Abstract
Background:
The beverages containing sugar are proven risk factors for obesity and dental caries. Therefore, owing to the shared risk factors, an interrelationship is suspected between BMI, sugar beverage consumption, and dental caries in children.
Aims:
The present trial was carried out to assess the interrelationship between BMI, sugar beverage consumption, and dental caries in children aged 6–10 years.
Materials and Methods:
Eighty-six children within the age range of 6–10 years answered the health questionnaire. The BMI was calculated, intra-oral assessment was done, the frequency of sweetened beverage consumption was recorded, and the collected data were subjected to the statistical evaluation to formulate results.
Results:
On evaluation, a non-significant difference was observed in BMI levels in the four groups (P = 0.12). Whole-milk intake also showed an inverse correlation with dental caries and BMI, but this correlation was statistically non-significant with the respective values of P = 0.57 and 0.55. A similar inverse relationship was seen for low-fat milk for caries and BMI with P = 0.65 and 0.45, respectively. Regarding soft drinks, 44.1% (n = 38) took soft drinks, and a non-significant relation between caries and intake as well as BMI and intake with P = 0.86 and 0.55, respectively.
Conclusion:
Within its limitations, the present study concludes that no correlation exists between BMI and dental caries as well as between sugar-containing beverage consumption and dental caries. Also, BMI and sugar-containing beverage consumption showed no correlation in children aged 6–10 years.
KEYWORDS: BMI, dental caries, obesity, overweight, sugar-sweetened beverages
INTRODUCTION
Dental caries is a chronic disease of microbial etiology affecting a large population irrespective of age causing pain, sensitivity, and eventually tooth loss if not treated. The data on caries prevalence show a great variation in its distribution with increasing incidence even in geographical areas with less caries prevalence, whereas a decrease in caries prevalence is seen in the developed countries owing to preventive measures and fluoride use.[1] There is a lack of an adequate tool to predict the caries risk owing to its multifactorial etiology including diet, time, microorganisms, and a host. However, various factors are considered to predict the caries risk including dietary habits, salivary properties, plaque, behavior, and time.[2]
A major health problem affecting children globally is obesity, which has reached an epidemic level in India according to NFHS (National Family Health Survey), involving 5% of the population with a great proportion of children. Obesity in children is assessed by age, gender, and BMI. Increasing obesity in children is attributed to the intake of fast foods and sugar-containing drinks. Sugar consumption is also a risk factor associated with dental caries and obesity in children compared to children with normal weight. Sugar is a cariogenic food promoting the growth of streptococcus mutans, which is the main causative factor of caries. Plaque removal and oral hygiene maintenance decrease caries in children despite high-sugar intake, and hence, is an important factor for caries.[3]
Sugar-containing drinks and beverages include soda drinks, sweetened milk, and fruit drinks, including juices, punches, and nectars, and are the main sugar source in children. These drinks are fat gaining in children than solid foods which have higher satiety value, and hence, limited intake and weight gain compared to liquids. Complete fruit juices contain fructose and glucose usually diluted with sugar syrup. Soft soda drinks are also sweetened with flavored sweeteners and high fructose corn syrups. However, milk has neutral pH and is shown to cause fewer caries with a higher intake than fruit juices.[4]
Beverages containing sugar are proven risk factors for obesity and dental caries. Therefore, owing to the shared risk factors, an interrelationship is suspected between BMI, sugar beverage consumption, and dental caries in children. Hence, the present trial was carried out to assess the interrelationship between BMI, sugar beverage consumption, and dental caries in children aged 6–10 years.
MATERIALS AND METHODS
The present clinical trial included subjects visiting the Department of Pediatric Dentistry. The study subjects comprised 86 children within the age range of 6–10 years with a mean age of 7.8 years. The inclusion criteria were the age of 6–10 years and the American Society of Anesthesiologists (ASA) status of I or II. The subjects who were below 6 years or above 10 years, having systemic diseases, and whose parents did not agree to give consent for study participation were excluded from the study.
After inclusion, a questionnaire was given to the parents of all the subjects. The questionnaire was concerning the sugar-containing beverages intake, their quantity, and water intake as defined by the previous trial.[5] However, questions concerning alcohol intake were eliminated and milk consumption was added. The beverages included were fruit juice, sweetened fruit drinks, milk, whole milk, milk without fat, tea, coffee, additive ice cream in beverages, soft soda drinks, energy drinks, chocolate-containing drinks, and/or protein shakes; 5 minutes was the allotted time for questionnaire completion.
After obtaining approval from the concerned ethical committee, informed consent, both in verbal and written forms, was taken from the parents of the participating children. Also, verbal consent was taken from the children. The study procedure was explained in detail before the commencement of the study. No compensatory rewards or benefits were given in return. The health status and the demographic characteristics of the study subjects were also recorded. After completion of the questionnaire, the height and weight were measured and recorded using the same scale for all the subjects. These height–weight data were used to calculate BMI in kg/m2.
Following this, the intra-oral assessment was done to record the prevalence of dental caries in the primary posterior teeth and permanent first molars owing to the missing anteriors frequently seen in the study age group. Along with the routine dental assessment, past dental data regarding dental caries and the available radiographs were also evaluated. The frequency of sweetened beverage consumption was also recorded.
The collected data were subjected to the statistical evaluation using SPSS software 21.0, Chicago, IL., ANOVA, t-tests, and Pearson correlation tests were applied to the procured data. The statistical significance was fixed at a P value of 0.05. The results were formulated after a statistical evaluation.
RESULTS
A total of 86 subjects of 6–10 years with a mean age of 7.8 years were assessed. The demographic data of the study subjects are described in Table 1. The mean BMI of the subjects was 17.6 ± 2.5. There were 43.02% males (n = 37) and 56.97% females (n = 49). Caries activity was seen in 83.72% (n = 72) of the subjects and was not seen in 16.27% (n = 14) of the subjects; 17.44% (n = 15) of the subjects were vegetarian, whereas 82.55% (n = 71) of the subjects were taking mixed diet.
Table 1.
Demographic characteristics of the study subjects
| Characteristics | Parameters | Values | % | n |
|---|---|---|---|---|
| Mean BMI | 17.6±2.5 | |||
| Mean Age | 7.8 | |||
| Age Range | 6-10 | |||
| Gender | Male | 43.02% | 37 | |
| Female | 56.97% | 49 | ||
| Caries Activity | Present | 83.72% | 72 | |
| Absent | 16.27% | 14 | ||
| Diet | Vegetarian | 17.44% | 15 | |
| Mixed | 82.55% | 71 |
Concerning BMI, one-way ANOVA was applied to assess the effect of age on BMI. The age groups were divided into four groups: 6–7 years, 7–8 years, 8–9 years, and 9–10 years. On evaluation, a non-significant difference was observed in the BMI levels in the four groups (P = 0.12). For gender-based evaluation of BMI in the study subjects, a t-test was applied and the results showed no significant difference in the BMI of females and males with a P value of 0.76. The relationship of BMI was also assessed based on the presence of dental caries in the study subjects, and it was seen that the difference seen in BMI was statistically non-significant in the study subjects with and without dental caries (P = 0.16) as shown in Table 2. Among 72 subjects with dental caries, 19.4% (n = 14) of the subjects were aged 6–7 years, 20.83% (n = 15) of 7–8 years, 33.3% (n = 24) of 8–9 years, and 26.38% (n = 19) were 9–10 years. Based on the age of the study subjects, no significant difference was seen in caries prevalence (P = 0.96). Similarly, no significant difference in the caries status based on gender (males or females) was seen (P = 0.81) [Table 2].
Table 2.
Effect of various parameters on the BMI and dental caries in study subjects
| Parameter | Subgroups | BMI (mean±SD) | P | % (n) | P |
|---|---|---|---|---|---|
| Age Group [years] | 6-7 | 17.1±3.03 | 0.12 | 19.4% (14) | 0.96 |
| 7-8 | 17.5±2.53 | 20.83% (15) | |||
| 8-9 | 18.1±3.07 | 33.3% (24) | |||
| 9-10 | 18.9±3.45 | 26.38% (19) | |||
| Gender | Males | 17.8±2.89 | 0.76 | 86.4% (32) | 0.81 |
| Females | 17.9±2.92 | 85.71% (42) | |||
| Caries | Present | 17.8±2.92 | 0.16 | ||
| Absent | 18.9±3.18 |
The present study also assessed the individual beverage intake and their effect on BMI and dental caries was calculated using Pearson correlation [Table 3]. Concerning water, it was seen that all subjects consumed water. Water consumption and caries showed a statistically significant inverse relation (P = 0.02) and no significant relationship between water intake and BMI (P = 0.06); 41.8% (n = 36) of the subjects consumed whole milk. Whole-milk intake also showed an inverse correlation with dental caries and BMI, but this correlation was statistically non-significant with respective values of P = 0.57 and 0.55. A similar inverse relationship was seen for low-fat milk for caries and BMI with P = 0.65 and 0.45, respectively. A total of 24.41% (n = 21) of the study subjects consumed low-fat milk. For fruit juice intake, a significant association was seen in juice intake and dental caries (r = 0.24, P = 0.01), but for BMI, non-significant and inverse relation was seen (r = -0.12, P = 0.15). Regarding soft drinks, 44.1% (n = 38) took soft drinks, and a non-significant relation was seen between caries and intake as well as BMI and intake with P = 0.86 and 0.55, respectively; 23.25% (n = 20) of the subjects consumed tea, and the intake of tea on Pearson correlation showed a non-significant correlation between its intake with BMI and caries with r = 0.14 and 0.07 and P = 0.39, 0.62, respectively.
Table 3.
Pearson correlation [r] showing association of sugar-sweetened beverages with BMI and dental caries
| Beverage | Correlation | BMI | Dental Caries |
|---|---|---|---|
| Water (n=86) | r | 0.14 | -0.16 |
| P | 0.06 | 0.02 | |
| Whole Milk (n=36) | R | -0.06 | -0.06 |
| P | 0.57 | 0.55 | |
| Low-Fat Milk (n=21) | R | 0.12 | -0.06 |
| P | 0.45 | 0.65 | |
| Fruit Juice (n=65) | R | -0.12 | 0.24 |
| P | 0.15 | 0.01 | |
| Soft Drink (n=38) | R | -0.06 | 0.03 |
| P | 0.55 | 0.86 | |
| Tea (n=20) | R | 0.14 | 0.07 |
| P | 0.39 | 0.62 |
DISCUSSION
The present study was cross-sectional to assess the relation between BMI and caries with sugar-containing beverages in children aged 6–10 years. The results showed no correlation between BMI and caries with sugar-containing beverages intake. These results can be attributed to a few limitations such as a small study population or inaccurate response to sugar intake. It was seen that 89.53% (n = 77) of the study subjects consumed sugar beverages in one form or another which is consistent with findings of the 2009-2010 data of NHANES.[6]
About 41.8% (n = 36) of the subjects consumed whole milk. Whole-milk intake also showed an inverse correlation with dental caries and BMI, but this correlation was statistically non-significant with respective values of P = 0.57 and 0.55. A similar inverse relationship was seen for low-fat milk for caries and BMI with P = 0.65 and 0.45, respectively. These findings agreed with Marshall et al.[7] in 2003, where the authors reported low caries in subjects taking milk than in subjects consuming less/no milk.
Concerning water, it was seen that all subjects consumed water. Water consumption and caries showed a statistically significant inverse relation (P = 0.02) and no significant relationship between water intake and BMI (P = 0.06). The subjects who consumed more water had fewer caries than the subjects consuming less water. For fruit juice intake, a significant association was seen between juice intake and dental caries (r = 0.24, P = 0.01), but for BMI, non-significant and inverse relation was seen (r = -0.12, P = 0.15). These results were similar to the findings by Sohn et al.[8] in 2006, where the authors reported more caries in subjects consuming fruit juice. However, the study by Vargas et al.[9] in 2014, showed contrasting results with no correlation of caries with fruit juice intake. Regarding soft drinks, 44.1% (n = 38) took soft drinks and there was a non-significant relationship between caries and intake as well as BMI and intake with P = 0.86 and 0.55, respectively. These findings were not in agreement with the findings of Lim et al.[10] in 2008, where the authors reported a significant relationship between caries with higher soft drink intake.
The findings of no relation between caries and BMI agreed with the studies of Macek et al.[11] in 2006 and were against the study of Hilgers et al.[12] in the same year where an association between BMI and caries was observed.
CONCLUSION
Within its limitations, the present study concludes that no correlation exists between BMI and dental caries as well as between sugar-containing beverage consumption and dental caries. Also, BMI and sugar-containing beverage consumption showed no correlation in children aged 6–10 years. Only fruit juice intake and caries showed a significant relation. The study had a few limitations including a smaller sample size, monitoring period, questionnaire response by parents, geographical area bias, and cross-sectional nature. Hence, more longitudinal studies with larger sample size and monitoring period are required to reach a definitive conclusion.
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.Chen X, Daliri EBM, Kim N, Kim JR, Yoo D, Oh DH. Microbial etiology and prevention of dental caries: Exploiting natural products to inhibit cariogenic biofilms. Pathogens. 2020;9:569. doi: 10.3390/pathogens9070569. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Laputkova G, Schwartzova V. Protein roles in oral health and as predictors of caries risk. Open Life Sci. 2018;13:174–200. doi: 10.1515/biol-2018-0023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Shannawaz M, Arokiasamy P. Overweight/obesity: An emerging epidemic in India. J Clin Diagn Res. 2018;12:1–5. [Google Scholar]
- 4.Mishra MB, Mishra S. Sugar-sweetened beverages: General and oral health hazards in children and adolescents. Int J Clin Pediatr Dent. 2011;4:119–23. doi: 10.5005/jp-journals-10005-1094. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hedrick VE, Comber DL, Estabrooks PA, Savla J, Davy BM. The beverage intake questionnaire: Determining initial validity and reliability. J Am Diet Assoc. 2010;110:1227–32. doi: 10.1016/j.jada.2010.05.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Han E, Powell LM. Consumption patterns of sugar-sweetened beverages in the United States. J ACAD Nutr Diet. 2013;113:43–53. doi: 10.1016/j.jand.2012.09.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Marshall TA, Levy SM, Broffitt B, Warren JJ, Eichenberger-Gilmore JM, Burns TL, et al. Dental caries and beverage consumption in young children. Pediatrics. 2003;112:e184–91. doi: 10.1542/peds.112.3.e184. [DOI] [PubMed] [Google Scholar]
- 8.Sohn W, Burt BA, Sowers MR. Carbonated soft drinks and dental caries in the primary dentition. J Dent Res. 2006;85:262–6. doi: 10.1177/154405910608500311. [DOI] [PubMed] [Google Scholar]
- 9.Vargas CM, Dye BA, Kolasny CR, Buckman DW, McNeel TS, Tinanoff N, et al. Early childhood caries and intake of 100 percent fruit juice. Data from NHANES, 1999-2004. J Am Dent Assoc. 2014;145:1254–61. doi: 10.14219/jada.2014.95. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Lim S, Sohn W, Burt BA, Sandretto AM, Kolker JL, Marshall TA, et al. Cariogenicity of soft drinks, milk and fruit juice in low-income African-American children. A longitudinal study. J Am Dent Assoc. 2008;139:959–67. doi: 10.14219/jada.archive.2008.0283. [DOI] [PubMed] [Google Scholar]
- 11.Macek MD, Mitola DJ. Exploring the association between overweight and dental caries among US Children. Pediatr Dent. 2006;28:375–80. [PubMed] [Google Scholar]
- 12.Hilgers KK, Kinane DF, Scheetz JP. Association between childhood obesity and smooth-surface caries in posterior teeth: A preliminary study. Pediatr Dent. 2006;28:23–8. [PubMed] [Google Scholar]