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RESEARCH

Are diet diaries of value in recording dietary intake of


sugars? A retrospective analysis of completion rates
and information quality
A. Arheiam,*1 S. Albadri,2 S. Brown,3 G. Burnside,4 S. Higham1 and R. Harris1

InInbrief
brief
Describes the return rate of diet diaries in a teaching Gives an idea about possible demographic and oral Evaluates to what extent diet diaries are capable of
dental hospital. health factors that might affect the return rate of diet capturing complex diet diary information and what
diaries are the commonly missing information.

Objectives Current guidance recommends that dental practitioners should routinely give dietary advice to patients, with diet
diaries as a tool to help diet assessment. We explored patients compliance with diet-diaries usage in a paediatric clinic within
a teaching hospital setting, where remuneration is not an issue. Objectives were to investigate associated factors affecting
diet diaries return rate and the information obtained from returned diaries. Methods A retrospective study of 200 randomly
selected clinical records of children aged 511years who had received diet analysis and advice as part of a preventive dental
care programme at a dental teaching hospital between 2010and 2013. Clinical records, with a preventive care pro forma,
were included in the study. Data on social and family history, DMFTdmft, oral hygiene practices, dental attendance and dietary
habits were obtained and compared with information given in completed diet-diaries. A deductive content analysis of returned
diet-diaries was undertaken using a pre-developed coding scheme. Results Of 174 complete records included in this study,
diet diaries were returned in 60 (34.5%) of them. Diet diaries were more likely to be returned by those children who reported
that they regularly brushed their teeth (P<0.05), and those who came from smaller families (P<0.05). Content analysis of diet
diaries enabled the identification of harmful types of foods and drinks in 100% of diaries. General dietary issues, frequency and
between-meals intake of sugars were also all captured in the majority of diaries (95.0%, N=56). Information on sugar amount
(53.0%, N=32), prolonged-contact with teeth (57.0%, N=34) and near bedtime intakes (17.0%, N=28) was reported in
fewer diaries. Conclusions The return rate of diet-diaries in this setting was low, and associated with patients demographic
and oral health characteristics. Returned diet-diaries showed a varied range of missing important dietary information, such
as sugar amount, which appears to compromise their validity as a diet assessment tool. Development of a more reliable and
acceptable dietary assessment tool for use in the dental setting is needed.

Introduction among others, have argued that one of the reasons health,10 forms the backbone of recommended
for the failure in combating this epidemic, is that evidence-based preventive dentistry in English
Dental caries is a considerable global health insufficient attention has been hitherto paid to its general dental practice. This positions issuing
problem affecting many children.1 According primary cause namely high sugar consump- dietary advice as central to the everyday clinical
to the Global Burden of Disease study, caries tion,3 others have counter-argued that fluoride, practice of general dental practitioners (GDPs);
in primary teeth affects 9% of children and particularly in toothpaste, makes dietary sugar stating that: healthier eating advice should
is the tenth most prevalent health condition control less necessary. However, there is now routinely be given to patients to promote
worldwide.2 Although Sheiham and James, growing evidence that sugar is still a key player good oral and general health. The guidance is
in dental caries incidence even in areas where explicit, that the main dietary messages given
1
Department of Health Services Research, School of fluoride is widely available.47 Bearing in mind a should be to reduce both the amount and
Dentistry, 2School of Dentistry, Institute of Learning
and Teaching, 3Department of Psychological Sciences, growing national focus on efforts to limit dietary frequency of consuming foods and drinks that
4
Department of Biostatistics, University of Liverpool, sugar consumption in order to address a growing have added sugar.10 It also mentions that there
Liverpool, UK;
*Correspondence to: Dr A. Arheiam obesity problem,8,9 it is now timely to consider is a consensus that avoiding sugar-containing
Email: arheiam@liv.ac.uk how dentists address dietary issues when caring foods and drinks at bedtimes is beneficial to
Refereed Paper. Accepted 4 September 2016 for children with dental caries. caries prevention, and draws attention to what
DOI: 10.1038/sj.bdj.2016.824 National guidance from Public Health a generally healthy diet looks like, in the form

British Dental Journal 2016; 221: 571-576 England in the form of Delivering better oral of an eatwell plate. While the guidance does

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not tackle issues related to how GDPs should the current system of dental remuneration.20 patients returned the diet-diaries, a sample size
approach the delivery of advice, it does suggest Therefore, in order to look more closely at of 200 records was identified as sufficient to
that in some cases it can be helpful to use a issues to do with patients compliance with the allow an estimate of the proportion of returned
diet diary, and an exemplar is given.10 This use of diet diaries in dentistry, and whether diet diaries to within 5%, given predicted 95%
template used contains a three-day diary, with useful information is yielded by their use, confidence intervals. Using record tracking
space to record time of consumption, alongside we set out to study the use of diet diaries in codes, a random sample of 200clinical records
a space for a free text entry describing the item a dental setting where clinician remuneration was selected. When retrieved, only 174of these
consumed. is not an issue a teaching hospital situation, clinical records contained completed preven-
In diet diaries, patients are typically asked where care protocols currently advocate tion pro formas and so only these records were
to keep diet records for three consecutive their use. The primary aim of this study was included in the study
days including at least one-weekend day. This therefore to investigate the return rate of diet
detailed dietary assessment is meant to enable diaries issued to child patients aged 511years Data extraction from clinical records
both a tailoring of dietary advice for individual old in a teaching hospital setting, and whether The following information was retrieved
patients, as well as prompting a detailed dis- this was associated with certain demographic from the prevention pro formas in case notes:
cussion between dentist and patient which or oral health-related factors. A secondary social history (childs age, gender and post
opens channels of communication and thus aim was to look at what type of information code of residence, number of siblings and
makes the forming of a therapeutic alliance was yielded by diet diaries, which had been parents in the household; and whether the
more likely.11 A further benefit envisaged, is completed and returned, in order to investi- grandparents lived with them in the same
that because diet diary keeping represents a gate the extent to which this tool is capable home); DMFTdmft (number of decayed,
real-time method of self-monitoring if used of capturing the variety of dietary behaviours missing and filled permanent and primary
correctly,12 this can, in itself, effect a positive relevant to developing dental caries. teeth); oral hygiene practices (tooth brushing
change in behaviour for evidence shows was considered regular if reported to be twice
that incorporating self-monitoring tools into Methods or more per day); and dental attendance (if
behaviour change interventions increases their patients reported a dental visit of any kind
effectiveness significantly.13 While the indi- Ethics (reference 14/LO/1204) and NHS within the last six months, this was considered
vidualisation of chair-side dietary advice has research governance approvals were obtained regular; if not, dental visiting was considered
been widely advocated in dentistry for some before commencing the study. irregular). Postcodes were used to identify the
time,1417 it is somewhat surprising that such corresponding Index of Multiple Deprivation
little evidence exists on the use of diet diaries Setting and sampling quintiles (IMD),20 ranging from Quintile 1
in dental practice. The study was carried out in the paediatric (the most deprived) through to Quintile 5 (the
In healthcare more generally, there is concern dentistry department of Liverpool University least deprived). Any completed diet-diaries
that poor patient compliance can compromise Dental Hospital (LUDH) a teaching hospital included in clinical records were photocopied
the efficient use of diet-diaries.12,18 Completing that provides secondary dental care for after anonymising the patients identity.
diet diaries prospectively and in a timely children referred from NHS dental practices
manner over several days is essential for their in the region. All children/parents with dental Content analysis of diet-diaries
successful use since these ensure the accuracy caries attending this centre are routinely asked In order to address objective 2, a content
of the record and its representativeness of to keep diet diaries as part of their caries risk analysis was applied to dietary information
habitual intake.18 Therefore, non-compliance assessment, at the start of their care. Clinic data contained for all completed diet-diaries. This
with diet diaries usage does not just concern shows that on average, 10% of children fail to form of analysis requires the use of a coding
the problem of a patient failing to return with keep this first appointment. Twenty percent of framework, comprising categories with con-
a completed diary, but also where patients fail those attending the first appointment also fail ceptual definitions, in order to inform the
to keep a full, contemporaneous account of to attend a subsequent appointment when the identification and classification of data.21 We
their diet and return either incomplete diaries diet diaries would be reviewed. In Liverpool undertook this analysis deductively using a
or those which have been backfilled.19 Missing clinicians routinely complete prevention pro coding framework which had been previously
information may undermine the validity of formas (information of social and dental developed from the dental literature17,18,2325
diet diaries and breach the rationale for their history and oral health behaviours) for all these and an earlier study involving GDPs responses
use, which is to enable a tailoring of dietary patients as part of the caries risk assessment to a diet diary vignette.26
advice to the patients dietary behaviours. Of process, and so completion of a prevention pro Content from photocopies of diet-diaries was
course low completion rates of diet diaries may forma in the clinical record, was taken as an transcribed verbatim before being transferred
also be due to a failure of clinicians to issue indicator that a diet diary had been issued. We into NVIVO software-version 10, to facilitate
them to patients in the first place. retrospectively evaluated a random sample of coding and analysis. The coding framework
A recent study of the use of diet diaries in records of children aged 511years attending used contained 11 aspects of dietary assessment
general dental practice, suggests low compli- prevention clinics in LUDH between January previously identified as potentially relevant to
ance might be an issue, although the matter 2010and December 2013. According to the the giving of dietary advice by GDPs (Table1).
was overshadowed by practitioners per- teaching hospital database, 519 eligible children To help ascertain whether a food/drink item
ceptions that the use of diet diaries in NHS attended during this period. Based on previous should be coded as harmful, or containing
dental practice is insufficiently supported by audit information suggesting that 30% of these hidden sugars, information in the diary was at

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times supplemented by referring to UK food was used as a cut-off point to include variables with a mean age 7.2 (1.7), and mean DMFT
tables and nutritional labels on market websites. in the multivariate model. dmft of 6.1 (2.8). While the majority of
Each of the 11 aspects of dietary assessment While a cut-off for the acceptable propor- sample was from areas of the most deprived
was coded as being missing from the diary tion of missing data in a data set that allow IMD quintile (121, 69.5%). The majority of
when there was either no description (defined valid statistical inferences to be made has the sample also reported regularly visiting the
as complete lack of relevant information) or never been established, it has been suggested dentist (129, 74.1%) and regularly brushing
insufficient description (defined as limited that if more than 10% of data is missing, this their teeth (132, 75.9%). The sample also had
information rendering the data misleading or is likely to cause biased analysis.27 Nearly 25% an even gender balance; with a roughly equal
judgement impossible) contained in the diary of values related to family size, number of balance also, between single parent/dual parent
for that category. siblings, household parents and grandparents households.
Data were coded by one investigator (AA) were found to be missing from prevention pro Bivariate comparisons of the return rate of
and verified by another independent assessor in formas. So in order to explore the potential diet-diaries by sample characteristics showed
the first 15 (25.0%) diet-diaries. Both assessors impact of missing data, an additional sensitiv- a higher return rate among regular brushers
were qualified dentists. Cohens was run to ity analysis using multiple imputations (MI) (P = 0.016) and small families (P = 0.035),
determine the level of agreement between the was performed. Five complete imputed data Table2. These differences disappeared in the
two coders. There was strong agreement in sets were created using the fully conditional adjusted multiple regression models. Yet, when
most of the codes, =(0.72to 1.00), P0.05. specification method, assuming that values the multiple imputations were applied, adjusted
Frequencies of these codes were obtained by were missing at random.28 The results from models showed that regular brushers were
simply counting the observations of each code. the analyses of the five imputed data sets were more likely to return diet-diaries (Table3).
combined to give pooled estimates for the Content analysis of the 60 completed diet-
Statistical analysis effects of the predictors. diaries is presented in Table1.It was possible
Data management and statistical analysis were to identify consumption of harmful items
performed using statistical software SPSS Results in all diaries, and also the frequency and
Version 22.0. (Armonk, NY: IBM Corp.). between-meals consumption of sugars, as
Descriptive statistics were used to profile Of 200 records sampled, 174 had preven- well as general aspects of the diet, from more
the study sample and to describe the return tion pro formas, and were included in the than 90% of diaries. However, information
rate of diet-diaries, with comparisons across analysis. Diet diaries were found in 60 out on the sequence of food/drink consumption
socio-demographic characteristics, oral health of 174 records, giving a return rate of 34.5% could not be elicited at all, and information
related practices and dental caries experience (95% confidence interval 27.4% to 41.6%). The on sugar amount and prolonged contact with
of the study sample using the Chi-squared socio-demographic and oral health-related teeth could only be identified from just over
test and the Mann-Whitney U test. Binary characteristics of the sample, as well as a com- half of diaries. The least frequently extracted
logistic regression models were used to identify parison of diet-diaries return rate by these information was the context of the intake
potential predictors of returning diet-diaries. A characteristics are shown in Table2.The final (17,28.0%) and whether the consumption was
significance level of 20% in univariate analyses study sample comprised records of children near bedtime (18, 30.0%) (Table1).

Table 1 Coding framework used in the content analysis of diet diaries and frequency of information extracted from diet diaries

Frequency recorded
Code Conceptual definition
in diet diaries

Items were categorised as harmful based on their cariogenic potential. These are foods with high sugar content.
These included dairy sweetened (yoghurt, milk drinks), confectionery (sweets, chocolate), cereals (Coco Rocks, Coco
Harmful items 60 (100.0%)
Pops, cereal bars), baked goods (cakes, biscuits), soft drinks and juice (drinking chocolate, sweetened carbonated
beverages), and fresh as well as dried fruits (apples, banana, dates, raisins)

Sugar frequency Possible to identify how many times per day the child was exposed to sugar/acid items 56 (93.0%)

Sugar amount The quantity of sugar/acid exposure per intake presented as number or portion size of items, servings or spoons 32 (53.0%)

A meal defined as: an intake representing a substantial contribution of daily energy, comprised many food groups and
Between meals sugars more than one course including at least one savoury course. It usually requires preparation and eaten at recognised 56 (93.0%)
meal-times snack: any single intake that does not meet the criteria of a meal

A prolonged exposure to sugary/acidic items which involves the consumption of sticky food, slow intake and sipping
Prolonged contact 34 (57.0%)
of drinks. This included also sugary foods mixed with starch (eg bread)

Sequence The order of items intake in each intake 0 (0.0%)

Type of foods and brands with unseen sugar content and which have the potential of being perceived as sugar free or very
Hidden sugars 50 (83.0%)
low in sugar. (eg fruit juices, salad dressings, soups and ketchup, yoghurt, ready meals, marinades, chutneys and crisps)

Combination Items eaten together which may aggravate or alleviate the cariogenic/potential of one of them 48 (80.0%)

Context The setting or the social event of sugar consumption 18 (30.0%)

General dietary issues Unbalanced diet of poor nutritional value and irregular eating habits 56 (93.0%)

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Discussion low return rate of diet-diaries observed in this advice aimed at preventing dental caries. Our
study, may also have something to do with the content analysis of completed diaries showed
Firstly we must recognise the study limitations fact that the majority of records included in an important and clinically relevant finding:
such as missing data which are inevitable in this study were related to patients from the that diet diaries did not consistently capture
this type of study.29 Some case notes were poorest end of the socioeconomic status (SES) the full range of complexities relevant to giving
excluded from the final analysis because they spectrum. Given that patients poor compli- dietary advice to dental patients. Information
did not contain prevention pro formas, and ance in health care settings is not uncommon, on sugar amount, consumption context,
this effectively reduced our sample size a little. for example, non-compliance rates of 1928% sequence of intake within meals, prolonged
Nevertheless, given the confidence intervals for attendance at medical appointments30 and contact with teeth and sugars consumed near
involved in the study, we were able to establish 3050% for treatment regimens31 have been bed-time all of which are recognized as being
the diet diary return rate at a precision rate reported, a compliance rate of 35% for diet detrimental to developing dental caries,15,23,24
of 6%; although we have also made the diaries usage among a predominantly low SES was often partially or completely missing from
assumption that completion of the prevention is not unexpected bearing in mind the moti- returned diet-diaries. Most striking on this list
pro forma meant that a diet diary had been vation required to complete the diary task. is that amount of sugar consumed could not
issued, and we have no independent verifica- In addition, diet diaries are found to be the be extracted from many diaries, even though
tion of this, and so this should also be borne least preferred method of dietary assessment national dental guidance10 articulates this con-
in mind when interpreting findings. by people from low SES backgrounds when sideration as one of the main dietary messages
Our study shows that a relatively low propor- compared with other diet assessment methods; which should be covered when giving advice.
tion of diet-diaries are returned (34.5%,60), owing to low literacy, numeracy and language This is of particular concern given very recent
even in a dental setting where NHS remunera- skills.32 Given that our sample were also those evidence which indicates that dietary sugars
tion is not an issue. This study also found that who evidently experienced high rates of dental amount may be a more important factor related
regular brushers, and children from small caries, it is a concern that those most in need to caries development, than frequency of sugar
families, were more likely to return diet diaries. of help with caries prevention, appear not to intake.6 Although it is beyond the remit of the
Since regular tooth brushing is a sign of the find the current approach to dietary assess- study to explain the reasons why information
patients and parents motivation and positive ment methods appealing. With caries now on sugar amount is not given by patients
attitudes towards oral health, and a smaller focused among low socio-economic groups in completing diet diaries, we can surmise that
family size probably indicates that these many countries,33 our study therefore calls into there are two possibilities either patients
families are those with more time to complete a question whether the routine use of diet diaries see this as unimportant, or too bothersome to
diary task, collectively our findings suggest that in dentistry is appropriate. report,34,35 or that dentists, when issuing the
many of those children/parents who would A second objective of the study was to diet diary, place more emphasis on recording
benefit most from detailed dietary advice for examine the quality of information yielded behaviours that they personally perceive as
caries prevention, lack the necessary motiva- by completed diet-diaries, which could be particularly important (and effectively prime
tion and time to comply with their usage. The seen as relevant to informing patients dietary their patients). Since we know that dentists see

Table 2 Study sample description and bivariate comparisons of diet diaries return rate (N=174)

Sample distribution Returned diaries No diaries returned


Variables P value
N (%) N (%) N (%)

Male 82 (47.1) 29(47.5) 53 (46.9)


Gender 0.936
Female 92 (52.9) 31 (52.5) 65.2 (53.1)

Quintile 1 121 (69.5) 39 (65) 82 (71.9)


IMD* 0.345
Quintiles 2-5 53 (30.5)) 21 (35) 32 (28.1)

Regular dental attendance 129 (74.1) 44 (73.3) 85 (74.6) 0.86

Regular tooth brushing 132 (75.9) 52 (86.7) 80 (70.2) 0.016

Single parent 66 (50.4) 24 (58.5) 42 (46.7)


Parents in household 0.144
Both parents 65 (49.6) 17 (41.5) 48 (53.3)

Mean (SD) Mean (SD) Mean (SD)

Family size 3.2(1.1) 3.0 (1.1) 3.37 (1.1) 0.035

Age 7.2 (1.7) 7.1 (1.7) 7.03 (1.6) 0.837

DMFTdmft 6.1 (2.8) 5.7 (2.7) 6.36 (2.8) 0.109


Chi-squared test and Mann-Whitney U test were used to compare study sub-groups.
*Index of Multiple Deprivation quintiles. P 0.05, Statistically significant. N = 131.
DMFTdmft means decayed, missing and filled permanent and primary teeth.

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reducing frequency of sugar consumption as to avoid negative feedback,37 we are left asking accessibility for these high risk groups and also
more practical than reducing the amount,23 the are diet diaries any use? for different age groups. Until this happens,
second explanation here is a real possibility. Thus we may need to look for more modern working on more upstream approaches to
Delivering Better Oral Health guidance10 tools to support dietary assessment in dentistry. tackle sugar consumption related to dental
also identifies that identifying hidden sugars Certainly digital technology offers new, more caries prevalence in these groups could be a
in the diet is a key objective. It is important, modern alternatives to the traditional paper better option.
therefore, to recognise that in our study, diet diary record. Such alternatives may
extraction of data from diet diaries allowed enhance patients compliance and engagement Conclusion
the seeking of additional information from in dietary assessment and self-monitoring
other sources such as food tables where activities by reducing the participant burden.38 The return rate of diet diaries by children and
hidden sugars/harmful dietary items required A recent systematic review of health interven- their families in a dental hospital setting is low,
clarification. A GDP undertaking a chair-side tions, including dietary interventions adminis- and appears to be associated with patients
interpretation of diet diaries would probably tered using mobile apps, indicates that mobile demographic and oral health maintenance
not be realistically able to also drawn on these apps supporting the self-monitoring of health habits. Returned diet diaries showed a varied
additional resources. On the other hand, one related data have a high level of feasibility and range of frequently missing, important dietary
could probably argue that what would happen acceptability.39 In line with the explosion of information. This included the amount of
in clinical practice in the event of such uncer- innovation in this area, Public Health England sugar consumed which is one of the main
tainties, is that the GDP would probe for this has recently launched the sugar smart app aspects of the diet recommended to be covered
missing information during a chair-side dis- which helps users to recognise total sugar by dentists in national guidance, and thus
cussion of the diary with the patient. However, in different dietary products, as part of the effectively compromises the validity of diet
relying on further prompting then effectively Change4Life advertising campaign.40 However, diaries as a diet assessment tool for everyday
compromises the prospective nature, temporal while this app may be helpful in identifying the clinical practice. This then raises questions as
proximity of recording and accuracy of presence of sugar in diet, it still fails to account to whether this tool is the most appropriate
recording dietary intake, which are all, con- for the complex nature of the association means to support caries prevention for groups
sidered to be the major strengths of diet diary between other aspects of sugar consumption most in need of advice.
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2731.

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