Diet is the sum of food consumed by a person and a balanced diet is the one which provides all the nutrients in required amounts and proportions.[1] Dietary habits and selections play an important role in human health. Eating nutrient-dense foods and balancing energy maintains the health essential at all stages of life. Unbalanced consumption of food high in energy and low in essential nutrients contributes to chronic diseases including dental caries. [2]
Dental caries is a major global public health concern in the present day [3, 4] and it is prososed that the consumption of harmful fermentable carbohydrates is recognized to be an essential etiological cause particularly among children from the lowest socio-economic groups. [5-8]
India has a remarkable conglomeration of populations in terms of social, economic and cultural conditions. Food is an imperative part of Indian culture and plays a significant role in daily life. The diverse regions of the country have different dietary patterns. Indian cuisine varies from region to region, reflecting the ethnically diverse subcontinent. Rise in per capita income in India along with the growing mass media has impacted on the fast changing lifestyles, including dietary pattern. In the present day, snacking in between meals primarily containing unhealthy junk food with high carbohydrate content the caries experience in India was reported high in all the age groups and the percentage of individuals with caries experience increased as age advanced. The treatment needs of Indian children were also significantly high. So, tailored pragmatic diet modification aiming at reducing fermentable carbohydrate and improving healthfulness of diet forms a key in prevention of dental caries. [8, 9]
Analysis of diet for its cariogenicity is a complex process because fermentable sugars are often consumed in combinations. Also the properties of food like retention time, frequency, nutrient composition, and potentiality to stimulate saliva makes it further difficult to recognize its cariogenic potential. [9-11]However, currently few tools are available to assess children’s diet related to caries risk and demonstrate how it can be successfully modified to reduce caries risk.
In 2002 American Academy of Pediatric Dentistry (AAPD) developed and advocated Caries risk assessment tool (CAT), which counts the frequency of in-between-meal sugar attacks and bedtime exposure from bottles. [12] In 2004 dental health diet score [13] was discussed that gave points earned as a result of an adequate intake of food from each of the food groups essential for achieving and maintaining dental health. However this index does account for physical properties of food, also does not explain the guidelines for dietary modification. In 2009 University of Iowa, The United States of America designed ‘The Diet Assessment of Caries Risk tool’ to help dental practitioners to identify dietary factors contributing to caries risk. [14] This collects information on frequency, amount, timing and manners of intake and supplemented with specific responses represented as low, moderate or high caries risk. However, it is subjective in nature. Further in 2013 cariogenicity index explained and concluded that because of the multifactorial nature of caries only liquid cariogenicity index has considerable potential in clinical settings. [15] In 2016 Moynihan P in contradiction to World Health Organization (WHO) issued guidelines (free sugars ≤10% ) recommended intake of ≤5% free sugars to protect dental health throughout life. [16]
So to the best of our knowledge an index that helps a clinician to reduce composite diet diary information to a simple quantifiable interpretation is lacking in literature. The aim of the present scientific paper was to explain the developed of a novel index for the assessment of the cariogenicity and healthfulness of child’s diet objectively and guide the professional to achieve pragmatic diet modification and to deliver realistic advice for effective prevention of dental caries in children.
The Diet’s Cariogenicity and Healthfulness Index
A team comprised of specialist from division of Pediatric dentistry, Community medicine and Diet and Nutrition were involved in development of DCHI.
DCHI index consist of 3 phases
Phase 1: Collection of Diet diary template
The child and parent duo were provided with a diet diary template (Figure 1) with verbal and written instructions to help them complete the diary along with examples of completed diaries. They were instructed to maintain a real-time record of what they drank and ate for 4 consecutive days including one weekend in the template provided to them. The diet diary template has a provision to record the time of consumption, alongside to describe the item consumed in detail (especially for the platter of multiple types), the amount in a household measuring systems and post-diet oral-cavity cleansing (rinsing).They were advised to provide details of each dietary intake such as the name of the food, brand names if any, additional items (sugar or sauces) as well as any medicine if consumed. Children were advised and encouraged to keep the diary with them all the time to instantly record any dietary intakes and avoid using atypical days that might be complicated by travel, illness, or unusual circumstances.
Phase 2 A: Analysis of diet diary template for assessment of cariogenicity
From the information collected through diet diary template, every intake of the child was analyzed by the clinician and scored as follows.
Step 1 (Figure 2)
1) Identify Food items consumed by the child at any given point of time, whether single type or a platter of multiple types?
a) If it is a Single type, check if it is a part of Miscellaneous from Table 2; if yes; assign score as per table 2. If no; proceed to step 2
b) If it is a platter of multiple types, check if it contains any food items belonging to Miscellaneous; if yes; give a single score of 3.5 for the entire platter of multiple types. If no; from the platter of multiple types identify major one food item and proceed to step 2
Examples for Single type: Biscuit, Pasta, Veg biryani
Examples for Platter of multiple types: Biscuit with milk, Pasta with potato chips, Lunch (2 Indian bread, 1 cup rice, 2 curries, 1 sweet, 1 vegetable)
Step 2 (Figure 3)
2) Identify the food, is it natural or processed**?
a) For natural food items,
i) Identify which food group it belongs to?
Scoring: For food groups: Grain, Fruit or diary assign score 0.5
For food groups: Protein or vegetable assign score 0
ii) Identify whether food is in solid, semisolid or liquid state?
Scoring: For solid add score 1, for semisolid add score 0.5 and for liquid add score 0
iii) Identify the nature of the food, sticky or non-sticky?
Scoring: If sticky add score 1 If non-sticky add score 0
b) For processed food items,
i) Based on its major ingredient identify which food group it belongs to?
Scoring: For food groups: Grain, Fruit or diary assign score 1.5
For food groups: Protein or vegetable assign score 0.5
ii) Identify whether external sugar has been added ?#
Scoring: If yes add score 1, If no add score 0
iii) Identify whether food is in solid, semisolid or liquid state?
Scoring: For solid add score 1, for semisolid add score 0.5 and for liquid add score 0
iv) Identify the nature of the food, sticky or non-sticky?
Scoring: If sticky add score 1 If non-sticky add score 0
- **Processed food is defined as food that has had some sort of chemical or industrial treatment in order to cook it, preserve it, or improve its taste or appearance.
- # Food item with added sugar or food belonging to miscellaneous food item consumed consecutively within 60 minutes interval, an addition of 1 for the later score.
- If child after every intake does not follow or is inconsistent in following the oral hygiene regime then add a score of 2 to per day diet score. If the child consumes food item with added sugar just before bed and skips oral hygiene regime an addition of score of 2 to per day diet score.
Based on the above criteria each intake of child was scored and added to obtain a cumulative score of four days.
The child’s diet’s cariogenicity score was computed as follows
Child’s Diet’s cariogenicity score = 4 day cumulative score /4
Inference
A score of 23 and above was considered cariogenic, and a score below 23 was considered non cariogenic (based on Receiver Operating Characteristic curves results obtained from pilot work explained in result section)
Phase 2 B: Analysis of diet diary template for its Healthfulness (Figure 3)
Identify Food items consumed by the child at any given point of time, whether the single type or a platter multiple types?
a) If it is a Single type, check if it is a part of Miscellaneous (Table 1)
Scoring If yes, assign score 0 for five basic food groups.
If no Identity which one of the five basic food groups the intake belongs to and quantify the intake in terms of servings*** and note under respective food group.
b) If it is a platter of multiple types, check if it contains any food items belonging to Miscellaneous?
Scoring For food items belonging to Miscellaneous assign score 0 for five basic food groups.
For the rest of the food, for each food items identify which one of the five basic food groups the intake belongs to and Quantify the intake in terms of servings.***
***- Convert house hold measurements written in diet diary in to serving using table 3
Based on the above criteria each intake of child was scored and the servings under each food group consumed by the child were computed for 4 consecutive days to obtain a cumulative four day score.
The child’s diet’s healthfulness score was computed as follows
Average servings score for each food group = 4 day cumulative score for each food group /4
Inference
Calculated average servings for individual food group; if is equal or above the indicated serving by FGP (2002) for moderate calorie level (2200 calories- Indicated for Children) [17] consider the child has consumed health full diet. Among the five food groups even if one food groups do not fulfill the indicated serving by FGP considered the diet as non-healthful.
Based on the inference of Phase 2 A and B, child’s diet was classified into one of the following categories,
- Category I-Non cariogenic, Healthful
- Category II-Cariogenic, Healthful
- Category III- Non cariogenic, Non Healthful
- Category IV- Cariogenic, Non Healthful
Illustration for Diet diary template analysis (Table 6)
Phase 3 -Diet counseling
Children categorized in Category I, need no counseling, instead, reinforcement for good diet practice and follow-up is needed. For children categorized in Category II, counseling by the dentist is advised; For Category III and IV counseling by a dietician in collaboration with the dentist is advised.
Guideline for diet counseling by dentist (from the cariogenic point of view)
Every child to be educated about the oral hygiene protocols to be followed using age-appropriate oral hygiene aids and to rinse after each food intake.
From diet diary received,
- Step1: Aim: To reduce miscellaneous food items to the maximum extent possible.
Clinician’s task: Identify and mark all the dietary intakes by the child that are not associated with food groups but sweetened by the addition of sugars (miscellaneous food).eg: Chocolates, candy, pastry, chips and sweetened medicine
Correction: Child and parent duo should be made aware of the findings and advised to reduce the frequency of above-said intakes. They are asked to club the intake of miscellaneous food with either lunch or dinner and absolutely refrain these intakes just before bed. If possible sugared medicines changed to artificially sweetened ones. Whenever they consume miscellaneous food oral rinsing should be compulsory.
- Step 2: Aim: To reduce the intake of fermentable sugar as much as possible without disturbing intake of food group servings.
Clinician’s task: Identify and mark all the dietary intakes by the child that are associated with basic five food groups but sweetened with the addition of sugars.
eg: milk with sugar, bread with jam, Chapati (Indian Bread) with ghee and sugar
Correction: Child and parent duo should be made aware of the effect of the addition of sugars and advised on a realistic type of correction. Each day one food item is considered for correction starting from the first meal of the day, Breakfast. The parents are advised to wean the added sugars without disturbing the main food group ingredient. Parents can substitute sugar, with honey or jaggery. Try to substitute sugar with no-sugar or permitted artificial sugar-based products without affecting the intake of the main course associated with food groups. This is expected to be followed for 4 weeks consecutively and advised on a recall follow up. Whenever they consume miscellaneous food oral rinsing should be compulsory
- Step 3: Aim: To improve the intake of Healthful diet.
Clinician’s task: Identify and mark all the dietary intakes by the child that are associated with basic five food groups.
Correction: Child and parent duo consuming adequate quantity of Healthful diet should be appreciated and encouraged to consume diet of a varied selection that contains an adequate quantity of the nutrients.
Illustration depicted in Table 7shows post diet counseling modifications suggested for day1 diet diary of child. Modification was done in the time of intake and emphasis on the oral hygiene instructions without omitting the miscellaneous diet of the child and converting the cariogenic diet score to non-cariogenic score. The healthfulness of diet was also improved by the addition of varied food groups to the diet that was lacking.
Determination of Diet cariogenicity score cut‐off value