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Association of Edentulism and Diet and Nutrition in US Adults
R.E. Nowjack-Raymer1,2,* and
A. Sheiham1
1 Department of Epidemiology and Public Health, University College London Medical School, 1-19 Torrington Place, London WC1E 6BT, UK; and
2 Division of Population and Health Promotion Sciences, National Institute of Dental and Craniofacial Research, 45 Center Drive, Room 4AS-43J, Bethesda, MD 20892-6401, USA;
Correspondence: *address to which correspondence and reprint requests should be addressed; corresponding author, Ruth.Nowjack-Raymer{at}nih.gov
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ABSTRACT
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Dental status and its relationship to diet and nutritional status have been little explored. In this study of a representative sample of the US civilian, non-institutionalized population (NHANES III), we predicted that the intake of nutritious foods, dietary fiber, and levels of biochemical analytes would be lower, even after adjusting for potential social and behavioral factors, among those who were edentulous and wore complete dentures than for those who had all their natural teeth. Multivariate analyses indicated that intake of carrots and tossed salads among denture-wearers was, respectively, 2.1 and 1.5 times less than for the fully dentate (p < 0.0001), and dietary fiber intake was 1.2 times less (p < 0.05). Serum levels of beta carotene (9.8 µg/dL), folate (4.7 ng/dL), and vitamin C (0.87 mg/dL) were also lower among denture-wearers (p < 0.05). Intakes of some nutrient-rich foods and beta carotene, folate, and vitamin C serum levels were significantly lower in denture-wearers.
Key Words: dentures • health disparities • nutrition • NHANES III • Healthy People 2010
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INTRODUCTION
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While the importance of eating fruits, vegetables, and dietary fiber is established (Steinmetz and Potter, 1996), their consumption in the United States is well below recommended levels (aUS Department of Health and Human Services, 2000a). The extent to which dental status is associated with the intake of nutritious foods has been little studied, despite the edentulous reporting chewing problems (Smith and Sheiham, 1980; Locker, 1992; Slade et al., 1996; Ettinger, 1998; Sheiham et al., 1999).
Denture-wearers consumed vegetables (Halling et al., 1988; Moynihan et al., 1994; Joshipura et al., 1996), whole meal bread (Moynihan et al., 1994), and dietary fiber (Moynihan et al., 1994; Johansson et al., 1994; Joshipura et al., 1996; Krall et al., 1998; Steele et al., 1998) less often than those who had some natural teeth. Comparisons made for general fruit intake were equivocal (Johansson et al., 1994; Joshipura et al., 1966), but the edentulous consumed apples and pears less often than did the dentate (Halling et al., 1988; Joshipura et al., 1996). With respect to biochemical analytes found in fruits and vegetables, significant differences were found for plasma retinol, alpha tocopherol, and vitamin C between the edentulous and the dentate in a national survey of older adults (Steele et al., 1998; Sheiham et al., 2001).
The objective of the present study was to assess, in a representative sample of the US adult population, whether the intake of specific nutritious food items, dietary fiber, and levels of blood analyte differed between those who were edentulous and reported wearing complete upper and lower dentures and those who had all of their natural teeth.
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METHODS
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Study Data and Design
Data for this study came from individuals aged 25 years and older who participated in the third US National Health and Nutrition Examination Survey (NHANES III), which was a nationally representative, cross-sectional survey conducted from 1988 to 1994. NHANES III used a stratified, multi-staged, probability sample design. Methods for the standardized dental examinations, laboratory analyses, interviews, and procedures for human subjects protection and consent have been previously described (Ezzati et al., 1992; National Center for Health Statistics, 1994; Drury et al., 1996).
Measurement of Diet and Nutritional Status—Dependent Variables
The diet-related variables were the intake per month of carrots and tossed salads from a food-frequency questionnaire and intake of dietary fiber derived from a quantitative, 24-hour dietary recall interview. Nutritional status variables were serum levels of beta carotene, folate, and vitamin C from blood analyte assessments.
Measurement of Dental Status—Independent Variables
Denture-wearers were defined as the totally edentulous who reported that they wore both upper and lower dentures "all of the time" or "only when awake". The fully dentate were those who had 28 permanent teeth (3rd molars were not counted in NHANES III).
Measurement of Covariates
Covariates used in the multivariate models included those socio-economic and behavioral factors that were identified in the literature as being associated with diet, nutritional status, and tooth loss (Willett, 1998;b US Department of Health and Human Services, 2000b). Accordingly, adjustments were made for age at time of examination, gender, race/ethnicity, caloric intake, vitamin and mineral supplement use, income, and education. Those with serum cotinine levels higher than 10 ng/dL were classified as smokers (Klebanoff et al., 1998).
Statistical Analyses
Multi-linear regression models were constructed to adjust for the influence of the covariates. Statistical comparisons were made between those who wore dentures and the fully dentate, by analysis of covariance and the Satterthwaite F adjusted statistic, with p values of < 0.05 considered statistically significant. SUDAAN software, appropriate weights, and design effects were used to produce unbiased SEs (National Center for Health Statistics, 1996; Shah et al., 1997 ).
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RESULTS
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Of the 3794 sample persons in the present study, 36% were edentulous and wore complete dentures; the remainder were fully dentate (Table 1 ). Denture-wearers were, on average, older than the fully dentate, female, black non-Hispanic, of the lower SES levels, smokers, and non-vitamin and mineral supplement users.
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Table 1. Unweighted Sample Size, Weighted Population Estimates, and Percent Distributions of Denture-wearers and the Fully Dentate by Demographic, Socio-economic, and Behavioral Characteristics (NHANES III: United States, 1988 –1994)
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The adjusted mean numbers of intakes of carrots (2.7 to 5.8) and tossed salads (6.9 and 10.3) per month were 2.1 and 1.5 times lower for denture-wearers than for the fully dentate, respectively, p < 0.0001 (Table 2). In addition, denture-wearers consumed 1.2 times less dietary fiber, 2.5 grams, than did the fully dentate, 15.1 grams vs. 17.6 grams, respectively (p = 0.04).
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Table 2. Mean Intake of Food Items for Complete-denture-wearers Compared with the Fully Dentate among Persons 25 Years and Older (NHANES III: United States, 1988 –1994)
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Biochemical analyte levels for nutrients found in fruits and vegetables were statistically significantly lower among denture-wearers (Table 3). The serum beta carotene level among denture-wearers was 1.7 times lower than that of the fully dentate, 9.8 vs. 16.6 µg/dL, respectively (p < 0.0003), 1.3 times lower for serum folate, 4.7 vs. 6.1 ng/dL (p < 0.003), and 1.1 times lower for serum vitamin C, 0.87 vs. 0.95 mg/dL (p < 0.04) than for that of the fully dentate.
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Table 3. Mean Levels of Biochemical Analytes for Complete-denture-wearers Compared with the Fully Dentate among Persons 25 Years and Older (NHANES III: United States, 1988 –1994)
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DISCUSSION
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Findings of this study indicate that the edentulous, complete-denture-wearing segment of the US adult population may be at a nutritional disadvantage when compared with the fully dentate. The intake of specific foods which are rich in dietary fiber and nutrients known to have anticarcinogenic and other positive health effects were lower among the denture-wearers than among the fully dentate. In addition, the corresponding intake of dietary fiber was lower among the denture-wearers and mirror the findings for the foods which are rich in fiber. Likewise, the blood analyte values were reflective of this lower intake of nutrient-rich foods by denture-wearers. Specifically, denture-wearers in the civilian, non-institutionalized adult population aged 25 years and older had lower intakes of carrots and tossed salads and dietary fiber than did fully dentate adults. The differences in the consumption of nutrient-rich foods between those who wore dentures and those who were fully dentate were also manifested in the biochemical analyte levels for nutrients found in fruits and vegetables, i.e., serum beta carotene, serum folate, and serum vitamin C.
Numerous methods for the quantification of diet exist, and each has its own inherent strengths and weaknesses. For example, some suggest that nutrition epidemiology methods such as the 24-hour dietary recall and food intake records may not provide a complete picture of what is being eaten on a routine basis. Other methods, such as Food Frequency Questionnaires, are criticized because people may not recall exactly what they have eaten over a period of time. Thus, it is recommended that, where possible, several methods be used to get as complete a picture of nutritional status as possible, and to verify that the results demonstrate a similar pattern. This study utilized data from three nutrition epidemiology approaches—a Food Frequency Questionnaire, 24-hour quantitative dietary recall, and biochemical analyte levels—to provide a picture of the intake of nutrient-laden vegetables that are also high in dietary fiber. The three biochemical analytes assessed are known to be particularly well-correlated with the recent intake of food items high in those nutrients (Bates et al., 1997; Hunter, 1998). The consistency of the findings of this study across the three nutrition epidemiology approaches used in NHANES III and with results of other studies (Halling et al., 1988; Johansson et al., 1994; Moynihan et al., 1994; Joshipura et al., 1996; Krall et al., 1998; Steele et al., 1998; Sheiham et al., 1999) lends strength to the evidence that findings of associations between dental status and diet and nutritional status are not artifacts of any one approach. This evidence of an association from these cross-sectional surveys is supplemented with that of one longitudinal study (Joshipura et al., 1996) that found that, as participants lost teeth over time, their intake of nutritious foods declined. The size and design of this NHANES study allowed for the adjustment for social and behavioral factors, such as smoking status and vitamin and mineral supplement use, that has not been possible in other studies. Adjustments for factors such as cotinine levels are of particular importance because of the known association between tobacco use and periodontal disease and diet as well as biochemical analyte levels. This study demonstrates that even when these factors are adjusted for, disparities exist between edentulous complete-denture-wearers and the fully dentate.
This study is one of two contemporary large-scale studies to include measures of biochemical analyte levels, as well as dental status, the other being the British National Diet and Nutrition Survey-NDNS (Steele et al., 1998; Sheiham et al., 2001). Differences in the levels of plasma vitamin C and plasma retinol were found between the edentulous and dentate older people (analytes for folate were not included in the NDNS analysis). The consistency of the findings for the two studies—despite the fact that the NDNS focused on seniors 65 years and older, did not differentiate between edentulous denture-wearers and non-wearers, and did not adjust for the influence of smoking—lends credence to the findings that the edentulous, across the adult life span, are at increased risk of having lower intakes of nutrient-rich foods, and that, in turn, is manifested in lower levels of nutrients in the blood.
While tooth loss is declining in the United States, the number of people who may be at nutritional risk is not insignificant, since an estimated 12,447,000 people, or 9.5% of the entire US civilian, non-institutionalized population aged 25 years and older, reported wearing complete dentures. Clinical studies indicate that providing the edentulous with conventional or mandibular implant-supported overdentures alone does not result in improvements in diet and nutrition (Sebring et al., 1995; Hamada et al., 2001 ; Roumanas et al., 2002). Innovative research, including both health promotion and clinical approaches, may be warranted to improve diet. In the meantime, nutritionists, caterers, and oral and other health professionals need to be aware of the potential diet-related problems faced by the edentate segment of the population.
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ACKNOWLEDGMENTS
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This work was funded by the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892. The support provided by Drs. Wagner Marcenes and Thomas Drury and Mr. Richard Oldakowski is gratefully acknowledged. This paper is based on a thesis submitted to University College London Medical School, in partial fulfillment of the requirements for the PhD degree.
Received for publication June 13, 2002.
Revision received October 25, 2002.
Accepted for publication November 5, 2002.
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Journal of Dental Research, Vol. 82, No. 2,
123-126 (2003)
DOI: 10.1177/154405910308200209
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ABSTRACT
INTRODUCTION