Severe Tooth Loss in Older Adults as a Key Indicator of Compromised Diet Quality

Abstract

Objective

Poor oral health influences the dietary quality of older individuals. The objective of this study was to relate the number of teeth to adherence to 2005 Dietary Guidelines for Americans among an ethnically diverse sample of older adults.

Design, setting, and subjects

A block cluster design was used to obtain a sample of 635 community dwelling older adults in two North Carolina counties with large African American and American Indian populations. Data were weighted to census data for ethnicity and gender. Dietary intakes were assessed using a food frequency questionnaire and converted into Healthy Eating Index-2005 (HEI-2005) scores.

Results

326 participants had severe tooth loss (0-10 teeth) compared to 305 participants with 11+ teeth. After controlling for socioeconomic factors, those with 0-10 teeth had lower total HEI-2005 scores and consumed less Total Fruit, Meat and Beans, and Oils and more calories from Solid Fat, Alcohol, and Added Sugar compared to those with 11+ teeth. Less than 1% of those with 0-10 teeth and 4% of those with 11+ teeth met overall HEI-2005 recommendations. Those with 0-10 teeth were less likely to eat recommended amounts of Total Vegetables, Dark Green and Orange Vegetables, and Calories from Solid Fat, Alcohol, and Added Sugar.

Conclusions

Older adults with severe tooth loss are less likely than those with moderate to low tooth loss to meet current dietary recommendations. Nutrition interventions for older adults should take oral health status into consideration and include strategies that specifically address this as a barrier to healthful eating.

Poor oral health among older adults is among the conditions that contribute to inadequate dietary intake(1-7). Functional limitations like not being able to chew properly or eat without pain discourage the consumption of foods that are crunchy, stringy, or dry, such as vegetables, whole fruits, certain meats, or seeds and grains(8, 9). These eating difficulties compound the effects of age-related declines in taste and nutrient absorption on the nutrient status of older adults(10). This increases the likelihood that diets will be inadequate within populations whose food choices are affected by their physical limitations, psychological decline, and financial barriers(11-16). When designing nutrition interventions or education programs for older adults, key issues are to identify individuals with these limitations and to address the influence that compromised dental status has on their food choices.

Reduction in number and functioning of teeth has been associated with poor diet quality among older adults. The number and location (anterior and posterior) of functional units (any opposing pair of natural or fixed prosthetic teeth) has been related to food avoidance and difficulties in chewing(9). Several investigators have examined the role of missing posterior functional units (premolar and molar combined) in relation to dietary intake of specific nutrients or overall diet quality(5, 17, 18). The fewer teeth an individual has, the more likely he or she is to have lost functioning teeth and thereby suffer compromised nutritional status.

In 1995, the United States Department of Agriculture (USDA) introduced the Healthy Eating Index (HEI) to provide an approach to assess how closely diets conformed to the then-current USDA dietary recommendations(19). The original HEI included a total score calculated from dietary components that represented types and amounts of foods(19). Since its introduction, HEI scores have been used to characterize the association between impaired dental status and diet quality. Lower total HEI scores in older adults have been associated with presence of fewer pairs of posterior teeth, denture use, poorly fitting dentures, and persistent chewing, swallowing, and mouth pain(5, 18, 20-22). The HEI concept that considers overall diet quality and its component foods has been useful for considering implications of impaired dental status on the diet quality of older adults.

In 2005, new dietary guidelines were issued by the USDA (the 2005 Dietary Guidelines for Americans). In response to the new guidance, the HEI was revised(23). This revision, now referred to as Healthy Eating Index-2005 (HEI-2005), reflects the Dietary Guidelines’ increased emphasis on whole grains (particularly vegetables), certain oils, and energy from sweets, solid fats, and alcohol. A second important consideration for the HEI-2005 was the use of density standards rather than absolute amounts of food, (i.e., the food amounts per 4,184 kilojoules (1000 kilocalories) of intake compared to amounts per day)(24). The use of this standard allows comparisons of nutrient intake to be independent of an individual’s reported energy intake. Thus, for older adults who often have reduced energy intake(25-27), the HEI-2005 density standard approach provides a useful method for understanding food choices of older adults regardless of the total amounts of food(24). To date, the HEI-2005 has not been examined among older adults, particularly those with compromised dental status.

This paper uses data from a population-based survey that considered oral health status and diet quality of a multi-ethnic older adult population. Its objectives are to (1) quantify the association between the number of teeth and overall diet quality as measured by the HEI-2005 and (2) compare the number of teeth with the individual components of the HEI-2005.

Methods

Sampling Plan and Recruitment

Between January 2006 and March 2008, The Rural Nutrition and Oral Health (RUN-OH) Study conducted a cross-sectional survey of the oral health and dietary intake of an ethnically diverse sample of older adults living in rural areas of the southern US. Participants were located using a random dwelling selection and screening procedure in which the primary sampling units (clusters) were stratified and selected with probability proportionate to size. University of Illinois Survey Research Laboratory consulted on the design and implementation of the procedure and provided final participant weights.

Clusters were stratified into 4 categories, based on the racial/ethnic composition of their residents as predominantly (more than 50%) African American, American Indian, white, or mixed (no ethnic group comprising 50% of the residents). Twenty clusters were randomly selected from each of the four types for a total of 80 clusters.

Within the 80 mapped clusters, 5,545 dwelling units were identified (Fig.1). Individuals were considered eligible if they were 60 years or older, spoke English, were able to give informed consent, and were physically able to complete the interview. Thirty-nine dwelling units were not screened, 4,647 were screened but did not include an eligible participant, and 859 included an eligible participant, yielding a screening rate of 99.3%.

Figure 1.

Sample and Recruitment for the Rural Nutrition and Oral Health Study

The eligible residents in 635 of the 859 eligible dwelling units completed the interview; 224 refused to complete the interview, for a response rate of 73.9%. The weights for each participant were based on size of the cluster from which he/she was selected, and his/her probability of selection within each dwelling unit. Eighty-eight percent of those who had at least one tooth underwent an in-home oral assessment.

Data Collection

All data collection procedures were approved by the university’s Institutional Review Board. The data were collected in face-to-face interviews at participants’ homes, lasting 1.5 to 2.5 hours. Data collection included the 1998 version of the Block Food Frequency Questionnaire (FFQ) (Nutrition Quest Block 98.2), which assesses the usual intake of 110 foods. The use of the FFQ among this population was previously validated with a sample recruited from the same region (rural southern USA)(25). Participants were asked about the typical frequency and portion sizes of foods they have eaten within the past year. Questions were read to participants and cue cards with response categories were used if necessary. All interviewers completed 8 hours of training and 6 hours of practice interviews. Ten percent of interviews were verified by telephone. To maintain quality after initial training, one interview every month was audio-recorded for each interviewer. This tape and accompanying completed FFQ were reviewed by research staff, who provided written feedback about recording errors or misinterpretations of the participant’s responses. Dental examinations quantified tooth counts and functional occlusal contacts clinically. Two dental hygienists conducted all dental examinations. They underwent an initial 1-day training and 1-day calibration with a research dentist using volunteers representative of the study population. Calibration was repeated annually. The research dentist conducted 5 replicate examinations with each hygienist, and performed an ongoing review of data collection forms to check for correct logic, legal values, and data ranges.

Demographic Measures

Ethnicity based upon self-report was categorized as African American, American Indian or white. Income was dichotomized as either above the poverty line or below the poverty line using current year federal poverty guidelines, taking into account household size(28). Education was categorized as (1) less than high school graduate, (2) high school graduate, and (3) more than high school based on the participants’ highest level of education completed.

Dietary Assessment and HEI-2005 Scoring

The HEI-2005 scores were calculated from the food frequencies and completed questionnaires were scanned by Nutrition Quest. In addition to standard output variables (daily micro- and macronutrient intakes and USDA food group servings of food), gram amounts and calories of each questionnaire item were provided by Nutrition Quest to assist in the calculation of HEI-2005 component scores. The USDA Food Search Tool 3.0(29) was used to provide necessary information to calculate HEI-2005 components, such as grams per cup or ounce, amounts of fat, or added sugar in certain reference foods.

HEI-2005 contains 12 components(23). These include cup equivalent (eq)/4184 kj (1000 kcals) of Total Fruit, Whole Fruit, Total Vegetables, Dark Green and Orange Vegetables and Legumes (after Meat and Bean component reach maximum values), and Milk (including soy milk). Meat and Beans (which includes eggs, nuts, and soy foods excluding drinks), Total Grains, and Whole Grains are calculated in oz eq/4184 kj (1000 kcals). The amounts of Oils (those found in mayonnaise, margarine, salad dressing, nuts and seeds, and fish) and Sodium, measured in g/4184 kj (1000 kcals), and the percent calories from Saturated Fat and Solid Fat, Alcohol, and Added Sugar (SoFAAS) comprise the remaining components. The Total HEI-2005 score, which ranges from 0 to 100, is the sum of the weighted scores for each component; the contribution (weighting) of each component to the total score varies. A maximum score of 5 was assigned to component values that met or exceeded recommended intakes of Total Fruit, Whole Fruit, Total Vegetable, Dark Green and Orange Vegetables and Legumes, Total Grains, and Whole Grains. A maximum score of 10 was assigned for meeting or exceeding recommended amounts of Milk, Meat and Beans, and Oils. Maximum values of 10 were also assigned when Saturated Fat and Sodium were equal to or less than recommended intake. And, finally, the recommended percent of energy contributed by SoFAAS was assigned a score of 20 if it is equal to or less than the recommendations. With the exception of Saturated Fat, Sodium, and SoFAAS, scores of zero were assigned to values of 0 for each of the components; and intermediate values were assigned proportionally between 0 and the maximum values.

Anthropometrics

Interviewers were trained and certified to use portable, calibrated electronic scales with a maximum weight capacity of 200 kg (Tanita BWB-800A, Tanita Corp., Arlington Heights, Illinois, USA) and portable stadiometers (Seca 214 Road Rod, Seca Corp., Hanover, Maryland, USA) to weigh and measure height. Participants wore light clothing when measured and measures were taken twice and then averaged. BMI was calculated as kg/m². Participants were classified as obese if their BMI was ≥30.

Oral Health Measures

Self-reported oral health was assessed by asking participants to rate the condition of their mouth and teeth, including prosthetic teeth and dentures, as excellent, very good, good, fair, or poor.

Number of remaining natural teeth was a four-level categorical variable: 0 teeth, 1-10 teeth, 11-20 teeth, and 21 or more teeth. Self-reported number of teeth was used to categorize those reporting 0 teeth or those dentate participants who refused the oral exam; otherwise, dentate participants were categorized based upon the clinical examination. The Pearson correlation between the self-reported and examination values for number of teeth was 0.92 for those who agreed to the oral assessment.

The number and location (anterior or posterior) of functional units was based on a count of functional contacts between two natural teeth, a natural tooth and a fixed prosthesis, or two fixed prostheses. Data on functional contacts were only available for the 362 oral assessment participants and those reporting zero teeth.

Statistical Analysis

All data analyses incorporated the multistage cluster sampling design. Rao-Scott Chi-Square test was used to quantify associations between gender and ethnicity, income, education, dental insurance, self-rated dental health, and obesity. This test is a design-adjusted version of the Pearson Chi-Square test. For continuous variables such as age, comparisons were made through regression analysis. Linear regression models were used to test for the unadjusted effects of age, ethnicity, gender, poverty status, education, dental insurance, and body mass index on total HEI score. Further analyses of the effects of two number of teeth categories (0-10 teeth and 11+ teeth) on total HEI score and its components were performed using a linear regression model after adjusting for covariates (age, gender, ethnicity, education, poverty and dental insurance). In addition, percentages meeting requirement were calculated for 0-10 teeth and 11+ teeth categories. Odds ratios were calculated after adjusting covariates mentioned above using logistic regression. The distributions of total HEI score and its components were checked using histograms and majority of these measures were bell-shaped, with exceptions that total fruit, whole fruit, dark green vegetables and milk were right skewed. However no transformations were made to the latter variables since the study sample was relatively large and asymptotically the distributions approached normality. All analyses were performed using SAS 9.1 (Cary, NC), and significance level was set at 0.05.

Results

The sample comprised 344 women (54.1%) of whom 40.4% were white, 35.5% American Indian, and 24.2% African American (Table 1). Among men (n=291), 56.7% were white, 25.3% American Indian, and 18.1% African American. Women were less likely to be married (33.5% vs. 62.1%, p<.001) and more likely to have income below the poverty line (39.7% vs. 23.2%, p=.001). More than half of the participants (55.7%) had less than a high school education. Fifty-five percent of participants reported having excellent, very good or good oral health, and 45% reported fair or poor oral health. Ten percent had private dental insurance. Women were more likely to be categorized as obese as defined as BMI ≥30 (44% vs. 30.9%, p=.03).

Table 1.

Demographic and health characteristics of participants

	TOTAL (Na= 635)		Men (N=291)		Women (N=344)
	N	%	N	%	N	%
Age
≥60 and <65	155	24.4	72	24.9	82	23.9
≥65 and <70	129	20.3	63	21.6	66	19.2
≥70 and <75	126	19.8	62	21.4	64	18.5
≥ 75 y	226	35.5	94	32.1	132	38.4
Ethnicity
African American	136	21.4	53	18.1	83	24.2
American Indian	195	30.7	73	25.3	122	35.5
White	304	47.8	165	56.7	139	40.4
Married	296	46.6	181	62.1	115	33.5
Income (below poverty level)	204	36.4	68	23.2	136	39.7
Education
Less than high school	354	55.7	155	53.1	199	57.9
High school	156	24.5	74	25.5	82	23.8
More than high school	126	19.8	62	21.4	63	18.4
Dental insurance	64	10.1	32	11.0	32	9.3
Self-rated dental health
Excellent	63	10.0	26	9.0	37	10.8
Very good	87	13.8	40	13.8	47	13.9
Good	197	31.2	97	33.2	100	29.4
Fair	170	26.9	79	27.0	91	26.9
Poor	114	18.1	50	17.0	65	19.0
Body mass index
≥30	233	37.9	88	30.9	145	44.0
25-29.99	218	35.5	114	40.1	104	31.5
<25	163	26.6	82	29.0	81	24.5

^aN=weighted sample size

Daily energy intake and macronutrient composition (mean ± SE) among men were 10615 ± 464 kj (2537 ± 111 kcal) and 39.8 ± 0.56 % from fat, 12.9 ± 0.30% from protein, and 48.0 ± 0.7% from carbohydrates. Women consumed 9088 ± 289 kj (2172 ± 69 kcal) each day with 39.1 ± 0.47% from fat, 12.8 ± 0.17% from protein, and 50.0 ± 0.60% from carbohydrates.

Participants who were 60-65 y had lower total HEI–2005 scores compared to those 75 y and older (mean ± SE, 58.68 ± 1.26 vs.62.97 ± 1.08, p =0.02) (Table2). Women had higher total HEI-2005 scores (63.18 ± 1.01 vs.59.19 ± 0.72, p <0.0001). Higher total HEI-2005 scores were associated with being above the poverty level (62.76 ± 0.87 vs.58.38 ± 1.03, p =0.0004) and having more than a high school education (66.18 ± 1.06) compared to those with only high school (62.22 ± 1.20, p =0.009) and less than a high school education (59.26 ± 0.76, p <.00001). Total HEI-2005 score was not associated with ethnicity, having dental insurance, or BMI.

Table 2.

Bivariate relationships between the total HEI-2005 score and descriptive and oral health characteristics (N ^a =635)

	Mean	SE	p
Age
60-65 y	58.68	1.26	0.02
65-70 y	61.24	0.93	0.15
70-75 y	61.84	1.23	0.26
≥75 y	62.97	1.08	*b
Ethnicity	64.27	0.89
African American	58.88	0.84	0.09
American Indian	61.63	1.20	0.06
White			*
Sex	63.18	1.01
Female	59.19	0.72	0.0008
Male			*
Income	58.38	1.03
Below poverty level	62.76	0.87	0.0004
Above poverty level			*
Education	59.26	0.76
Less than high school	62.22	1.20	<0.0001
High school	66.18	1.06	0.009
More than high school			*
Dental Insurance	64.71	2.28
Yes	61.0	0.78	0.14
No			*
BMI	62.12	0.94
≥30	62.04	1.08	0.1440
25-29.99	59.57	1.38	0.0668
<25	58.68	1.26	*

^aN=weighted sample size

^breference value

Participants with 1-10 teeth had few teeth (median = 5 teeth), a median number of zero anterior or posterior functional units, and 11.2% had at least one or more functional units (Table 3). The overall dental status of this category is very similar to individuals without any teeth. In contrast, participants with 11-20 teeth had a median number of 16 teeth with 97.5 % having one or more functional units. Participants in the 21+ category had a median of 25 teeth with 100% having one or more functional units. Those with 11-20 teeth had fewer functional units in both anterior and posterior locations. Based on the similarities between the zero and 1-10 categories and the 11-20 and 21+ categories, we evaluated diet quality with two categories, severe tooth loss [0-10 (N=326)] and moderate to low tooth loss [11+ teeth (N=309)].

Table 3.

Number of teeth, anterior functional units, and posterior functional units by number of teeth category

Oral Health Characteristic	Number of Teeth
	0	1-10	11-20	21+
	(Na=221)	(N=105)	(N=131)	(N=178)
Number of teeth (median)	0	5	16	25
Number of anterior functional units (median)	0	0	4	6
Number of posterior functional units (median)	0	0	2	6
Participants with at least one functional unit (%)	0	11.2	97.5	100

^aN=weighted sample size

After adjusting for gender, ethnicity, age, poverty status, and dental insurance, participants with 11+ teeth had a higher total HEI-2005 score (mean ± SE, 64.89 ± 0.04) when compared to those with 0-10 teeth (59.39 ± 0.87, p<0.0001) (Table 4). Those with 0-10 teeth compared to those with 11+ teeth consumed less Total Fruit (0.53 ± 0.03 vs. 0.62 ± 0.8704, p=0.015), Meat and Beans (2.19 ± 0.08 vs. 2.43 ± 0.08, p=0.01), and Oils (4.81 ± 0.87 vs. 6.10 ± 0.38, p=0.011). Those with 0-10 teeth had higher intake of calories from Solid Fat, Alcohol, and Added Sugar (29.31 ± 0.67 vs. 26.38 ± 0.56, p=0.0001) compare to those with 11+ teeth. In addition, two trends were found. When compared to those with 11+ teeth, those with 0-10 teeth consumed fewer Total Vegetables (0.77 ± 0.06 vs. 0.88 ± 0.04, p=0.08) and Dark Green and Orange Vegetables and Legumes (0.40 ± 0.04 vs.0.47 ± 0.03, p=0.08).

Table 4.

Total HEI-2005 score, estimated intake of HEI components, and the percentage of participants meeting HEI-2005 recommendations for each category

	HEI Values					Percent Meeting HEI Recommendations
HEI-2005 Category	0-10 teetha		11+ teetha			0-10 teeth	11+ teeth
Recommendations	Meanb	SE	Mean	SE	p	%	%	Odds Ratio	95% CI
Total Score	59.39	0.87	64.89	0.04	0.000	0.3	3.5	0.092	0.02, 0.50
≥80
Total Fruit	0.53	0.03	0.62	0.04	0.02	15.5	20.9	0.69	0.44, 1.09
≥0.8 cup eq/4184 kjc
Whole Fruit	0.35	0.03	0.39	0.03	0.11	28.5	37.8	0.66	0.38, 1.12
≥0.4 cup eq/4184 kj
Total Vegetable	0.77	0.06	0.88	0.04	0.08	14.7	24.2	0.54	0.30, 0.98
≥1.1 cup eq/4184 kj
Dark Green and Orange Vegetables and Legumes	0.40	0.04	0.47	0.03	0.08	27.1	43.6	0.48	0.33, 0.70
≥0.4cup eq/14184 kj
Total Grains	2.56	0.10	2.61	0.09	0.67	28.8	27.0	1.09	66, 1.82
≥3.0 oz/4184 kj
Whole Grains	0.96	0.08	1.02	0.08	0.30	15.4	19.6	0.75	0.45, 1.24
≥1.5 oz/4184 kj l
Milk	0.46	0.04	0.47	0.04	0.77	3.8	3.6	1.05	0.38, 2.88
≥1.3 cup eq4184 kj
Meat and Beans	2.19	0.08	2.43	0.08	0.77	30.6	40.8	0.64	0.37, 1.12
≥2.5 oz eq/4184 kj
Oils	4.81	0.52	6.10	0.38	0.011	2.7	5.1	0.52	0.20, 1.35
≥12 g eq/4184 kj
Saturated Fat	11.17	0.21	10.93	0.22	0.42	1.2	1.6	0.75	0.32, 1.78
≤7% of energy
Sodium	1321.2	26.1	1324.4	24.1	0.85	0.00	0.00	-
≤700 mg/4184 kj
Calories from Solid Fat, Alcohol, and Added Sugar	29.31	0.67	26.38	0.56	0.0001	59.1	73.6	0.52	0.35, 0.77
≤20% of energy

^aweighted samples for tooth loss categories; 0-10 teeth, N= 326 and 11+ teeth, N=309

^bAdjusted for gender, ethnicity, age, poverty status, and dental insurance.

^c4,184 kj = 1000 kcals

While few participants met the overall recommendation for total HEI-2005 score, less than 1% of those with 0-10 teeth met the recommendation as compared to 3.5% of those with 11+ teeth {[odds ratio (95% confidence limits)], [0.092 (0.02, 0.50)]}. Those with 0-10 teeth were less likely to meet recommendations compared to those with 11+ teeth for Total Vegetables {(14.7% vs. 24.2%), [0.54 (0.30, 0.98)]}, Dark Green and Orange Vegetables and Legumes {(27.1% vs. 43.6%), [0.48 (0.33, 0.70)]}, and Calories from Solid Fat, Alcohol, and Added Sugar {(59.1% vs. 73.6%), [0.52 (0.35, 0.77)]}.

For six of the twelve HEI food components, there were no significant differences between the number of teeth categories for either mean intake or percentage meeting recommended values. Whole Fruit and Total and Whole Grains requirements were met by approximately 20-35% of all participants. Fewer than 5% of participants met milk and saturated fat recommendations. All participants exceeded recommended sodium intake.

Discussion

In this ethnically diverse sample of older adults, we found that approximately half of this sample had severe tooth loss (0-10 teeth) and that these individuals had lower adherence to the USDA 2005 Dietary Guidelines(30) compared to those with 11+ teeth. Our findings that those with 0-10 teeth had few functional units in any location are consistent with reports of older adults with chewing problems having fewer teeth, fewer total functional units, and fewer posterior functional units compared to those with no chewing complaints.(9) Independent of the effects of age, sex, poverty status, dental insurance status, and education, having 0-10 teeth was associated with a five-point lower diet quality score compared to those with 11+ teeth. This difference was comparable to or greater than differences found in total HEI scores associated with age, sex, poverty status, and education.

The participants with fewer teeth had either low intake or rates of adherence to recommendations for six of the twelve food groups emphasized by the current USDA guidance(30). Differences in estimated intake per 4184 kj (1000 kcals) of Total Fruit, Whole Fruit, Total Vegetables, Meat and Beans, and Oils between those with 0-10 teeth and those with 11+ teeth represented about 10% of the recommended amounts of these food categories. The differences in Dark Green and Orange Vegetables and Legumes and Calories from Solid Fat, Alcohol, and Added Sugar represented 15% of current recommendations.

The six components related to the number of teeth represent 55% of the 100 points that comprise the total HEI-2005 score. The remaining 45% of this score included Whole Fruit, Total and Whole Grains, Milk, Saturated Fat, and Sodium components. Regardless of the number of teeth, at least 96% of participants failed to consume enough milk products and exceeded guidelines for saturated fat and sodium. The majority (70-80%) of all participants failed to consume adequate amounts of Whole Fruit and Total and Whole Grains.

A report using the original HEI index found that total HEI and HEI Fruit component scores were higher for those with 5 to 8 posterior functional units than those with fewer functional units, without teeth, and those with a full denture(5). However another report found few associations between the number of posterior functional units and the original HEI total and component scores(18). Among older adults assessed for their consumption of certain foods, nutrient and dietary intake, and nutritional status, those with 1-10 teeth had significantly more difficulty eating apples and certain kinds of bread and vegetables(17). Those with fewer teeth had lower intake of fiber, total carbohydrates, energy, protein, fat, and certain micronutrients and comparable differences were found for those with fewer posterior functional units(17). It appears that both number of teeth and posterior functional units have similar relationships with dietary intake and nutritional status.

Two-thirds of participants in this present research with severe tooth loss (0-10 teeth) were edentulous (having no teeth), and, among the remaining third, only 11% had any functional units. The USDA has found that edentulous persons had less varied and poorer quality diets containing fewer servings of fruits and vegetables, compared to the population as whole(31). Among older adults (age 70-79 y), edentulous persons consumed less energy from protein, dietary fiber, and fruits and fruit juices as well as more sweets, desserts, fats and oils(32). Within a large sample of male health professionals, those who were edentulous consumed fewer vegetables, less dietary fiber, apples, pears, and carrots compared to those with 25 or more teeth(2). A report from NHANES (1988-1994) found that those who had only 1-10 teeth consumed fewer carrots and salads and had lower serum levels of beta-carotene, folate, and vitamin C(33). This is consistent with the present findings where those with severe tooth loss ate fewer fruits and vegetables and consumed less meat and more calories from solid fat and added sugar.

The effect of impaired dental status on efforts to improve the diets of older adults has important implications for public health nutrition, particularly as it relates to fruit and vegetable consumption. Younger and older adults who were more socially isolated, had poor self-reported health, were obese, and had fewer pairs of posterior teeth were at the highest risk of consuming low amounts of fruits and vegetables.(6) Lack of dental insurance leading to tooth loss was identified by older low income women as a barrier to increased fruit and vegetable consumption(34). Perceived chewing ability explained 4% of the variance in fruit and vegetable consumption among middle to older age adults (35).

Fruit and vegetable interventions for older adults have focused on psychosocial variables, such as locus of control or self-efficacy(36). Others were designed to increase knowledge and skills related to healthful recipes and shopping(37, 38). Including recipes modified for those with impaired chewing ability may be a useful strategy for older adults(39). When barriers to fruit and vegetable intake were measured at baseline, “chewing or dental problems” were reported by 19% of participants only exceeded by “cost’ (24%) and “difficulties with digestion” (20%)(38). The perception of “chewing or dental problems” remained unchanged at the end of the four-month intervention.(38) The large number of participants with 0-10 teeth suggests that dietary interventions targeted at older adults should consider categorizing participants based on the simple measure of the number of teeth to assess the severity of their tooth loss. Intervention strategies to address the needs of those with severe tooth loss should be considered.

This study has several strengths. It is a population-based sample that includes older adults from three ethnic groups and considers oral health status along with diet quality. It utilizes the HEI-2005 scoring system, which represents the most recent USDA recommendation and, as such, provides an opportunity to examine the components based on a density standard. Although many reports have considered the effectiveness of posterior functional units in relation to diet quality, we have demonstrated that categorizing individuals based on severe tooth loss vs. moderate to low losses can provide useful information about diet quality of older adults.

This study has limitations. First, the HEI-2005 as developed by USDA relies on a single 24-hour recall to assess individual food choices(40). We adapted the HEI-2005 scoring system to the FFQ output using an approach to categorizing foods similar to HEI-2005 guidance. The use of the FFQ is considered to be a valid approach for comparison of groups providing a better description of usual diet than a single 24-hour recall and is suitable for this present investigation(41). Prior research validated the FFQ using the average of six 24-hour recalls for comparison. The FFQ provided results that allowed the comparison of dietary intake across participants in this study population(25). Second, underreporting of energy intake by rural older adults can potentially introduce bias into comparisons between groups(27,42). These previous reports have found that rural older adults are failing to report both healthful and unhealthful foods. The HEI-2005 density standard approach can minimize the impact of underreporting by allowing scoring to be independent of individual’s reported energy intake(23). Third, this study was a cross-sectional investigation, and thus a causal relationship between oral health status and food choices can not be established.

In summary, older adults with severe tooth loss have low adherence to the USDA 2005 Dietary Guidelines for Americans. Although overall older adults were not meeting recommendations, our findings showed that in food groups emphasized in the 2005 USDA guidance, older adults with severe tooth loss had a greater disadvantage compared to those with more teeth. The oral health status of older adults should become a key consideration in efforts to understand and improve the diet quality of older adults.