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4, Fall 2008
Obesity and Dental Caries in Children Aged 2-6 Years in the United States: National Health and Nutrition Examination Survey 1999-2002
Liang Hong, DDS, MS, PhD; Arif Ahmed, BDS, PhD, MSPH; Michael McCunniff, DDS, MS; Pam Overman, EdD; Moncy Mathew, DDS, MPH
Abstract Objective: This study assessed the associations between obesity and dental caries in young children participating in a national survey. Methods: Participants included 1,507 children aged 2-6 years who received dental examinations and had at least 10 primary teeth in the National Health and Nutrition Examination Survey 1999-2002. Decayed/ﬁlled teeth (dft) counts of primary dentition were obtained, and weight and height were measured. Body mass index (BMI; kg/m2) was calculated, and participants were categorized using age- and gender-speciﬁc criteria as underweight (<5th percent), normal (5th-85th percent), at risk for overweight (>85th and <95th percent), and overweight (Ն95th percent). With appropriate sample weighting, relationships between dft and BMI were assessed using the Kruskal–Wallis test and multivariable logistic regression. Results: Seventy-four percent of children were classiﬁed as normal weight, 11 percent as at risk for overweight, and 11 percent as overweight; 58 percent did not have caries; 30 percent had 1-5 dft and 12 percent had >5 dft. When caries experience was compared across BMI categories stratiﬁed by age and race characteristics, statistically signiﬁcant association between caries and obesity was found only for 60- <72-month age group. In the comparison between children with normal and at-risk BMI only, signiﬁcant associations were also found in the Hispanic and non-Hispanic Black strata. In multivariable logistic regression models to predict caries experience, family income and age were statistically signiﬁcant predictors for severe early childhood caries only. Conclusions: There appears to be no signiﬁcant association between childhood obesity and caries experience after controlling for age, race, and poverty/income ratio. However, further studies are needed to better understand this relationship. Key Words: obesity, dental caries, childhood, primary teeth
Introduction Although the prevalence of dental caries has declined in the past several decades, it continues to be a signiﬁcant public health problem among children in the United States (1). In particular, racial and ethnic minority children and children living in poverty have a disproportionately higher burden of dental caries (2). Dental caries is the most common chronic childhood disease—in some age groups it is ﬁve times more prevalent than asthma (1). Early
childhood caries, which affects primary teeth during early stages of life, can have a profound impact on a child’s oral and general health, and quality of life. Twenty-eight percent of the children in the United States aged 2-6 years old have caries, and the prevalence increased by 15 percent during the past decade (3). Among the children with caries, three-quarters of tooth decay remain untreated (3). Childhood obesity is currently the most prevalent nutritional condition
of children in the U.S and is increasingly being cited as a growing epidemic and public health crisis (4,5). One study estimated that 25 percent of 10-year-old children were at risk for overweight and 11 percent were obese. Nationally, the proportion of overweight children aged 6-11 years has more than doubled, and the rate for overweight adolescents has tripled since 1980 (5). There has been a growing interest in the relationship between dental caries and childhood obesity. Some studies have identiﬁed a positive association between these two common childhood conditions and have suggested that obese children are at an increased risk for dental caries (6,7). Other studies, however, have reported a negative association based on the failure to thrive among children with early childhood caries and the corresponding lower body mass index (BMI) (8,9). Additional studies have also reported no association between dental caries and childhood obesity (10,11). A recent systematic review of the literature published between 1984 and 2004 found only one study with a sufﬁcient level of evidence for direct association between obesity and dental caries (12). The association between dental caries and obesity is complicated because both are complex conditions with multiple contributing factors, including biological, genetic, socioeconomic, cultural, dietary,
Send correspondence and reprint requests to Liang Hong, DDS, MS, PhD, Department of Dental Public Health and Behavioral Science, School of Dentistry, University of Missouri-Kansas City, Kansas City, MO 64108. Tel.: 816-235-2496; Fax: 816-235-5472; e-mail: email@example.com. Liang Hong, Michael McCunniff, Pam Overman, and Moncy Mathew are with the Department of Dental Public Health and Behavioral Science, University of Missouri-Kansas City, Kansas City, MO. Arif Ahmed is with the Department of Public Affairs, University of Missouri-Kansas City, Kansas City, MO. The results of this report were presented at the 2006 National Oral Health Conference, Little Rock, Arkansas, May 1-3, 2006. Manuscript received: 3/5/2007; accepted for publication: 11/9/2007. © 2008, American Association of Public Health Dentistry DOI: 10.1111/j.1752-7325.2008.00083.x
507 – among those. ethnicity.000 persons each year from 1999 to 2002. Dietary data were collected by trained and calibrated registered dietitians through 24-hour recall interviews to estimate the intake of food energy. including information on asthma. hay fever. The PI was computed as a ratio between the midpoint of the reported family income category and the poverty threshold value deter- . c2 analyses and Kruskal–Wallis tests were used to compare socialdemographic. Since this study was limited to children 2-6 years old. normal weight – 5th percentile to less than 85th percentile. cancer or malignancy. and the poverty index (PI). one or more decayed or ﬁlled surfaces in primary maxillary anterior teeth from ages 3 to 5 years. The survey. such as exfoliation and trauma. Nevertheless. and gender. Consequently. Further. daily total carbohydrate intake. medical history.and gender-speciﬁc criteria recommended by the Centers for Disease Control and Prevention (15): underweight – less than 5th percentile. More detailed information on the sample design and operation of NHANES 1999-2002 can be found elsewhere (14). Since few children had arthritis. The number of decayed and ﬁlled teeth (dft) was calculated for each participant. or Ն6 (age 5) (14). Weight was measured when the child stood on a digital scale that was connected to the Integrated Survey Information System (ISIS) and standing height was measured with an electronic stadiometer that was also connected to the ISIS. race. root caries. and childhood obesity is also associated with low socioeconomic status (SES) in the United States (13).23 explorer. Logistic regression models were developed to predict caries experience (yes/no). is based on a nationally representative sample of approximately 5. The ﬁlling component represented a tooth surface that has been restored with either a permanent or a temporary restoration as a result of caries. Individual characteristics were categorized and presented as percentages or means (standard error). c2 test was used to test for categorical associations between caries prevalence and BMI categories after stratifying by age and race. severe early childhood caries (S-ECC) was deﬁned as follows: any sign of smooth surface decay in children younger than 3 years of age. environmental. cancer or malignancy. Since very few studies have explored this issue using large-scale national samples. oral health examinations were completed on 1.904 children aged 2-6 years. This age group was chosen to focus the analysis on primary tooth caries. Weight and height were measured during a physical examination. and stroke. and overweight – equal to or greater than the 95th percentile. coronary heart disease. at risk of overweight – 85th to less than 95th percentile. chronic bronchitis. Because of difﬁculty of correctly distinguishing among teeth extracted for caries and other reasons. arthritis. Children were classiﬁed into four categories using age. dental sealants. missing teeth count was not included in this analysis. Our study was limited to children who were 2-6 years old with at least 10 primary teeth present in the mouth at the time of the oral examination.to 6-yearold children. and daily total sugar intake. using criteria from the American Academy of Pediatric Dentistry. and nonnutrient food components from foods and beverages consumed during the 24-hour period (from midnight to midnight) prior to the MEC examinations (16). Household interviews provided information on demographic variables. the aim of our study was to assess the associations between obesity and dental caries in children aged 2-6 years (24 to <72 months) who participated in the National Health and Nutrition Examination Survey (NHANES) 1999-2002. The number of children meeting the eligibility criteria of this study was 1. diabetes. children at the highest risk for dental caries are disproportionately from minority households and/or live in poverty (1). and healthrelated behaviors of the 2. daily total fat intake. ear infection. medical. childhood obesity and caries may share some common risk factors. BMI categories were compared between caries-free children and those with S-ECC using c2 test after stratifying by age. Dietary variables included in this analysis were daily total energy (kcal) intake. coronary heart disease. coronal caries. Medical history was obtained in the interview. Of those. and lifestyles issues. Participant’s caries status was categorized into three groups: 0 dft. BMI was calculated using the standard formula: weight in kilograms (kg) divided by height in meter squared (m2). incisor trauma. The dentition assessment included tooth count. Oral health examinations were conducted in the mobile examination centers (MEC) and included dentition and periodontal assessments. only coronal caries was included in the analysis. which entailed interviews and physical and laboratory examinations. Further. Coronal caries was assessed by trained and calibrated dentists using a visual-tactile method with standardized equipment and supplies. age at examination. The model included the variables that were signiﬁcant in bivariate analyses or thought to be potentially important: child’s BMI category. 71 percent had all 20 primary teeth. dietary. and enamel ﬂuorosis. nutrients. Demographic variables included gender. or dfs Ն4 (age 3). Over the 4 years of data collection 21. diabetes. Methods Data from NHANES 1999-2002 were used for this cross-sectional study. 1-5 dft. For example. only asthma was included in our analysis. a PI value below 1 indicates that the family income is below the poverty threshold. child’s age. chronic bronchitis. and >5 dft.228 Journal of Public Health Dentistry mined by the Census Bureau. and/or stroke.004 persons were selected and interviewed. Ն5 (age 4). Each quadrant was dried with air and examined with a surface reﬂection mirror and a No. and dental variables between caries experience categories and among BMI categories.
6 percent were obese.9 percent had normal weight.4%) (0. and 10. and WTMEC4YR provided with the NHANES 1999-2002 data were used for this purpose (14).5%) 34.0 percent had at least one decayed and/or ﬁlled tooth – 30. daily total energy intake.2) 64. mean (SE).5%) (1.02 (P = 0. Overall. SE.0% (1. or quantiles Gender (%) Male Female Race (%) Non-Hispanic White Non-Hispanic Black Hispanic Other Poverty index (PI) Mean <2. except for percentages in the 60.<72-month age group (P = 0. The NHANES Analytic and Reporting Guidelines were followed to apply appropriate weighting methodology for adjustment for the complex sample design and the unequal probability of selection.1) (0. 11. Results Characteristics of the 2. 176.02).0 percent had more than ﬁve dft.9) 14% (1. medical. SDMVPSU. race. No statistically signiﬁcant difference was found in the comparison of BMI category distribution – stratiﬁed by age and race – between caries-free children and those with S-ECC (Table 4).1%) 1823.01) and Hispanic (P = 0. Table 2 presents caries experience and BMI categories according to social-demographic.8% (1. or daily total sugar intake.0) 236. 73.5%) (0.05 level of signiﬁcance.9%) (2.9%) 65. 42.01 (P = 0. 229 48. When the comparison was only between the children with at risk BMI and the children with normal BMI.3% 10.3 (162.5 (71.0 percent had one to ﬁve dft and 12. daily carbohydrate intake. The correlation coefﬁcients were 0. 94. Age 2-6 Years Percentages (SE).0) 122. daily total sugar intake.5%) child’s carbohydrate intake.92) for fat intake. The majority of children in both groups had a normal BMI and only a few were underweight.0 (1330.Obesity and Dental Caries in Children Table 1 Characteristics of Study Sample.28) for sugar intake. although percentages and mean dft for BMI categories varied in different strata. Four dietary variables including daily total carbohydrate intake. About 4. dietary.9% 11.3.2% (1.0 Ն2.049) and mean dft among African-American race (P = 0.7% 13.8 (SE 0. Generally. asthma condition. 75th percentile) Asthma (%) Dental caries Mean dft 0 dft 1-5 dft >5 dft Dental visit in last year (%) Yes No dft. daily fat intake.5%) (1.3%) 44% (2.4.7%) (1. those with at-risk BMI had a signiﬁcantly higher percentage with caries and higher mean dft in the 60-<72-month age group and signiﬁcantly higher mean dft in the AfricanAmerican (P = 0. 75th percentile) Daily total fat intake (gm) Median (25th.02) strata (last column in Table 3). the mean number of dft was 1. 0. the variables SDMVSTRA. and family income.9% (2. 323. race.09) (1. 75th percentile) Daily total carbohydrate intake (gram) Median (25th.6% (0. A logistic regression model predicting caries experience (any .04 (P = 0.3%) 16.1 at the 0.2 4.0% 12.0% 30. children with at-risk BMI or overweight BMI had a higher percentage of caries and higher mean dft than children with normal BMI.2% 73.5%) 60.5% 5.71) for carbohydrate intake.2 (43.to 6-yearold children are summarized in Table 1. PI.09). decayed/ﬁlled teeth.79 58. Most of these differences across BMI categories were not statistically signiﬁcant.2 (0.1) 56% (2. there was no statistically signiﬁcant difference in percentage distribution of caries experience and BMI categories by gender. All statistical tests were conducted in SAS 9. and dental visit characteristics.2 percent were underweight. Caries experience (both percent of children with caries and the mean dft score) was compared across the BMI categories stratiﬁed by age and race (Table 3). 0.9% 19. The results comparing percentage distribution of only normal and at risk BMI between caries-free children and those with S-ECC showed a similar pattern (last column in Table 4).9%) (1. and 0.002 (P = 0. daily total fat intake.0 Body mass index (BMI) Mean Underweight Normal At risk Overweight Daily total energy (kcal) Median (25th.5.1%) 2.0% (0.4%) 1.3 percent were at risk of overweight. and daily total energy intake were examined for individual relationship with caries experience using Spearman correlation analysis.1%) (1.51) for total energy intake. National Health and Nutrition Examination Survey 1999-2002.5%) 52. 2407. standard error. dental visit in the previous 12 months.0% (1. 75th percentile) Daily total sugar intake (gm) Median (25th.0.
4 (1.4 (1. One possible explanation is that both are agerelated cumulative conditions and thus the older group is more likely to exhibit a stronger relationship.9) 9.8 (1. non-Hispanic Black. 178.9 (0.0) 261.3 (0. 323.7.2 (1.4) 58.9 (1.2 4.2) (0. P = 0. however. 19).01] and PI (OR = 0. a logistic regression model was also ﬁtted for predicting S-ECC (yes/no in Table 5).5) 188.8.131.52.2) 10.6) (0.2) 58.8. P < 0.5) 257.7 1991. Discussion Using data from NHANES 19992002. race (non-Hispanic White.7) 41.1 (0. Using the same ﬁve predicator variables.7 (153.3 (1332.8 4.5) 70.and gender-speciﬁc criteria.9) Median (25%. 178.2. gender.1 (0.1 (1.0 12.7) (0.0) (0.1 (0. 2426.6) 77.4 (1.7 137.7) 58.1) 58.01) were statistically signiﬁcant in predicting severe early childhood caries. After stratifying by age.7 6. 311.0 (1357.4) 56.7) 75. the relationship between childhood obesity and dental caries was assessed.2 7.4.6 (0.1) 43.1 (150.4) (1.0) 134. 320.4) (0.230 Table 2 Caries Experience and Body Mass Index (BMI) Categories According to Characteristics of Children Aged 2-6 Years Caries experience Caries-free Percent Percent Caries present Underweight BMI Normal BMI At-risk BMI BMI categories* Overweight BMI Gender Poverty index† Race Has asthma Dental visit in previous year Male Female <2 Ն2 Non-Hispanic White Non-Hispanic Black Hispanic Others No Yes No Yes 4.1) 6.9) 41. body mass index.3. 98.3) (44. 2459.5. 322.3 (1.7.6 (1.8) (0.9) (159. about 11 percent were at risk of overweight and 10 percent were actually overweight. This is consistent with some studies that have reported higher prevalence of both obesity and dental caries among children from minority groups and/or low SES families (1.0 (163.4 (0. the relationships between childhood obesity and dental caries were not statistically signiﬁcant. The observation is consistent with other studies related to childhood obesity (17-18).2.6 7.4 (0.7) 11.1) 80. BMI.9 (1. a signiﬁcant association was detected not only for the 60-<72 months age group. but also for the AfricanAmerican and Hispanic children.5) 57.9 (2.3) 14.59. and carbohydrate intake (tertiles: <187 mg.3) 57.5 12.2) 1887.7 (0. Ն288 mg).0 (1318.8) 66. Age [odds ratio (OR) = 1. or others).8) 31.1 9. 96.4.6 3.2) (0.0 (0.8 (1.8) 75. 165.6) (1.5) 11.5) (0. 2447.8 (79.3 (0.7 (42.9 (0.5 17.6 (2.9) 72.0 2006.2) 136.2. 2339.9 259. 75% percentile) 1948.7 (1.2 3. none of these factors was a statistically signiﬁcant predictor of caries experience. In this sample of 1.5) 11.7 (0.3 1.6) 71.82.5) 56. race.0 (1.4 259. poverty (PI.0) (1285. † Poverty index was computed as a ratio between the midpoint of the family income category reported by the participant and the poverty threshold value determined by the Census Bureau. It is unclear why the dental caries-obesity relationship for the 60-72 month group differs from the other age groups. In the comparison between children with at risk BMI and those with normal BMI.1.5.507 2.2) 71. 177.5 134.6) 45.2) 237.3) 2209.1 11. Children were classiﬁed into four categories using age. except among children aged 60-72 months.6) (0.9) (0.9) 11.1) 41.3 (0.0.2 (1.8 5.0 (67.5) 12.9 (1.6) (1.3) (73.5.0 (1. 2327.4.4 (0.5) (0.9 (42.9) 11.8.6) 118.2) (0. decayed/ﬁlled tooth: yes/no) was ﬁtted using ﬁve predictor variables: age (years).5) (1402. Hispanic.8) Median (25%.6.7.<288 mg.8 (0.2 (1.8 (1.9) 12.3) 77. 2208.4) 72.9.1 74. <2 or Ն2).5) 58.9) 42.0 10. 323.to 6-year-old children.6 10.9 (1309.4) 14.2 (1.4 (77.3 (46.8) (1. Most children had normal BMI.2) 74.9) 55.4) (0.7 (1.4 0.6 (1.3) 41.7 3. 187. 87.1) 146.2) 11.3 (1.8) 75.0) 289. 96.2) (88. 13.6) 42.9 (1.1) (44. 75% percentile) 1986.0) (0. obesity (BMI Ն95 percentile).0 184.108.40.206 (1.2 4.6 (1.1) Daily total energy intake Daily total carbohydrate intake (gm) Daily total fat intake Daily total sugar intake (gm) 58.9 (1. 178.6) 41.1 (1.2) (0.9 (0. 175. dental caries was a prevalent disease.5) (0.2) (0. The observed association Journal of Public Health Dentistry .4 (0.8 (1.3 (1. and family income.7) (173.2) * BMI was calculated using weight in kilograms (kg) divided by height in meter squared (m)2.6 10.2 (163.5 9.3 5.4) 71. In this multivariable logistic regression model (Table 5).2 (46. 94.0) 68.8 (76.0) (0.3) 41.8) 73.3 2. 84.3) 43. 302.
92 dft mean (SE) * BMI was calculated using weight in kilograms (kg) divided by height in meter squared (m)2.3 81.8 50.1) (0.8) (1.5) (0.42 0.3) (2.1 20.44 0.8 39.2 11.9 6.31 0.6 54.2 2.92 0.8) 11.5 4.5) (2.1) (0.64 0.0 39.9) (0. † P-value from c2 test for proportions or ANOVA for means.32 0.5) (0. † S-ECC was deﬁned using criteria from American Academy of Pediatric Dentistry.4 1.7) (0.4 41.9 (0.1) (0.1 74.27 * BMI was calculated using weight in kilograms (kg) divided by height in meter squared (m)2.0) (1.8 (4.0 32.01 0.97 NA 0.and gender-speciﬁc criteria recommended by the Centers for Disease Control and Prevention: underweight – less than 5th percentile.4 1.9) (4.5) (5.6) (0.4) (0.68 0. between BMI and caries among African-American and Hispanic children might be a reﬂection of the role of SES in both conditions.05 0. and overweight groups.4) (0.6) (3.4 11.5 2.4) (5.54 0.2 9.13 0.2) (0.6) (0.60 0.5) (1.6) (0.6 40.5) (2.6 3.8) (1. ‡ P-value from c2 test comparing percentage distribution of normal.26 0.7) (0.6) (0.7) (1. standard error.8 (1.3) 38.7 11.6 83.5 1.7) (0.0 3.9) (0.1 (1.6) (0.7) (1.3 3.0) (3.5) (1.3 9.1) (4.3 66.0 94.6 1.6 (2.3 4.2) (0.5) 0 (0.3) (0.0 8.1) (6.8) (1.6 44.4) (0.38 0.2) (0.7 4.89 0.1) (1.97 0.2 34.1) (1.5 5.5) 54.0 73.3 6.9 0. together with those of other investigators.3) (3.5) 79.44 0. comparing normal.2) (1.4 41.71 0.0) (2.8 14.69 0.8) (2.0 1.6) (2.4) (0.6 12.6 1. Considering the results from this analysis.3 47. and overweight groups. speciﬁc groups of children.4 (3.2) (0.2 43.8) (2.5 73.2 8.9) (0.5 2.1 29.7 75.1 73.4) (0.3 8.7) (1.3 51.2) (0. particularly when samples consisted of local.4 15.6) (0.0 84.23 0. Children were classiﬁed into four categories using age.5) (4. dft.7) (3. at risk of overweight – 85th to less than 95th percentile.0 1.Obesity and Dental Caries in Children 231 Table 3 Percentage with Caries and dft by Body Mass Index (BMI)* Category Among Children Aged 2-6 Years P-value P-value Normal BMI At-risk BMI Overweight BMI (3 groups)† (2 groups)‡ Percent of children Age with caries (SE) 24-<36 months (417) 36-<48 months (276) 48-<60 months (295) 60-<72 months (276) Race Non-Hispanic White (355) Non-Hispanic Black (351) Hispanic (445) Others (62) Age 24-<36 months (417) 36-<48 months (276) 48-<60 months (295) 60-<72 months (276) Race Non-Hispanic White (355) Non-Hispanic Black (351) Hispanic (445) Others (62) 39.6) (5.6 2. comparing only normal and at-risk groups.6 10.4 3.4 9. SE.40 0.6) (0.7) (1.02 0.7) (0.4 2.9) (0.2) (2.4) (1.1 11.39 0.04 0.9) (0.01 0.1) (0.2) (2.7 1.2) (2.5 1.0) (2.5) (2.2) (0. at risk.8 3.6 (3.8 41.2) 0.6) (2.4 47. ¶ P-value from c2 test comparing percentage distribution of only normal and at-risk groups. suggest an intricate .4) (2.and gender-speciﬁc criteria.8 1. it is not surprising that different studies (6-11) have observed different relationships.4 1. Table 4 Percentage Distribution of Body Mass Index (BMI)* Categories in Caries-Free and Severe Early Childhood Caries (S-ECC)† Children Underweight BMI Normal BMI At-risk BMI Overweight BMI P-value‡ P-value¶ Age Caries S-ECC 36-<48 months Caries S-ECC 48-<60 months Caries S-ECC 60-<72 months Caries S-ECC Race Non-Hispanic White Caries S-ECC Non-Hispanic Black Caries S-ECC Hispanic Caries S-ECC Others Caries S-ECC 24-<36 months Free Free Free Free Free Free Free Free 6.5 77.1) 0 0.6) (0.0) (2.21 0.88 0.4) (0.69 0.3) (1.8) (1.01 0.83 0.56 0.9 37.8 1.8 3.5 47.9 50.9) (2.3) (3.4) (2.4 1.77 0.6 3.5) (1.97 0.4 7.4) (1.1) (4.7 3. normal weight – 5th percentile to less than 85th percentile.8 82. ‡ P-value from c2 test for proportions or t-test for means.5 3.4) (1.4) (0.51 NA§ 0. Children were classiﬁed into four categories using age.4 2.76 0.02 0.7) (0. Our ﬁndings.7 6. § No P-value was calculated due to zero observations in the cell.2) (2. decayed/ﬁlled teeth.7) 3.63 0.3 21.52 0. at risk.9 1.2) (1.8) (2.8 11.2) (1. and overweight – equal to or greater than the 95th percentile.6 5.24 0.3) (2.8 75.2) (0.9 2.9 18.7 8.3 5.0 14.22 0.8 2.9) (0.8 5.9) 0 (0.17 0.4 10.7 64.8) (0.2) (1.7 78.27 0.2) (0.7 1.6 1.9) (2.42 0.5 68.0 10.2) (0.5) (1.
Vargas CM. environmental. Marshall et al. and BMI category. Furthermore.44 Severe early childhood caries (S-ECC)¶ (yes/no) * Poverty index was computed as a ratio between the midpoint of the family income category reported by the participant and the poverty threshold value determined by the Census Bureau.88) (0. with low SES individuals being at higher risk of caries (2. Part of the data was based on self-reports and thus subject to recall bias. results from this analysis of a large national sample of young children suggest a complex multifactorial relationship between childhood obesity and dental caries. picture in which many factors may simultaneously inﬂuence the relationship between caries and obesity. characteristics of the population. 3.129:1229-38. highly reﬁned food choices and dietary habits have been identiﬁed as important contributors to the obesity epidemic (25-27). 19). identiﬁed measures of SES (parents’ education and family income) that were predictive of both caries experience and obesity among children in an Iowa cohort (19).59 1. 1988–1994.11 0.41-0. 22). 17-18.31) (0. National Institutes of Health.02 1. Furthermore. Identiﬁcation of children at risk of being overweight early in life may give health care providers and parents the opportunities for early intervention to decrease risk for both obesity and 2.08 1. Atlanta (GA): CDC.26) (0. 23).98-1. parents’ education and occupation. including longitudinal studies.11 1. One of the important ﬁndings of this study was that children at risk of being overweight generally had higher caries experience than their normal weight peers.” but rather a common risk factor increased the likelihood of both diseases. 7. Crall JJ.01 0. Both obesity and dental caries are complex conditions and many biological. causal relationships cannot be established and the observed association could be due to other unexplored factors. Although the mechanism is not clear. In some developed countries. 10. † Overweight was deﬁned as having a body mass index of Ն95 percentile.20 1.38) P-value 0. CDC morbidity and mortality weekly report 2005. CDC. This analysis utilized a nationally representative sample and thus allowed for greater examination of complexity in the relationship between obesity and dental caries. must be considered when the relationship between childhood obesity and dental caries is assessed. ‡ Carbohydrate intake was categorized into tertiles based on frequency distribution: <187mg.62 0. Acknowledgment We thank Drs. genetic. to identify the particular pathways through which different factors inﬂuence dental caries and obesity. after controlling for age.10 (0. US Department of Health and Human Services. A dietary habit that contributes to obesity could also increase caries risk. National Institute of Dental and Craniofacial Research. However.01 0. Schneider DA. since the reasons for missing teeth could not be explicitly sought. Teresa Marshall and Steven Levy for their constructive suggestions on data analysis and interpretation.67-1. Since the data was crosssectional. Rockville (MD): US Department of Health and Human Services.gov/ MMWR/preview/mmwrhtml/ss5403a1. 2005 [cited 2006 April 12].33 0.232 Journal of Public Health Dentistry Table 5 Logistic Models Predicting Children’s Caries Experience caries.03) (0.cdc. Oral in America: a report of the surgeon general – executive summary. This may have excluded a certain number of teeth lost due to caries.43-2. some limitations must be observed.62-1. J Am Dent Assoc. within study limitations.99-1. caries co-existed with the risk of being overweight in these studies.82 0.28 0.]. Available from: http://www.81-1. Additionally.10 1. Energy-dense.84 1.83 <0.23) (0. 2000.23) (0.17) (0. educational interventions addressing dietary issues should highlight both consequences (overweight and dental caries) simultaneously. htm Outcome variable Any decayed and/or ﬁlled tooth (yes/no) Predictor variables Age (years) Poverty index* Overweight† Race Carbohydrate intake‡ Age (years) Poverty index Overweight Race Carbohydrate intake Odds ratio (95% CI) 1.86-1.Therefore. including a broader set of socioeconomic and contextual characteristics. In our analysis. In the United States childhood obesity is also associated with low SES (14. relationships between health outcomes and contextual characteristics – particular aspects of places where people live – have been documented in a number of empirical studies of various health conditions (24). Sociodemographic distribution of pediatric dental caries: NHANES III. such as family income. Marshall et al. with frequent consumption of sugars considered to increase the risk. and behavioral factors are known to be involved in these conditions (19-21). 54(03):[44 p. . Dietary habits (how much and how often the beverage or food is consumed) can modify caries risk.43) (0.08 0.82-1. family income was identiﬁed as an important predictor of caries experience. 1998. This observation is consistent with what other investigators reported (6. ¶ S-ECC was deﬁned using criteria from American Academy of Pediatric Dentistry.17) (1. It is well established that a dietary component is necessary for the caries disease process. This demands carefully deﬁned research designs. dental caries has been linked to SES factors. In conclusion.08 0. References 1. Ն288mg). 187-288 mg.09 0. race.81-1. missing teeth were excluded from the analysis. Dietary factors and SES were hypothesized to be common risk factors that potentially link obesity and dental caries. (19) suggested that neither “obesity increases risk of caries” nor “caries increases risk of obesity.
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