Background and evidence base for Position Statement on Free Sugars Intake July 2017 Poor oral health is a major concern for Māori, ranging from tamariki to older Māori.1 Across all age groups, Māori are consistently and significantly more likely to have had greater lifetime experience of dental caries that non-Māori, and are significantly less likely to be caries free and to have teeth removed as a result of dental caries.2–4 Of greatest concern is the large proportion of tamariki Māori, especially those under 5y, requiring dental treatment (including often multiple extractions) under general anaesthetic; they are two and a half times as likely as non-Māori children to be admitted to hospital for dental care.5 In 2015/16, approximately 11,000 tamariki Māori (aged 1-14y) reported having a tooth removed due to decay in the previous 12 months, almost as twice as likely as non-Māori (RR, 1.7).4 Further, a greater proportion of older Māori are retaining their natural teeth, and expected to do in the future.2 The annual incidence of dental caries among older Māori, is likely similar to that of adolescents.6 Poor oral health and oral health inequalities substantially impact Māori health and well-being, and is associated with substantial personal, social and economic costs.2,3,7 Preventing dental caries, improving oral health, and reducing inequalities are key priorities for Māori.1 Evidence demonstrates an association between dental caries and both the amount and frequency of consumption of free sugars,1–5 that is all added sugars (added to foods by the manufacturer, cook or consumer) plus the sugars that are naturally present in honey, syrups, fruit juices and fruit juice concentrates. It does not include sugar naturally present in milk or whole fruit and vegetables.5 Free sugars are a risk factor for all dentate Māori regardless of age, but particularly tamariki and older Māori, and the most vulnerable. Consumption of free sugars is higher among Māori and the most vulnerable than other population groups.2,6 Many of the foods and beverages with added sugars are cheaper, more accessible, widely available and ubiquitously promoted, than healthy foods and beverages.7–9 Free sugars consumption is also associated with obesity, type 2 diabetes mellitus, cardiovascular disease and some cancers. Māori are also disproportionately burdened by such conditions.10,11 Sweet drinks Te Rōpu Niho Ora is particularly concerned about the consumption of sweet drinks. Sugar-sweetened beverages (SSBs) substantially contribute to free sugars consumption and are a key risk factor for dental caries.1–4 They also displace the consumption of healthy drinks, substantially contribute to energy intake with little or no nutrient benefit, and are particularly associated with obesity and type 2 diabetes mellitus.12,13 Children and young people are the greatest consumers of SSBs.2,6 Both SSBs and artificially-sweetened beverages (ASBs) are highly acidic and have the potential to erode tooth enamel, making teeth more vulnerable to dental caries, its consequences and other dental issues.14 Emerging evidence also suggests that ASBs stimulate sweet taste receptors and contribute to glucose intolerance, and therefore, should not be promoted as healthy alternatives to SSBs.15,16 The international evidence showing the health and fiscal benefits of taxes on sweetened sugary beverages (SSBs) is now overwhelming.1-3 At least 54 countries have introduced a tax on SSBs. Data indicates that these taxes successfully reduce sugar consumption from SSBs, and led to reformulation of SSB products, reducing the amount of sugar in these beverages without loss of revenue to the industry.2 Low-income consumers and young people get the greatest health benefits from taxes. While countries as a whole can make savings on healthcare, and revenues raised from taxes can be used to promote the health of the population1 (including funding expanded oral health services in Aotearoa). The World Health Organization guidelines on free sugars for children and adults (and quality of evidence) are:5 •Reduce the intake of free sugars throughout the life course (strong evidence); •Reduce the intake of free sugars to less than 10% of total energy intake (strong evidence); •For further health benefits, to reduce the intake of free sugars further to below 5% of total energy intake (conditional evidence). This recommendation is made based on the positive dose-response relationship between free sugars intake below 5% of energy intake and dental caries. Strategies to reduce the consumption of free sugars that would benefit all Māori of all ages, from tamariki Māori to older Māori, include:7 •Providing, and ensuring the accessibility of, nutrition information and guidelines; •Introducing fiscal measures (including a tax) that increases the retail price of SSBs by at least 20%;17 •Implementing the Set of Recommendations on the Marketing of Foods and Non-alcoholic Beverages to Children18 to reduce the exposure of tamariki Māori to, and the power of, the marketing of foods and beverages with free sugars; in particular, implementing regulations to restrict unhealthy food and beverage marketing; •Implementing interpretive front-of-pack labeling, particularly on SSBs, and appropriate educational support; •Requiring the creation of healthy food environments in the various settings in which Māori live, work and play, by establishing food and beverage policies in (but not only) early childhood education centres, schools and tertiary education institutions; Kura Kaupapa Māori; marae; hospitals and other health care locations; workplaces; sport and community events; and public amenities and facilities; and instituting mandatory standards for the provision of food and beverages in public-sector settings. •Implementing kura/school-based programmes that encourage healthy eating; •Measures that provide equitable access to the social determinants of health. Te Rōpu Niho Ora supports the following: •The National DHB Food and Drink Environments Network National 2016 Healthy Food and Drink Policy; •Ministry of Health 2015 Eating and Activity Guidelines for New Zealand Adults; •Ministry of Health 2015 Childhood Obesity Plan; •WHO Commission on Ending Childhood Obesity Report7 recommendations; •WHO Set of Recommendations on the Marketing of Foods and Non-alcoholic Beverages to Children.18 Reducing the consumption of free sugars is only one strategy in a range of strategies to reduce the risk of dental caries. While exposure to fluoride (through community water fluoridation or direct application through varnishes, toothpastes and mouth rinses) protects the teeth and reduces the risk of dental caries, it does not prevent it absolutely; people exposed to fluoride are still at risk of developing dental caries.5 Other key preventive measures include good oral health practices in the home. References 1.Ministry of Health. NZ Food NZ Children: Key results of the 2002 National Children’s Nutrition Survey. (Ministry of Health, 2003). 2.Ministry of Health. A Focus on Nutrition: Key findings from the 2008/09 NZ Adult Nutrition Survey. (Ministry of Health, 2011). 3.Vartanian, L. R., Schwartz, M. B. & Brownell, K. D. Effects of Soft Drink Consumption on Nutrition and Health: A Systematic Review and Meta-Analysis. Am. J. Public Health 97, 667–675 (2007). 4.Tahmassebi, J. F., Duggal, M. S., Malik-Kotru, G. & Curzon, M. E. J. Soft drinks and dental health: A review of the current literature. J. Dent. 34, 2–11 (2006). 5.World Health Organization. Guideline: Sugars intake for adults and children. (WHO, 2015). 6.Ministry of Health. NZ food NZ children: Key results of the 2002 national children’s nutrition survey. (Ministry of Health, 2003). 7.WHO. Report of the Commission on Ending Childhood Obesity. (World Health Organization, 2016). 8.Institute of Medicine of the National Academies, Committee on Food Marketing and the Diets of Children and Youth. Food Marketing to Children and Youth: Threat or Opportunity? (Institute of Medicine of the National Academies, 2006). 9.Cairns, G., Angus, K., Hastings, G. & Caraher, M. Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite 62, 209–215 (2013). 10.Ministry of Health. Health Loss in New Zealand 1990–2013 A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study. (Ministry of Health, 2016). 11.Ministry of Health. Annual Update of Key Results 2015/16: New Zealand Health Survey. (Ministry of Health, 2016). 12.Malik, V. S., Schulze, M. B. & Hu, F. B. Intake of Sugar-Sweetened Beverages and Weight Gain: A Systematic Review. Am. J. Clin. Nutr. 84, 274–288 (2006). 13.Malik, V. S., Popkin, B. M., Bray, G. A., Després, J.-P. & Hu, F. B. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation 121, 1356–1364 (2010). 14.Jaeggi, T. & Lussi, A. in Dental Erosion 20, 9–16 (Karger, 2006). 15.Borges, M. C. et al. Artificially Sweetened Beverages and the Response to the Global Obesity Crisis. PLoS Med. San Franc. 14, (2017). 16.Fowler, S. P. et al. Fueling the Obesity Epidemic? Artificially Sweetened Beverage Use and Long-term Weight Gain. Obesity 16, 1894–1900 (2008). 17.WHO. Fiscal policies for diet and prevention of noncommunicable diseases: technical meeting report, 5-6 May 2015, Geneva, Switzerland. (World Health Organization, 2016). 18.World Health Organization. Set of recommendations on the marketing of foods and non-alcoholic beverages to children. (World Health Organization, 2010). 1.World Health Organisation. Taxes on sugary drinks: Why do it?, 2017. 2.Obesity Evidence Hub. Countries that have taxes on sugar-sweetened beverages (SSBs), 2022. 3.JS W, S B, S K, KA M, SB V-B, D S. Evaluation of the sugar-sweetened beverage tax in Oakland, United States, 2015–2019: A quasi-experimental and cost-effectiveness study. . PLoS Med 2023; 20 (4): e1004212.