Position Statement Reducing the impact of sugar-added drinks and food Endorsed May 2023 Page 1 of 8 PURPOSE This document summarises the Australian Dental Association Queensland Branch’s (ADAQ) views on public health actions that should be taken in Queensland and Australia, to reduce harmful sugar intake levels in the general population. EXECUTIVE SUMMARY • Regular consumption of added sugars has a direct link to caries (tooth decay) and other non-communicable diseases such as diabetes, and obesity. Per-capita sugar consumption in Australia remains higher than WHO recommendations (12.5%). Indigenous communities, especially young people in remote areas, consume far more sugary drinks and foods than non-Indigenous counterparts, perpetuating the post-colonial health gap. • Evidence suggests Australians are ready to support meaningful government action on this issue, including a ‘sugar tax’ and clearer labelling. Urgent public policy measures should be taken now to restrict sugar in products such as sugar-sweetened drinks (SSB) and foods with high free sugar content and low or no nutritional value, and to regulate their access. • ADAQ will support a sugar tax and/or the implementation of other evidence-based solutions to reduce the impact of sugary drinks and food with no nutritional value, including mandatory front-of-package labelling and point-of-sale signage. International experiences exemplify success of similar levies and campaigns. • ADAQ supports the Australian Medical Association’s (AMA) modelling of a 20% rise in the customer price of the average sugary drink sold in Australia. Money raised through such levies could fund effective dietary health campaigns, and go towards free oral care. • ADAQ calls on the Queensland Government to regulate the sale and advertising of sugary drinks and foods in public settings, including schools canteens and sports facilities, as well as social media promotions. Product labelling should also be reviewed, to avoid high health star ratings on high sugar foods, and provide clear, legible sugar content information to consumers. • ADAQ is open to collaborate with the Queensland Government and other stakeholders on educational campaigns and work on solutions for expanding access to much needed dental care and oral health education for disadvantaged cohorts. Position Statement Reducing the impact of sugar-added drinks and food Endorsed May 2023 Page 2 of 8 STRATEGIC ALIGNMENT ADAQ’s strategic vision: All Queenslanders deserve excellent oral health and access to ethical and effective dental care, driven by clinical excellence. See also: ADA Inc., Policy Statement 2.2.2- Community Oral Health Promotion: Diet & Nutrition (2020) CONTEXT • Sugar is naturally present in many unrefined and intact foods and drinks, such as unflavoured milk. ‘Free sugars’ are sugars extrinsic to foods in their intact state, and include honey and syrups, as well as fruit juices. ‘Added sugars’ are free sugars in the form of refined sugar products, included in foods and drinks during processing or preparation. Added sugars are present in their most harmful form in sugar-sweetened beverages (SSBs). These include soft drinks, energy drinks, cordials, vitamin waters and sports drinks. • According to the World Health Organisation (WHO), dental caries (tooth decay) is the most common preventable non-communicable disease worldwide, with multi-factorial, cumulative, and diet-related characteristics. The most important dietary factor in the development and worsening of caries, is frequent and/or high consumption of free sugars. SSBs remain a primary source of free sugar intake in Australia, especially for children and young adults. For further information on WHO’s position: Sugars and dental caries Key Facts. • WHO recommends that, for both children and adults, free sugars should make up less than 10% of an individual's dietary energy, and that a further reduction to less than 5% of dietary energy would provide better health benefits. In 2020-21, per capita apparent consumption of free sugars in Australia was 68.8 grams per day , equivalent to 12.4% of all dietary energy available from sales of food and non-alcoholic beverages (ABS, 2021). • Indigenous communities in Australia, especially young people in remote areas, consume far more SSBs than non-Indigenous counterparts. This is an international trend that interests other Indigenous populations in post-colonial countries, and which contributes directly to perpetuating the health gap (Wright et al . 2019; Cartwright et al . 2023). • In 2022, the European Food Safety Authority (EFSA) Panel on Nutrition, upon request by the European Commission, issued a scientific opinion to establish a tolerable upper intake level (UL) for dietary sugars. EFSA found that: A level of sugars intake at which the risk of dental caries/chronic metabolic diseases is not increased could not be identified over the range of observed intakes, and thus, a UL or a safe level of intake could not be set . Based on available data and related Position Statement Reducing the impact of sugar-added drinks and food Endorsed May 2023 Page 3 of 8 uncertainties, the intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet (EFSA, 2022. Emphasis is ours). A Plain Language Summary of the advice is available here. • The negative role of excess dietary salt and saturated fat is widely accepted worldwide, including by industry stakeholders, with successful reduction or reformulation activities already making their mark in countries were public measures have already been implemented (Pell et al., 2021). However, the negative role of excess sugar has not been as readily addressed by public policy actions in most countries. • The cariogenic role of sugar in particular continues to be contested, as opposed to its role in cardiovascular issues or obesity, for example. This may be in part due to the persisting perception that tooth decay is a problem which: a) can be simply contained by fluoride and good hygiene habits, and/or b) does not impact on general health and quality of life as much as, for example, diabetes or being obese. Regarding point a), research has shown that sugar consumption rates correlate to caries rates, irrespective of oral hygiene practices or levels of access to basic dental services ( for example, Skafida & Chambers, 2018). As for point b), this perception shows how, despite remaining the “most prevalent of all health conditions” (WHO), the impact of dental caries on burden of disease and quality of life has been often underestimated. However, many studies confirmed the negative impacts of tooth decay and poor oral health on quality of life measures across population groups , and especially for children. • In its detailed report, A tax on sugar-sweetened beverages: Modelled impacts on sugar consumption and government revenue , the Australian Medical Association (AMA) proposes a 20% rise in the customer price of the average sugary drink sold in Australia (AMA 2021). This proposal mirrors those explored or implemented by policy makers in other countries, including South Africa (Murukutla, 2020) and the United Kingdom. As of 2021, 54 countries have introduced some form of taxation on SSBs, with many reporting positive results for public health within a few years of implementation For example, Public Health England’s (PHE) report Sugar reduction: report on progress between 2015 and 2019 estimated a 43.7% reduction in the total sugar content of branded drink products subject to levy and an overall reduction in sugary drink purchases in all socio-economic groups, of around 30% (PHE 2021). Interestingly, positive outcomes for public health did not seem to translate into reduced industry profits (see for example, Pell et al ., 2021). Position Statement Reducing the impact of sugar-added drinks and food Endorsed May 2023 Page 4 of 8 • The Australian Bureau of Statistics (ABS) reported that, between 2019 and 2021, there was a notable increase in apparent consumption of soft drinks , up 6.6. grams to 178 grams per day (3.9%). The increase was larger for energy drinks, raising over 20%. (ABS 2020-21). • In 2018, Research Australia’s Opinion Poll questioned Australians on whether they would: Support a tax on soft drinks, sport and energy drinks with high levels of sugar if the revenues raised were used to fund programs to reduce the damaging health effects associated with consuming high levels of sugar? The results showed 45% would definitely support, and 27% would probably do so (Research Australia, 2018). Other studies, such as Miller et al . (2019) and AnR Liu et al . (2021) have since confirmed that, in Australia, consumer support for regulatory action on sugar-sweetened beverages (SSB) has grown significantly since 2014 . Policy initiatives such as taxation, warning labels and targeted education are strongly favoured by the majority of Australians (66 to 88%. Miller et al . 2019). • Today’s ‘sugary environment’ contributes to, and overlaps with, the ‘obesogenic environment’ in Western societies. The term refers to undercurrent influences from physical, economic and social conditions or factors that promote obesity (Hobbs & Radley, 2020, citing Swinburn et al. , 1999). • The Obesity Collective (Obesity Australia) recently summarised the arguments against a SSB Tax in Australia. These arguments are relevant to dental caries as well: for example, the individual responsibility of one’s own dental hygiene habits has often been brought up by opponents, as well as an overall decrease in sugar consumption and dental problems. The summary is available on the Obesity Evidence Hub website here. • Australia is the world’s fourth largest exporter of sugar. 95% of Australian sugar is grown in Queensland, with 85% of raw material for export . Research is identifying viable alternative uses of sugarcane, with demand for sugar-derived biofuels growing worldwide, as potential environmentally friendly substitutes for coal. These alternative avenues for profit should allay Queensland sugar industry’s anxieties about reduced demand for human consumption. POSITION • ADAQ strongly believes that the incidence of caries due to added sugar consumption, in particular in children and young adults, must be considered, and addressed, through a socio-economic lens as well as a health burden. Public policy actions are only effective if they deal with both these dimensions concurrently. • ADAQ supports the introduction of a levy on sugary drinks and foods with no nutritional value, to help reduce consumption and improve health outcomes for Queenslanders, Position Statement Reducing the impact of sugar-added drinks and food Endorsed May 2023 Page 5 of 8 especially around caries, obesity and diabetes. A sugar tax is not to be seen as the only, or best, solution to the complex problem of excessive sugar intake, however it is a good place to start. • ADAQ supports the Australian Medical Association’s (AMA) modelling of a 20% rise in the customer price of the average sugary drink sold in Australia. Money raised through such levies will help fund effective dietary health campaigns, and free oral care. • ADAQ calls on the Queensland Government to regulate the sale and advertising of sugary drinks and foods in public settings, including schools canteens and sports facilities, as well as social media promotions. Product labelling should also be reviewed, to avoid high health star ratings on high sugar foods, and provide clear, legible sugar content information to consumers. • ADAQ is open to collaborate with stakeholders to explore solutions for expanding access to dental care and oral health education for disadvantaged cohorts. • ADAQ acknowledges the significant role a strong sugar farming industry plays for regional communities and the wider Queensland economy. ADAQ further acknowledges the recent efforts made by this industry to actively participate in delivering healthy eating messages to consumers, including calling a ‘Health Forum’ in 2020, and the resulting Australian Sugar Milling Council & Cane Growers’ public information website: sugar.org.au. However, ADAQ is concerned that the underlying message in these public resources remains that sugar has been unfairly ‘singled-out. The evidence that sugar restriction measures are likely to result in long-term benefits to many consumer cohorts, with attached health care cost savings, is undeniable. Therefore, ADAQ invites sugar industry stakeholders to acknowledge the role unregulated corporate activities can play in the issue more openly, and to reframe their view towards a communal goal of correction of product use/misuse, rather than cancelling products and industry. A focus on correction will avoid the perception that dietary sugar-reducing policies will ‘kill’ the sugar farming industry. • While the multi-factorial nature of caries cannot be disputed, ADAQ does not agree this multi-factoriality constitutes automatic proof that ‘sugar intake is not the problem’, as international sugar industry interests have attempted to do in the past (see for example, Kearns & Watt. 2019). • In the past, strong economic interests may have stood in the way of public health policies involving sugar and based on sound evidence. This should no longer be the case with viable alternative uses for sugarcane (e.g., biofuels). Effective solutions need to be proposed, that would improve or save lives that have been impacted by sugary products, and prevent future health care burden. ADAQ invites all sugar and food & beverage Position Statement Reducing the impact of sugar-added drinks and food Endorsed May 2023 Page 6 of 8 industries stakeholders to use their combined research capability and influence in a genuine fashion, to help reverse the ill effects and health burdens of sugar in our society. • ADAQ is open for genuine collaboration with the state government and the sugar industry on researching alternatives. These alternatives should be proved, at a minimum, to match the objectively positive results already obtained in other countries with a simple levy, or provide related program funding equivalent in value to funds that would be raised through a levy. CONTACTS If you have any queries relating to this Position Statement, please contact us: adaq@adaq.com.au or 07 3252 9866. ADAQ acknowledges the Traditional Owners across Australia and their continuing connection to land, sea and community. We pay respect to First Nations Peoples and their Elders, past, present and emerging. Position Statement Reducing the impact of sugar-added drinks and food Endorsed May 2023 Page 7 of 8 REFERENCES & BIBLIOGRAPHY An R, Liu J, Liu R, Barker AR, Figueroa RB, McBride TD. (2021). Impact of Sugar-Sweetened Beverage Warning Labels on Consumer Behaviours: A Systematic Review and Meta-Analysis. Am J Prev Med . 2021 Jan;60(1):115-126. doi: 10.1016/j.amepre.2020.07.003. Epub 2020 Oct 12. PMID: 33059917. Australian Bureau of Statistics. (2020-21). Apparent Consumption of Selected Foodstuffs, Australia . ABS. https://www.abs.gov.au/statistics/health/health-conditions-and-risks/apparent-consumption-selected-foodstuffs- australia/2020-21. [Note: Apparent consumption refers to sales data, and does not account for food and beverages purchased but not consumed]. Australian Medical Association (2021). A Tax on sugar-sweetened beverages: modelled impacts on sugar consumption and government revenue. Brisbane: Australian Medical Association. [Link to pdf report available at: A tax on sugar-sweetened beverages: What the modelling shows | Australian Medical Association ] Australian Medical Association (2021). Sugar tax will cut disease and save lives. Webpage published 9 June 2021. https://www.ama.com.au/media/sugar-tax-will-cut-disease-and-save-lives. Accessed February 2023. Australian Sugar Milling Council & Canegrowers Australia. Is sugar? ... www.sugar.org.au Website. Accessed February 2023. Pages accessed: What is the sugar industry doing? ; Sugar Policy; Is sugar rotting my teeth? Cartwright J, Netzel ME, Sultanbawa Y, Wright ORL. Seeking Sweetness: A Systematic Scoping Review of Factors Influencing Sugar-Sweetened Beverage Consumption in Remote Indigenous Communities Worldwide. Beverages . 2023; 9(1):11. https://doi.org/10.3390/beverages901001 1 EFSA NDA Panel (EFSA Panel on Nutrition, Novel Foods and Food Allergens), Turck, D, Bohn, T, Castenmiller, J, de Henauw, S, Hirsch-Ernst, KI, Knutsen, HK, Maciuk, A, Mangelsdorf, I, McArdle, HJ, Naska, A, Peláez, C, Pentieva, K, Siani, A, Thies, F, Tsabouri, S, Adan, R, Emmett, P, Galli, C, Kersting, M, Moynihan, P, Tappy, L, Ciccolallo, L, de Sesmaisons-Lecarré, A, Fabiani, L, Horvath, Z, Martino, L, Muñoz Guajardo, I, Valtueña Martínez, S and Vinceti, M, 2022. Scientific Opinion on the Tolerable upper intake level for dietary sugars. EFSA Journal 2022; 20(2):7074, 337 pp. https://doi.org/10.2903/j.efsa.2021.7074 Hobbs, M., Radley, D. (2020). Obesogenic environments and obesity: a comment on ‘Are environmental area characteristics at birth associated with overweight and obesity in school-aged children? Findings from the SLOPE (Studying Lifecourse Obesity PrEdictors) population-based cohort in the south of England’. BMC Med 18, 59. https://doi.org/10.1186/s12916-020-01538-5 Kearns CE, Watt RG. (2019). Transnational corporations and oral health: examples from the sugar industry. Community Dent Health . 2019 May 30;36(2):157-162. doi: 10.1922/CDH_SpecialIssueKearns06. PMID: 31046204. Kearns, CE, Bero LA. (2019). Conflicts of interest between the sugary food and beverage industry and dental research organisations: time for reform. The Lancet , Volume 394, Issue 10194, 194 - 196 National Health and Medical Research Council (2013). Australian dietary guidelines . Canberra: National Health and Medical Research Council. Miller CL, Dono J, Wakefield MA, et al (2019). Are Australians ready for warning labels, marketing bans and sugary drink taxes? Two cross-sectional surveys measuring support for policy responses to sugar-sweetened beverages. BMJ Open. 2019;9:e027962. doi: 10.1136/bmjopen-2018-027962 Miller C, Dono J, Wright K, Pettigrew S, Wakefield M, Coveney J, Wittert G, Roder D, Durkin S, Martin J, Ettridge K. (2022). "No Child or Adult Would Ever Probably Choose to Have 16 Teaspoons of Sugar": A Preliminary Study of parents' Responses to Sugary Drink Warning Label Options. Nutrients. 2022 Oct 7;14(19):4173. doi: 10.3390/nu14194173. PMID: 36235825; PMCID: PMC9571345. Murukutla N, Cotter T, Wang S, Cullinan K, Gaston F, Kotov A, Maharjan M, Mullin S. (2020). Results of a Mass Media Campaign in South Africa to Promote a Sugary Drinks Tax. Nutrients . 2020; 12(6):1878. https://doi.org/10.3390/nu12061878 Obesity Evidence Hub. (2020) Cancer Council Victoria, Melbourne. Available from: www.obesityevidencehub.org.au. Accessed February 2023. Pell D, Mytton O, Penney TL, Briggs A, Cummins S, Penn-Jones C, Rayner M, Rutter H, Scarborough P, Sharp SJ, Smith RD, White M, Adams J. (2021). Changes in soft drinks purchased by British households associated with the UK soft drinks industry levy: controlled interrupted time series analysis. BMJ . 2021 Mar 10;372:n254. doi: 10.1136/bmj.n254. PMID: 33692200; PMCID: PMC7944367. Position Statement Reducing the impact of sugar-added drinks and food Endorsed May 2023 Page 8 of 8 Public Health England (2021). Sugar Reduction. Report on progress between 2015 and 2019. October 2020. London: PHE. Available from: https://www.gov.uk/government/publications/sugar-reduction-report-on-progress-between-2015-and-2019 Research Australia (2018). Health and Medical Research Public Opinion Poll. Available from: Public Opinion Polling - RESEARCH AUSTRALIA Skafida V, Chambers S. Positive association between sugar consumption and dental decay prevalence independent of oral hygiene in pre-school children: a longitudinal prospective study. J Public Health (Oxf) . 2018 Sep 1;40(3):e275-e283. doi: 10.1093/pubmed/fdx184. PMID: 29301042; PMCID: PMC6166585. Sugar Nutrition Resource Centre. Sin Taxes, the arguments for and against . 2023. Webpage. www.sugarnutritionresource.org. Accessed February 2023. Sugar Nutrition Resource Centre. NZ Ministry of Education consultation on regulation of sugar sweetened beverages in school. 25 July 2022 . Webpage. www.sugarnutritionresource.org. Accessed February 2023. Swinburn B , Egger G, Raza F. (1999) Dissecting Obesogenic Environments: The Development and Application of a Framework for Identifying and Prioritizing Environmental Interventions for Obesity, Preventive Medicine, Volume 29, Issue 6, 1999, Pages 563-570, ISSN 0091-7435, ttps://doi.org/10.1006/pmed.1999.0585. Vandevijvere, S, Barquera, S, Caceres, G, et al. (2019). An 11-country study to benchmark the implementation of recommended nutrition policies by national governments using the Healthy Food Environment Policy Index, 2015- 2018. Obesity Reviews . 2019; 20( S2): 57– 66. https://doi.org/10.1111/obr.12819 World Health Organization. (2015). Guideline: Sugars Intake for Adult and Children WHO: Geneva, Switzerland. https://www.who.int/publications/i/item/9789241549028. Accessed February 2023. World Health Organization. (2023) Sugars and Dental Caries Key Facts ; WHO: Geneva, Switzerland. Webpage. https://www.who.int/news-room/fact-sheets/detail/sugars-and-dental-caries. Accessed February 2023. Wright, K.M.; Dono, J.; Brownbill, A.L.; Pearson, O.; Bowden, J.; Wycherley, T.P.; Keech, W.; O’Dea, K.; Roder, D.; Avery, J.C.; et al. Sugar-sweetened beverage (SSB) consumption, correlates and interventions among Australian Aboriginal and Torres Strait Islander communities: A scoping review. BMJ Open 2019, 9, e023630