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TOWARDS BETTER ORAL HEALTH IN CHILDREN: ANALYSIS OF CONSULTATION RESPONSES

CHAPTER 4: CHILDREN'S DIET

The consultation stated:

Dental disease in childhood may be broadly attributed to a high sugar diet - especially sweets and confectionery, fizzy drinks and sugar-sweetened foods."

Healthy eating will result in healthy mouths. Diet is therefore especially crucial from the earliest age.

Diet in Scotland is…a significant factor in the poor status of our oral health.

Diet is a crucial factor in oral health as recognised in the appointment of the Scottish Food and Health co-ordinator. A broad spectrum of activity is being carried out, within the framework of the Scottish Diet Action Plan, to bring about improvements in the Scottish diet, with a particular focus on children.

Consultees views were:

In Detail:

GENERAL

General comments regarding the role of diet in affecting children's oral health were submitted by 194 (16%) respondents, 149 of these (77%) coming from individuals.

The overwhelming message was one of support for the strategy of tackling diet as a means to improving oral health. People acknowledged the relatively high levels of sugar consumption amongst children and expressed this plainly, e.g. " the real cause of the problem is too many sweets and sugary drinks" (indiv 59); " sugar is the main cause of the tooth decay problem" (indiv 45).

The link between a sugary diet and tooth decay was not questioned with one clear solution summed up as, " simply eat and drink sensibly……it's not rocket science!" (indiv 497). Particular contemporary problems were viewed as the increased tendency to "graze" on food snacks and sweets (indiv 141) and the modern culture of consumption of fizzy drinks and junk food especially amongst children and young people. Scottish culture and stereotypes were seen as exacerbating the problem, one respondent remarking, " as a nation of toothless Irn Bru drinkers, I feel we need to fundamentally change our soft drinking habits" (indiv 1388).

People tended to see the problem of poor diet as increasing. Some referred back to their earlier days when rationing and the limited availability of sugary foods had a positive impact on their oral health, " I still have my own teeth owing to not too much confectionery" (indiv 508), " I have good teeth because I was brought up during the war when no sweets were available" (indiv 595), " …brought up during rationing…we drank water if we were thirsty" (indiv 1188).

Organisations and professionals also viewed the link between oral health and diet as very strong. Representative comments included, " diet should be seen as a central feature of oral health and hygiene" (Argyll and Bute Council), and " the major problem causing caries is sugar in the diet" (Community Dental Service Lerwick). Various organisations confirmed the public view that, " there is no magic formula for looking after children's teeth except good diet and good oral hygiene" (N.W. Council against Fluoridation) with others identifying the support of "programmes to address the poor Scottish diet" as a priority (Scottish Consumer Council).

Interestingly, various bodies identified the role of self-help and responsibility as central to addressing the problem of poor diet (e.g. Forth Valley Local Health Council; Erskine Elderly Forum). However, this was viewed against the background of, " heavily promoted foods and drinks loaded with sugar" (GP 143), with easy availability, and posing a constant temptation for young people and children. Schools were viewed as key culprits in facilitating the access to sugary food and drink (e.g. indiv 828), (but also had the potential to deliver effective diet programmes targetted directly at children and young people (e.g. indiv 893)). Many individuals used emotive terms to describe the pressure they felt children were under to partake of sugary foodstuffs, - " it is obvious that tooth decay is linked to the deplorable diet, pushed on children by manufacturers of soft drinks, sweets, etc." (indiv 888). Some emphasised the link between poor diet and contemporary lifestyle (e.g. indivs 799, 1105), which made the establishment and sustainability of healthy eating habits a challenge.

A recurring theme was the foundation of good eating practice at an early age. Breastfeeding was seen as providing an excellent start (indiv 346), with " adequate nutrition antenatally and in the early years…essential for the foundations of good teeth" (NCH Action for Children in Scotland). A high sugar diet may be established in infancy and constituted, " the underlying cause of dental disease" (Royal College of Physicians of Edinburgh).

Some respondents recommended viewing and tackling children's diet issues at a holistic family level (South Ayrshire Council) with the importance of a healthly diet, "at home" emphasised (indiv 1374, indiv 215, Directorate of Public Health Tayside) and parents providing a good example and making health foods accessible (indiv 215, indiv 627). The Association of International Cancer Research saw a role for the Scottish Parliament in helping parents to give their children better diets and discouraging the consumption of fizzy drink and other sugary products.

People were in favour of tackling poor diet not just for the positive impact on oral health, but because they foresaw much wider health benefits, e.g. " healthy eating is the answer for all sorts of health problems" (indiv 19); " any positive changes to our poor dietary habits will have an enormous affect on our general health" (Springburn Health Centre Respondent 6). Potential improvements suggested related to reductions in obesity, diabetes, cancer, strokes and heart disease.

Some respondents defined what they saw as healthy food and drink. Amongst those products receiving most comments were water (e.g. indivs 729, 817, 825 - " water should be more widely available…and all should be encouraged to drink water"); milk (indivs 62, 241); " real food" such as porridge (indiv 657) and fruit (indivs 540, 1108, 1389).

The frequency of consumption of carbohydrates as opposed to overall levels was raised as an issue by the Scottish Food and Drink Federation and the Biscuit, Cake, Chocolate and Confections Alliance.

People who were against adding fluoride to water were amongst those most strongly supporting the focus on diet in tackling oral health. Their argument could be summed up as, " all the fluoride in the world will not stop children eating sweets or drinking sweetened drinks" (indiv 529). Many others adhered to the view that if, " dental disease is caused by high sugar consumption…then…address the diet issue. Don't use this as an argument for water fluoridation" (indiv 7).

DIET WITHIN THE SCHOOL CONTEXT

The Problem

A key theme to emerge was concern that the school environment and context perpetuated poor dietary habits. The main bugbears were unhealthy food sold in school tuck shops or from vending machines and unhealthy school meals. A representative selection of viewpoints is presented below:

A further concern was what was seen by some as school incentive schemes whereby good work/behavior is rewarded by " sweets as prizes, rewards" (e.g. indiv 196). Such responses gave children mixed messages on healthy eating, suggesting " that the school approves of sweets" (MSP 200) which undermined parents efforts to encourage good oral health in their children (Voluntary Health Scotland).

Solutions

Respondents proposed many ideas for solutions to tackle the school diet problem. These included:

Some respondents acknowledged the increased resources required to introduce such initiatives (e.g. Inverclyde Councils Education and S.W. Department) and considered the possibility of financial incentives to schools to attract them to develop particular schemes (Angus Council). Prioritisation of available resources was suggested (Tayside NHS) with the emphasis placed on fresh fruit for nurseries, P1 and P2 in the Social Inclusion Partnership areas at least.

School Meals

School meals came in for criticism from some (Ellon Health Centre, Govan Health Centre, Scottish Green Party, Scottish Consumer Council).

There was a call for higher standards for school meals (Royal College of Physicians in Edinburgh, Highland NHS Board) and meals to be made more appealing (Borders Local Health Council, Scottish Civic Forum) with healthier choices (Springburn Health Centre Respondent 4, Unison). Many individuals commented on the poor standard of current school meals, some suggesting that schools should offer healthy packed lunches as an alternative, perhaps with a collectable item as at McDonalds (indiv 145) or make school lunches more " substantial" (indiv 165).

Diet in Other Public Places

The focus of responses relating to environment outwith schools was, in the main, on sports and leisure centres. Many respondents considered it to be appropriate for such locations to make drinking water freely available via water coolers, fountains and other such water dispensers (indivs 32, 470, 550, 850, 1107, British Society for Paediatric Dentistry, Scottish Green Party, Community Dental Department, Western Isles, NHS Shetland, Paediatrics, Stirling Royal Infirmary, Dental School, University of Glasgow, Angus Council Education Department, Department for Dental Health Promotion and Epidemiology, Ayr Hospital).

A further recurring theme was the focusing of initiatives and their prioritisation within areas of deprivation. Also advocated were community diet projects and initiatives (Scottish Green Party, Falkirk Council, Greater Glasgow PCT), local food co-operatives (LHCC Hamilton, Blantyre and Larkhall, Falkirk Council, indiv 805, Unison) and " easy access to fresh fruit and vegetables by those living in socio-economically disadvantaged areas" (Royal Society of Edinburgh, Dental School University of Glasgow).

Finally, continued support and expansion of breakfast clubs was mooted by many (South Lanarkshire Council, Royal College of Physicians Edinburgh, Dental Surgeon 1276, NHS Lanarkshire).

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