce sugar by 20% by 2020 in the categories of food that contribute most to the sugar intakes of children aged up to 18 years is voluntary. Setting meaningful regulation works. Reacting to the sugar reduction report in October, BDA Chair ' You only need to look at the data to see giving the consumer freedom to make their own choices over regulation does not work. 'Voluntary action from industry on reformulation is making next to no headway. We need a real sense of urgency, wedded to mandatory targets. COVID-19 needs to focus minds on the need for sustained action on preventable diseases like tooth decay and obesity. Hard-won gains will only slip into reverse as lockdown diets take their toll.' A lyric from a famous song aside, you have to wonder what the profession makes of the war on sugar. The most recent data from PHE revealed around one in four (23%) 5-yearolds in 2019 had dental decay. 5 These findings are identical to the results of the previous survey in 2017 which suggests that no progress has been made towards tackling an unacceptable level of childhood tooth decay in England. Tooth decay remains the number one reason for hospital admissions among young children costing the NHS millions. Oral health inequalities are expected to widen further, driven by unprecedented access problems, the suspension of public health programmes, and sugar-laden lockdown diets. During the first lockdown, research by the Oral Health Foundation highlighted staying at home led to more than one in three (38%) British adults increasing the amount of times they snacked throughout the day. Nearly two in three (61%) under 35s admitted they were eating more often in between meals, but of more concern was snacking has also risen amongst families with younger children. Seven in 10 families (70%) with children under five reported more snacking in the household, more than double compared with those who are not living with children. 6 Dentistry is based on prevention, and to make that a reality, it involves patient education. I have long held the belief that patient education has failed too many people who need it the most. How many dental professionals have told a patient that an electronic toothbrush, floss or interdental brushes and regular visits to the hygienist and dentist are essential to their oral health maintenance when cost prohibits almost one in four from even seeing the dentist in the first place? Imagine wasting a minimum of a quarter of your day on oral hygiene advice. Targeted interventions in Scotland and Wales reduce the need for education and choice, but pose a wider question: is there a strategic plan to promote oral hygiene improvement in communities where cost is a major determinant of their decision-making process? Would it be an intervention model, like Childsmile and Designed to Smile, or would it be an education model, putting the onus on the individual to make the right choices? The difficulty comes when you go back to the supermarket and consider the gauntlet. On 27 May, I visited Tesco Groceries online and Sainsbury's store in my home-town to see how easy it is to make unhealthy choices driven by financial factors. Online I was greeted with a selection of 'promoted offers' . These included an eight pack of cakes at a (Clubcard) price of £1.15, four ice creams at £2, a 1.75l bottle of 'double concentrate' juice at £2 and cereal at £2, a grand total of £7.15. Compare that to a 500g bag of spinach (with a two-day fridge life) at £.199, two salmon fillets at £3.25, and asparagus bundles at £2, and you've spent more money on a meal for two that won't leave you feeling full. Even the £5 meal deal is 66% of the cost of the highlighted promoted offers, and it's only for one meal. It was a similar story in Sainsbury's. Packs of six cakes, each priced at £1, the same cost as a 100g bag of spinach. How can any individual or family concerned about cost justify buying the healthy version of these shopping lists? The pandemic has pushed more and more families closer to and below the breadline. Foodbanks across the country cannot keep up with the demand, and here are two examples of unhealthy foods being subsidised ahead of healthy foods, even when the government knows obesity is a huge issue, never mind a risk factor for COVID-19. A report published last year found that too many people faced 'significant barriers to eating healthy diets' , amidst the government's reluctance to subsidise healthy foods. The report estimated that, before lockdown, 20 million people could not afford healthy food, 19 million people struggled to find healthy food in stores near their homes and subsidises for healthy foods could help to tackle obesity levels. 7 All of these issues -let alone the oftdiscussed backlog to dental care caused by the pandemic -are nothing short of a nightmare for the profession. While battles are being won on the sugar front, battles on patient education and voluntary regulation are being lost elsewhere. It creates this perpetual cycle of appearing to be making progress on improving children's oral health, when the reality is very different. While supermarket shoppers may be getting past my sister with mum's sofa cushions, for dentistry it is a long way to the finish line in the garden, and the harsh reality is the profession will be stuck running this gauntlet until meaningful change occurs with no end in sight. ◆ ' Dentistry is based on prevention, and to make that a reality, it involves patient education. I have long held the belief that patient education has failed too many people who need it the most.' https://doi.org/10.1038/s41404-021-0794-4 Sugar reduction: Report on progress between Sugar reduction: Report on progress between Necessary or nanny? Obesity and covid-19: the role of the food industry Available onlin eat: www.gov.uk/government/statistics/oral-healthsurvey-of-5-year-old-children-2019 National Smile Month 2020 Survey' United Kingdom Making healthy choices easier for consumers