PHLR Annual Meeting: Legal Interventions to Reduce “Mountain Dew Mouth”
Citric acid-based drinks have been linked to devastating tooth erosion, especially in Central Appalachia where the drinks are widely consumed by people of all ages. The issue was selected for a five-minute “Critical Opportunities” presentation that garnered more votes than any other issue in the session at the most recent Public Health Law Conference. This year, the issue has moved to a general session on the main day of the Public Health Law Research (PHLR) Annual Meeting, as an emerging issue in public health law. Priscilla Harris, JD, an associate professor with the Appalachian School of Law in Grundy, Va., will present “Finding Legal Interventions to Impact Purchase and Consumption of Sugar-Sweetened Beverages and Citric Acid Drinks: Trying to undo the damage of the Dew.”
According to the American Dental Association, 65 percent of West Virginia's children ages three through seven suffer from tooth decay—and near-constant sipping of Mountain Dew and other citric acid-based drinks plays a role. Harris, together with Dana Singer, JD, a program developer and researcher at the Mid-Ohio Valley Health Department and Mary Beth Shea, a dental hygienist with the health department, spoke at an information session to the Mid-Ohio Valley Board of Health a few weeks ago to present the research they have worked on to show the damaging health effects of the beverages for the people of the region. NewPublicHealth spoke with the three public health professionals just before the PHLR annual meeting began.
NewPublicHealth: What research are you working on to look at the impact of citric acid on tooth health?
Priscilla Norwood Harris: We conducted surveys to determine purchase and consumption patterns for sugar-sweetened beverages and citric acid drinks. We also interviewed and sent surveys to dentists in Central Appalachia about their perceptions of oral health problems in the region. We also went to five clinics that offer medical, dental and vision care to low-income people, and asked patients about these drinks. In addition, have almost 2,000 surveys of students in grades K through 12. We have also reviewed journal articles, many from Europe, that examine the issue of dental erosion. While it’s under the radar here in America, the studies we’ve reviewed are making the connection between dental erosion and the citric acid in drinks.
A lot of the attention in the U.S. has been focused on the sugar in these drinks and their contribution to obesity as well as the sugar with regard to oral health and cavities. Unfortunately, the acids in these drinks and the connection to dental erosion have been almost ignored. “Mountain Dew Mouth,” a term used in Central Appalachia for severely damaged teeth, involves the acids in these drinks, which can take away the tooth’s enamel.
Mary Beth Shea: From a dental health professionals’ perspective, we see a high number of adults who have said they didn’t have a clue that the beverages they’re consuming are causing the damage in their mouth and they haven’t had money for dental care.
In the U.S. today, we have fluoride in our water, fluoride in our toothpaste, we know about prevention, but the citric acid beverages are working against us because they are marketed like they are going to make you happy and healthy and the population does not realize that the way they are consuming them—often sipping them all day—is causing serious damage to the health of their mouths.
NPH: Can you tell us a little bit more about sipping citric acid beverages all day? What is the typical behavior pattern that leads to this problem?
Mary Beth Shea: Citric acid is in a lot of lemon- or lime-flavored beverages, and all carbonated beverages have phosphoric acid. Acids are what erode the teeth, and there are some people who drink these beverages all day long. We know that from consumer surveys. Dental professionals know that if you consume something with a meal or right after and then you clean your teeth, that’s less harmful than if you keep introducing that harmful beverage all day long.
In addition, we’re seeing that there’s the combined problem of not having money for dental care coupled with a habit that’s hard to break. Mountain Dew has the highest caffeine content of all soft drink beverages, and so it has an addictive quality. It’s very destructive.
Dana Singer: The other problem is that SNAP [the supplemental nutrition assistance program, formerly known as Food Stamps, which is a program of the U.S. Department of Agriculture] dollars can be used to buy soft drinks and we’re seeing younger and younger people drinking them. In a recent study of soft drinks purchased only at grocery stores with SNAP dollars, over $2 billion was spent on sugar-sweetened beverages, so we know the real expenditure on soft drinks using SNAP dollars is really much higher when you add convenience and big chain stores. Young moms are putting Mountain Dew in the sippy cups for their infants, and don’t realize they’re causing harm. So, by the time those first baby teeth come in, their mouths are already regularly bathed in Mountain Dew. The use of federal money meant to supplement nutrition to purchase these beverages that are empty calories, have no nutrition, and cause oral health and other health problems and then expect Medicaid to treat the health issues that need to be addressed – this cycle does not make sense from a nutritional, health or economic perspective.
NPH: What are the specific health consequences of that?
Dana Singer: There’s a huge economic impact. You see 20-year-olds with their front teeth rotted out. What kind of job can they get? Even getting into college can be a problem. If you have an admissions interview and all of your teeth are rotted out, that takes a toll. The situation also impacts a worker’s productivity. If they’re in pain, if they can’t brush their teeth, the agony of dental pain is so distracting that workers would have to be absent and take breaks and lose their concentration or ability to work if their mouth is not healthy. And now we also know that heart disease is linked to poor oral health.
Mary Beth Shea: Also, if a woman has poor oral health and is pregnant, that can result in low birth weight and premature delivery. And decay-causing bacteria can be transferred. Fixing a mouthful of decay in a preschooler can cost thousands of dollars and requires hospitalization. So that’s also a huge economic toll on the system.
Priscilla Norwood Harris: Here in Central Appalachia I think it’s even more of a problem because the Medicaid programs do not cover dentures. So people lose their teeth and they just have no teeth because they can’t afford dentures. And we also have problems with drinkable water. There are some areas that are very remote and they don’t have access to public water and so people end up buying bottled water and may instead buy the citric acid drinks. And when we asked high school kids why they drink the citric acid beverages, they themselves were calling it a habit. And many were also drinking sports drinks such Gatorade and PowerAde, assuming them to be healthy, but they have both sugar and citric acid.
A lot of people in the region just think bad teeth run in their family. They don’t associate the drinks with the oral health problem they are seeing.
Dana Singer: There is very much a fatalistic approach to health in Appalachia. There are a lot of people who are convinced that their health problems are inevitable and that they’re genetic, and that their personal behaviors do not impact their health.
NPH: What are some of the solutions you’d propose?
Dana Singer: We really need to focus a lot more on education. I can’t imagine that a young mother, once she’s told of the consequences, is going to keep putting it in the sippy cup. One of the things that we are advocating for is requiring retailers to put up signs at the point of sale on the dangers these drinks can pose, and to have the health department enforce the signage. This is not to totally prevent people from consuming them but to do it in a responsible manner.
We’d also like to ban the drinks on school grounds. We have schools in West Virginia that don’t have good water so students are encouraged to bring in their own beverages, and the beverages are also sold on some school grounds.
Priscilla Norwood Harris: We’ve come up with quite a lengthy list of possible legal interventions:
- Implementing an excise tax on soda. West Virginia already has that but it’s not very high. The only state that really has the excise tax that makes money is Arkansas. Arkansas has an excise tax that brings over $40 million a year and that goes to their Medicaid program.
- Limiting purchase of the drinks with SNAP dollars.
- Educating new and young mothers about dental health and best practices.
- Making dental care a part of the well-baby visit since many children in Appalachia may not see a dentist until they are five years old.
NPH: Why do you think Appalachia has been hit so hard by this issue?
Mary Beth Shea: These drinks are cheaper than buying milk.
It’s also very important to point out the cultural aspect. People think it’s inevitable that they will lose their teeth. The health department is really trying to do one on one education and treat the individual, so we can share the information that individuals can make a difference in their own health.
Priscilla Norwood Harris: And the drinks don’t go bad. That’s important in a region such as Central Appalachia where many people have limited transportation and can only get to the grocery store every so often.
Dana Singer: I think a lot of it relates to disparities. The drinks are a short term, feel-good antidote, really. There are not a lot of jobs, there’s not a lot of hope for the future here, and sometimes a small thing can become a habit. You open a drink and you get that caffeine kick and you get that sugar kick. There are a lot of rural places where you just don’t drink the water. But you can buy something that tastes better and makes you feel good.
NPH: And how does marketing the beverages impact its appeal?
Dana Singer: People in Appalachia are inundated with all the advertising from the beverage companies that show, for example, that you look cool if you’re drinking Mountain Dew. It’s a status thing. They have this huge push in advertising that’s getting aimed at younger and younger kids. There’s even a new video game out that’s literally sponsored by Mountain Dew.
NPH: What are your next steps?
Dana Singer: We’re in the process of forming a multi-state Appalachian oral health coalition. We’re looking for some potential funding sources in order to fund a full time champion of this endeavor. West Virginia has a pretty strong oral health coalition, so we’re hoping to build on that. The three of us also spoke before the Mid-Ohio Valley Board of Health meeting as an informational session. The Board and staff were very interested in the information. They will be discussing future steps that can be taken by the health department directly to address the problem.
Some other potential actions we’re exploring include legal action that may be taken to restrict advertising and placement of this product in school and petitioning the USDA to prohibit these citric-based sugar drinks from being purchased with SNAP benefits.