Perceptions of diet diaries’ usage in pediatric dental practice

ABSTRACT

Background:

Diet diaries are a significant tool for dietary assessment and advice. There is paucity of studies assessing the usage of diet diaries by pediatric dentists during their patient management. Hence, this study was designed and conducted to explore the perceptions of the pediatric dentists regarding the possible difficulties and their solutions for the usage of diet diaries in their dental office.

Materials and Methods:

A questionnaire was designed to understand the awareness of pediatric dentists regarding the utility of diet diaries while preparing the diet modifications for their patients. The factors related with adherence of pediatric patients to the diet diaries were understood by using qualitative research method.

Results:

The information regarding the diet was collected verbally by 78% of pediatric dentists. Monetary constraint (43%), time (35%), poor compliance (12%), and lack of skills (10%) were the other reasons. The results of the qualitative study showed that adhering to diet diaries was a multi-contextual phenomenon.

Conclusions:

Utilization of diet diaries by pediatric dentists and adherence to the diet modifications by the patients are very poor. A supportive health-care system, motivation of parents as well as children, along with an efficient tool seem to be needed for achieving success in utilization of diet diaries.

Introduction

According to the World Health Organization, consumption of sugar is the most common risk factor for obesity and dental caries.[1] Various national and international policies and guidelines related to well-being of individuals promote healthier dietary habits. Nine percent of children are suffering from dental caries worldwide.[2] According to Keys Triad, dental caries is the result of action of acid-producing cariogenic bacteria on fermentable carbohydrates in a susceptible host.[3] Studies on cariogenic foods have shown that the quality and frequency of consumption of carbohydrates are more important that the quantity.[4] Results of other studies have also reported the detrimental effect of intake of sugar between meals to oral health than with meals.[5]

Modification of diet of caries high-risk pediatric patients can help in reducing the incidence of dental caries. The effectiveness of dietary modification depends upon the customization of the diet as per the needs of the individual. Various tools are available to assess the diet of an individual. Diet diaries are commonly used as a tool for monitoring and assessment of diet. One of them is called 3-day diet diary. Here the parent is asked to keep a record of drinks and food consumed for three consecutive days. They have to record the timing, quantity, and type of the food consumed. The parent is asked to include one day of weekend for better assessment.[6] A recent study reported the effectiveness of self-monitoring of diet.[7] Evidence from a recent systematic review shows that use of interactive health communication tools improves the dietary behavior of the patients.[8] Hence, it is important to obtain the information of the diet for assessment, customization, and monitoring the dietary behavior of the individual.

A systematic literature survey in relation to the usage of diet diaries in dental practice and the influence of factors affecting it revealed that only two studies are conducted so far. These studies investigated the frequency of usage of diet diary by the dental hygienists for providing dietary advice.[9,10] In spite of known advantages of the diet diaries, there is paucity of work done in this field. This study was conducted to investigate the role of diet diaries in management of dental caries of children by pediatric dentists. A questionnaire was designed to understand its perception and utilization by the pediatric dentists while preparing the diet modifications for their patients. A qualitative research methodology was used to understand the factors associated with adherence of pediatric patients to the issued diet dairies.

Aims and objectives

The present study investigated the frequency of use of diet diaries by pediatric dentists in their clinical practice.

1. To understand the perception of pediatric dentists regarding the usage of diet diary as a dietary assessment tool for the diet modification of caries high-risk patients

2. To investigate the factors associated with adherence of pediatric patients to the issued diet dairies

Materials and Methods

The study consisted of two parts. The first part consisted of the cross-sectional survey of Indian pediatric dentists based on a questionnaire. It was conducted between April 2021 and December 2021. A sample size of 350 was considered with 95% confidence interval. Based on the response rate of previous surveys, the response rate of 35%–45% was assumed. In order to compensate for the same, the sample size was increased to 778 using the formula 350 × 100/45. A questionnaire based on the literature of diet diaries was prepared for this survey.

The second part of the study was to explore the factors associated with adherence of the pediatric patients to the issued diet dairies. This was done by face-to-face semi-structured interviewing and observing the pediatric patients and their parents in the dental hospital. This allowed collection of in-depth data via both nonverbal and verbal modes of communication.

Pediatric patients in the age range of 4–8 years with moderate to high caries were selected. This age group was selected because during this time, the child develops preference for particular food. Also, this is a significant time for cognitive development for establishment of independent food choices and dietary pattern.

The study was approved and conducted according to the ethical standards established by the Institutional Ethical Board (approval no. 001108/GDCHA/IEB-TRE/EC/2016) at the Government Dental College and Hospital, Aurangabad. Before the study, written assents and informed consent were obtained from all the participants (pediatric dentists, parents, and children). They were informed about the purposes of the study, and their queries were resolved before the start of the study. They were assured confidentiality of the information. The participation was voluntary, and no incentives were offered to them. The clarity and suitability of the questionnaire and informing charts were tested within a group of five dentists and three patients (parents and their wards) at the Department of Pediatric and Preventive Dentistry, Government Dental College and Hospital, Aurangabad.

Questionnaire for the first part of the study

A questionnaire, based on the literature of diet diaries, was prepared for this survey [Table 1]. A pilot test was conducted to check the validity and clarity of the questions in a sample of 10 pediatric dentists of Aurangabad district. They were asked to provide their valuable feedback regarding the understanding and interpretation of the questions, as well as any suggestions to improvise. Pediatric dentists who participated in the pilot test were not included in the final study population. The questionnaire was sent to the pediatric dentists via e-mail. The questionnaire was sent along with a cover letter stating that the information shared would be strictly confidential and would not be judged for their method of practicing pediatric dentistry. This was done to minimize the nonresponse and social desirability bias.

Table 1.

Questionnaire for pediatric dentists

Question	Response
Gender - male/female
Year of passing MDS-
Number of patients managed in your clinics per day- less than 20, more than 20
Dietary advice given by you to the percentage of the patients- less than 50%, more than 50%
Do you use diet diary for diet counselling in your daily practise? Yes/No
Do you use any other method of collection of information regarding diet? If Yes, please specify
For how many days do you ask the patients to record their diet in the diaries?
Do you ask them to include at least one weekend? Yes/No
Do you ask your patient to record the content of their food and drinks in the diary? Yes/No
Do you use the diet diary to modify the dietary behaviour of your patients? Yes/No
Do you discuss the information provided by the patients in their diet diary routinely? Yes/No
How much time it takes to analyse the information from the diet diary? (in minutes)

Study design framework for the second part of the study

The study was conducted in the Department of Pediatric and Preventive Dentistry. The design of the study is shown in Figure 1. The children visiting the department were screened. The children suffering from active dental caries and within the age group of 4–8 years were included. The parents were informed about the study procedure. After obtaining the consent and assent, the diet diaries were issued to the willing participants. A total of five cases were included for this part of the study. The parents were asked to fill the information regarding the daily diet of their child and bring the diary back in their next appointment. In the second appointment, the analysis of the diet diary was done, which was followed by giving recommendations for dietary changes. This was done using face-to-face interviews. The questionnaire for the interview was prepared [Table 2]. The field notes recorded the date, demographic data, and other relevant information. The verbal and nonverbal interaction between the dentist and the participant were observed by the principal investigator. The pro forma for the observation is given in Table 3. The interview focused on the perception of the participating parents and children regarding diet diaries. The reasons for adherence as well as nonadherence to the diet diaries were also explored. Qualitative analysis was conducted to analyze the data.

Figure 1.

Flow chart for the case study

Table 2.

Questionnaire for interviewing the participants

Question	Response
(A) First appointment
General information about the participant- family, occupation, place of residence
Do you know about the role of diet in development of dental decay?
Do you consider assessment of diet is important for your child’s dental health?
Are you aware about diet counselling?
Do you know about diet diary?
Have you ever filled information regarding the daily diet of your child in the diary?
Do you know how to fill the diet diary?
Do you consider it to be important to fill the diet diary?
(B) Second appointment
Describe your experience of using diet diary
How did you fill the diet diary? Was it filled immediately or after sometime of intake of meals?
Did you face any difficulty in filling up the information in the diet diary?
Were you able to fill the complete information?
Did you observe any changes in the dietary habit of your child?
Did you find diet diary to be beneficial in changing the dietary habits of your child?
Was it time consuming process for you?

Table 3.

Pro forma for observation of dentist-participant interaction

Location- Department of Paediatric and Preventive Dentistry, GDCH

Date-

Duration of interview-

Observation

Who came with the child for the interview?

Did the dentist introduce himself/herself?

Who started the talk?

What is the child’s involvement during this discussion? Is the child sitting with the parent or playing?

How is the interaction between the dentist and the participants- active or passive?

Are the participants showing any interest? Are they clarifying any doubts?

How is the body language of the dentist and the participants?

Statistical analysis

To manage and analyze the quantitative data, the Statistical Package for the Social Sciences (SPSS), version 20 software was used. Descriptive statistics describing the participants’ demographics and professional characteristics were used. When the P value was less than 0.05, it was considered statistically significant.

Results

A total of 600 questionnaires were sent to the pediatric dentists via e mail. Out of these, 314 responded. Hence, the response rate was 52.33%. The demographic and professional characteristics of the pediatric dentists who responded are shown in Table 4. Out of 314 responses, only 13 (4.14%) pediatric dentists preferred the use of diet diary in their routine clinical practice. Majority of the pediatric dentists collected information regarding the diet verbally without using diet diaries. More than 86.5% of pediatric dentists were providing advice for diet modification during recall appointments. The most common reason was constraints, that is, monetary (43%) followed by time (35%). Other reasons were poor compliance of parents and pediatric patients (12%). About 10% of pediatric dentists perceived that they lacked the skills needed for appropriate dietary counseling. The information obtained regarding the usage of diet diaries in their routine dental practice is summarized in Table 5.

Table 4.

Demographic and professional characteristics of the study population

Characteristics of the study population	Number (%)	Mean	Standard deviation	P *
Gender
Male	118 (37.58)	28.74	3.04	0.01
Female	196 (62.42)	23.65	4.56
Years of practice
Less than 15 years	217 (69.11)	24.46	2.89	0.004
More than 15 years	97 (30.89)	21.05	1.09
Number of patients managed in your clinics per day
Less than 20	214 (68.15)	20.02	2.18	0.002
More than 20	100 (31.84)	22.43	2.41
Dietary advice given by you to the percentage of the patients
Less than 50%	78 (24.84)	24.08	4.47	0.001
More than 50%	236 (75.16)	20.13	3.29
Do you use diet diary for diet counselling in your daily practise?
Yes	13 (4.14)	18.19	2.16	0.004
No	301 (95.86)	20.07	2.28

*P<0.05 is statistically significant

Table 5.

Information obtained from diet diary (n=13)

	n (%)	Mean	Standard deviation	P *
Do you ask them to include at least one weekend?
Yes	8 (61.54)	14.57	2.01	0.02
No	5 (38.46)	10.98	1.86
Do you ask your patient to record the content of their food and drinks in the diary?
Yes	4 (30.77)	14.54	2.06	0.02
No	9 (69.23)	16.84	2.83
Do you use the diet diary to modify the dietary behaviour of your patients?
Yes	7 (53.85)	12.87	3.87	0.00
No	5 (38.46)	11.03	2.76
Do you discuss the information provided by the patients in their diet diary routinely?
Yes	10 (76.92)	14.03	2.07	0.03
No	3 (23.08)	13.11	2.17
How much time it takes to analyse the information from the diet diary? (in minutes)
Less than 30 min	4 (30.77)	16.84	2.83	0.02
More than 30 min	9 (69.23)	14.54	2.06

^*P<0.05 is statistically significant

The analysis of the second part of the study revealed that the parents considered the diet diary to be a test that judged their parenting. They wanted to agree with the dentist both verbally and nonverbally (nodding of head) regarding the importance of diet and diet diary. The parents’ absence of belief in the usefulness and the requirement of diet diaries, as well as their busy schedule were reasons cited for forgetting to fill up the diet diary. It was observed that dentists were concerned regarding the issue of nonacceptance of diet diary. They did not want to depend upon the parents for the primary preventive measure. Rather, they were found to be more comfortable with other interventions like application of fluoride and pit and fissure sealants. Mutual interactions between pediatric dentist, child, and parents were needed for the success of diet diary–based dietary modifications.

Discussion

Development of dental caries in children is associated with establishment of dietary habits during their childhood. During this period, children develop preferences for a particular kind of food and dietary pattern. The cognitive abilities of children undergo series of transitions during which they develop the cognitive underpinnings and acquisition for independent food choice.[11] Studies conducted on the diet show that children consume more sugar as they progress toward the last stages of the childhood.[12] Various studies have shown that dental caries develop during the first few years of tooth eruption.[13] Therefore, it is important to establish and promote healthy dietary habits in childhood. This healthy dietary behavior will have a lifelong impact on the caries experience of the individual.

Pediatric dentists can play a crucial role in development of such behavior by providing the necessary skills and knowledge to the parents of children. For patients having high probability of developing dental caries, a six-step dietary advice model has been suggested. The first step consists of conduction of initial risk assessment for finding those patients who are at an increased risk of development of dental caries. The second step is to recognize the dietary behavior of the individual. This can be done with the help of diet diaries. The third step is analyzing the collected information and setting up of realistic behavior-changing goals after discussion with the patient. The fourth step is achievement of the agreed goals by the development and implementation of the customized plan. The fifth step is to monitor and review the progress toward the agreed goals. It also includes providing support in the form of feedback. The sixth step involves referral of patients having specific or complex dietary problems to dieticians for their guidance.

In this study, approximately 50% of pediatric dentists responded. Majority of the pediatric dentists obtained the dietary information of their patients verbally. An exploratory assessment was preferred by the pediatric dentists in our study, which is in accordance with the data obtained from the previous studies in the literature.[14] Only 4% of dentists in this study used diet diaries as the assessment tool. The most common reason for this was monetary constraints (43%). The amount of time spent on collection and assessment of diet data was more than the honorarium. Around 10% of the pediatric dentists perceived that they did not have sufficient skill for assessment of the information obtained from the diet diaries. This was in accordance with the results obtained from the previous studies.[15,16,17] A detailed evaluation of the cariogenic potential of each food item was difficult. About 12% of the pediatric dentists reasoned lack of compliance by both parents and their wards for adherence to the dietary advice. Adherence of parents and children to the diet diary involves multiple factors associated with the child, parent, dentist, diet, as well as the diet diary. In this study, we found that the parents perceived the diet diary as a form of exam where their parenting was judged. Most of the parents expressed fear of criticism. These findings were in accordance with the other studies, where most of the participants reported to modify the information to prevent any embarrassment. Poor oral health, bad attitude, and lack of motivation of parents were also some of the contributing factors to diminished adherence to the dietary advice.[16] The controlling attitude as well as authoritative communication of dentist can make the parent uncomfortable, leading to poor adherence to the diet diary. Hence, it is very important to develop a healthy dentist–patient relationship for the success of this method. The verbal and nonverbal modes of communication play a key role in the success of the diet assessment for caries management. Educated parents not belonging to poor socioeconomic class follow the practice of proper maintaining of the diet diary.

The basic goals for assessment of diet of the patients are to find out the dietary needs, customize the diet, and monitor the recommended changes in their diet. In dental practice, there are basically two types of tools for dietary assessments, exploratory and detailed assessment of diet. The exploratory assessment of diet is conducted routinely for all dental patients for identification of caries high-risk patients. The detailed assessment of diet is recommended for patients identified as caries high risk. The retrospective method consists of 24-h dietary recall and diet histories. The information regarding the food and drink consumed by the patient in last 24 h is obtained via chair-side interview. The diet history consists of the data regarding the dietary intake typically for 1 week duration. Retrospective methods are time consuming and require skill. They are thought to be fit for adolescents and people who are not much educated. The prospective method consists of recording the diet using diet diaries or diet sheets.[17,18,19,20,21] This method is considered to be more valid due to its accurate representation of the patient’s dietary habit. It is considered as an effective dietary assessment tool for incorporating behavior changes in the dietary pattern of the patient. The parents of the child are advised to maintain a detailed account of the quantity, quality, and the time of consumption of food and drinks consumed on a daily basis. They should be encouraged to maintain the record as accurately as possible. The pediatric dentists should appreciate their efforts, help them to identify the sugary items, and educate the parents regarding the significance of frequency of sugary intake.

Diet diaries are utilized in various studies exploring the role of various dietary components. The most common approach is retrospective, where the diet is recorded by the patient and later assessed by the clinician. A specific component of the diet, like the fat or sugar intake, is assessed rather than the whole diet. Although the diet diaries have plus points like being accurate and simple, its demerit is being cumbersome. It also requires patients to be cooperative and educated.[20] Involvement of latest technological aids like mobile apps, camera, audio and video recordings has shown more promising results.[22,23,24,25]

Strengths and limitations of this study

The study consisted of observation of patient–dentist communication in the normal dental setting. In addition to this, data was collected from interviews. However, this process also endures the risk of “Hawthorne effect,” where the response of the participants might change as they are aware of being studied.[23] In order to avoid this, the principal investigator spent some time in the department with the participants before the beginning of collection of data. The assurance of confidentiality was also given to the child and the parents. Small sample size for the second part of the study was also one of the limitations.

Conclusion

The development of healthy dietary habits in a child is basically done by his/her parent or the caretaker. They monitor the quality as well as the quantity of the food intake of their child. Parents with healthy diet and habits can positively motivate their children to adopt healthy habits. The adherence of patients to the dietary advice is influenced by the communication between the dentist and the patient. In addition to it, the perception of parents, their education, and socioeconomic background play an important role.

Recommendations

Following are the recommendations for further studies:

1. Development of mobile apps of socially acceptable and easily comprehensible dietary assessment tool. It should be affordable, feasible, and effective.

2. Dietary advice should be accompanied with motivation.

3. Dentists should be trained in the efficient use of diet diary as a part of primary intervention.

Significance of this study for the practice of primary care and family physicians

The primary care physicians and family physicians have a significant role in management of health and prevention of diseases. This is mainly related with provision of dietary advice to their patients. Insufficient knowledge, inadequate incentives, and time constraints are some of the reasons for the lack of provision of dietary advice. This article focuses on the significance of diet diary as a dietary assessment tool for children. The questions provided in this article would help the physicians to gather information about the diet of their patients. This would help them to provide needful dietary recommendations and behavior modifications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Key message

Diet plays a crucial role in the overall health of an individual. The information obtained from diet diaries can be used to provide a realistic, comprehensive, and customized dietary advice to patients with caries and other health-associated risks in order to modify their eating behavior.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.