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| Year : 2014 | Volume
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| Issue : 5 | Page : 602-606 |
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| Problematic eating and its association with early childhood caries among 46-71-month-old children using Children's Eating Behavior Questionnaire (CEBQ): A cross sectional study
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Latha Anandakrishna1, Neha Bhargav2, Amitha Hegde3, Prakash Chandra1, Dhananjaya Gaviappa1, Ashmitha Kishan Shetty1
1 Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, MSRUAS, Bengaluru, Karnataka, India
2 Private Practitioner, Adarsh Dental Clinic, Adarsh Nagar, Jaipur, Rajasthan, India
3 Department of Pedodontics and Preventive Dentistry, A B Shetty Memorial Institute of Dental Sciences Medical Sciences Complex, Mangalore, Karnataka, India
Click here for correspondence address and email
| Date of Submission | 24-Jun-2014 |
| Date of Decision | 20-Jul-2014 |
| Date of Acceptance | 25-Aug-2014 |
| Date of Web Publication | 16-Dec-2014 |
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 Abstract | | |
Context: Problematic eating behavior in children presents a wide spectrum from anorexia, selective eating, and fussy eating to neophobia. Pouching of food and slow eating represents eating behavioral problems that may be relevant to pediatric dentist as far as early childhood caries (ECC) is concerned.
Aim: The aim of this study was to determine the prevalence of problematic eating and its association with ECC among 46-71-month-old children in Bengaluru city, India.
Settings and Design: A cross-sectional study was carried out in 250 children aged 46-71 months old in various schools of Bengaluru city.
Subjects and Methods: All the selected children were clinically examined for dental caries using decayed, missing, filled surfaces index. Children's eating behavior was assessed using Children's Eating Behavior Questionnaire (CEBQ) which was filled by the parents.
Statistical Analysis Used: Both descriptive statistics as well as Chi-square test was used with SPSS 16.00.
Results: The prevalence of dental caries was found to be 34%. It was observed that 81.6% of the children did not have a tendency to keep food in their mouth all the time and ECC was found to be significantly less. Furthermore, approximately 90% of the children did not have a tendency to eat too much and in those, 68% of them were caries free which was statistically significant. Prevalence of ECC was highest (52.6%) in children who ate more when they had nothing else to do.
Conclusion: Problematic eating behavior is prevalent in the preschooler group and needs to be considered by the pediatric dentist. Keywords: Children′s eating behavior questionnaire, early childhood caries, problematic eating
How to cite this article:
Anandakrishna L, Bhargav N, Hegde A, Chandra P, Gaviappa D, Shetty AK. Problematic eating and its association with early childhood caries among 46-71-month-old children using Children's Eating Behavior Questionnaire (CEBQ): A cross sectional study
. Indian J Dent Res 2014;25:602-6 |
How to cite this URL:
Anandakrishna L, Bhargav N, Hegde A, Chandra P, Gaviappa D, Shetty AK. Problematic eating and its association with early childhood caries among 46-71-month-old children using Children's Eating Behavior Questionnaire (CEBQ): A cross sectional study
. Indian J Dent Res [serial online] 2014 [cited 2023 Jun 5];25:602-6. Available from: https://www.ijdr.in/text.asp?2014/25/5/602/147101 |
Dental caries is the most common communicable disease of childhood, affecting 41% of children in the United States American Academy of Pediatrics, 2009; Centers of Disease Control and Prevention, 2005a). [1] It is an infectious disease caused by interaction of bacteria especially Streptococcus mutans producing acid from the fermentable sugars on the surface of tooth enamel. Early childhood caries (ECC) is defined as the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled teeth in children under 71 months of age. [2] It can rapidly destroy the primary dentition of toddlers and small children, and if left untreated, can lead to pain, acute infection, nutritional insufficiencies, and learning and speech problems.
Various risk factors involved in causation of ECC are high intake of fermentable carbohydrates, poor oral hygiene, prolonged breast feeding and transmission of S. mutans from mothers to infants. Low fluoride in drinking water, poor saliva buffering capacity and behavioral factors are other causes. The risk factors involved in the development of dental caries are infinite and hence it is undoubtedly regarded as multifactorial.
Eating behavior in childhood may vary on a continuum ranging from picky eating, irregular eating, overeating, and food refusal, negativistic behavior during eating, slow eating and tantruming during mealtimes. Picky eating at one extreme of the continuum is also known as "fussy eater" and "problem eaters" while selective eaters confirm themselves to eating only certain types of food. Neophobia is associated with refusal to try out any new food. Overeating and binge eating is related to eating large amounts of food, more rapidly than normal, eating until uncomfortable and eating when not physically hungry. [3] The fact that the effects of problematic eating behavior including slowness in eating, pouching of food over a long period of time and selective eating has been relatively unexplored in the causation of ECC has to be considered.
There is an increasing recognition that problematic eating behaviors that manifest in early childhood may be a precursor of disordered eating later in life. These eating disorders have been classified by Diagnostic and Statistical Manua- IV as Eating Disorder Not Otherwise Specified. [4]
In the past, a number of psychometric instruments have been developed to assess eating behavior in children, including the Children's Eating Behavior Questionnaire (CEBQ), the Dutch Eating Behavior Questionnaire, the Children's Eating Behavior Inventory and the Bob and Tom's method of assessing nutrition. The CEBQ is generally regarded as one of the most comprehensive instruments in assessing children's behavior. The instrument was developed and has been validated in the United Kingdom and in Portugal. The instrument has been used for different research purposes like body mass index, to compare appetite preferences in children of lean and obese parents, to discover continuity and stability in children's eating behavior across time and to examine eating behavior of children with idiopathic short stature. [5]
However the relationship between such eating disorders and ECC has never been established. Hence this study was an attempt to determine whether the problematic eating and feeding behavior is associated with ECC in 46-71-month-old children in Bengaluru city, India using CEBQ.
| Subjects and methods | |  |
A cross-sectional study was carried out in schools of Bengaluru city, Karnataka, India. The city was divided into north and south zone. From each zone, private and government schools were randomly selected to get an equal distribution of children. Sampling method used was Stratified Random Sampling. A sample size of 250 achieved 90% power to detect an R 2 of 0.06 attributed to 4 independent variable (s) using an F-test with a significance level (alpha) of 0.05. All school going children from preschool to first standard from the selected schools were included in the study. Ethical clearance was obtained from Institutional review board of Nitte University. Permission from the school authorities and informed consent from the parents was obtained to carry out dental examination and also to collect data by questionnaire from the parents. All the selected children were clinically examined for dental caries by a pediatric dentist utilizing the World Health Organization (WHO) criteria 1997 for diagnosis of dental caries. The examination was carried out using mouth mirrors, community periodontal index probe under natural light/torch as per guidelines of American Dental Association for Type 3 examination. A trained assistant recorded the findings on data collection forms. The decayed missing filled primary tooth surfaces decayed, missing, filled surfaces Index, as given by Gruebbel A.O. in 1944 was used. If both the deciduous and permanent teeth were present, only the primary teeth were evaluated. Clinical data for caries detection was collected based on the criteria developed by WHO (1997).
Child's eating behavior was assessed by using CEBQ developed by Jane Wardle, Carol Ann Guthrie, Saskia Sanderson and Lorna Rapoport, 2001, University College, London. Detailed eating behavioral history was recorded from the parents that included food responsiveness, enjoyment of food, food fussiness, and satiety responsiveness, emotional under eating (EUE), desire to drink (DD) and slowness in eating on a dichotomous scale to probe for the presence or absence of each item. Each parent was assisted by the investigators and entire 250 forms were filled. Translation of the questionnaires into local language was also done to facilitate understanding by Institute of translational studies, Bengaluru the collected data was analyzed by using Chi-square test.
| Results | | |
It was observed that there was an almost equal gender distribution in the study population with 49.6% males and 50.4% females [Table 1]. The prevalence of ECC was found to be 34% in Bengaluru children aged 46-71 month old [Table 2]. Prevalence of ECC as according to the response to the CEBQ was subjected to Statistical Analysis using SPSS 16.00 (SPSS 16.00 version of IBM) [Table 3] and [Table 4].
| Discussion | | |
Dietary patterns among children and adolescent have shifted dramatically during the last few decades. Milk consumption has decreased, while consumption of soft drinks and non-citrus juices and drinks has increased. Some meals, such as breakfast, often are skipped altogether. [6] Teenagers who miss breakfast are more likely to snack during the day and snacks have the highest sugar content of any meal (i.e. breakfast, lunch, dinner or snacks). [7]
Children who reject certain types of foods and/or groups of food that parents think are appropriate may be perceived as picky eater, problem feeders, or neophobics. [8],[9] Studies have shown that toddlers who were perceived as picky eaters their mothers reported that their children accepted a limited number of foods, were unwilling to try new foods, limited their intake of vegetables and some other food groups and exhibited strong food preferences. [10]
Lot of literature has concentrated on eating disorders like Anorexia Nervosa and Bulimia nervosa, but eating disorders in infancy, childhood have not gained much of attention. Strict criteria for anorexia nervosa and bulimia nervosa have been laid down, but it has been seen that children do not display these well-defined criteria but rather show a spectrum of these behaviors. The habits reared in childhood are carried on in the later life hence it becomes of utmost important to identify and manage these psychological problems early in life.
Literature on oral aspects of these disorders occurring in children has been largely empirical and undocumented. Hence, this was an initial attempt to know whether there was any association between such eating behavior in children and its relationship with dental caries.
In the present study, CEBQ developed by Jane Wardle, Carol Ann Guthrie, Saskia Sanderson and Lorna Rapaport was used. The CEBQ is generally regarded as one of the most comprehensive instruments in assessing children's eating behavior. The instrument was developed and validated in the United Kingdom and recently the instrument has been validated in a Portuguese sample. This instrument has been used for different research purposes, e.g. to examine association with child body mass index, to compare appetite preferences in children of lean and obese parents, to discover continuity and stability in children's eating behavior across time and to examine eating behavior with idiopathic short stature. [5] This was the first time CEBQ was used to assess association with dental caries.
A total of 250 children aged between 46 and 71 months attending both private and government schools were assessed for the study. There was a near equal distribution of gender achieved with 124 boys and 126 girls, so as to avoid gender bias [Table 1]. Prevalence of ECC was around 34% [Table 2], which is within the range of 19.2-44% reported in other parts of South India. [11],[12],[13]
Satiety responsiveness represents the ability of a child to reduce food intake after eating to regulate its energy intake. Infants tend to be highly responsive to internal hunger and satiety cues, whereas this level of responsiveness decreases with advancing age. [5] Slow eating is characterized by a reduction in eating rate as a consequence of lack of enjoyment and interest in food. Slow eating can be a major concern among children, and is one of the most frequent problems reported by mothers. It has also been observed that maternal pressure to eat was associated with food responsiveness, slowness and fussiness [14] In response to Factor 1 (satiety responsiveness/slowness in eating) 74.4% of the parents responded that their children did not eat a meal if they have had a snack just before and 69.6% of the parents also reported that their children eat slowly. However 65% of these children were without ECC. No statistical difference was observed between children with or without ECC.
Food fussiness is usually defined as rejection of a substantial amount of familiar foods as well as "new" foods, thereby leading to the consumption of an inadequate variety of foods. This type of eating style is characterized by a lack of interest in food and slowness in eating. In this study highest ECC prevalence was seen in children who were difficult to please with meals; however this difference was not statistically significant. In response to factor 2 (fussiness) highest ECC prevalence of 64.9% was found among the children who were difficult to please with the meals. However no statistical significant difference was found between children who had ECC and those without ECC.
Food responsiveness reflects eating in response to environmental food cues. In response to these cues, appetitive responses and eating rate have been found to strongly increase in overweight or obese children [15],[16] It was observed that most of the parents responded that their children do not have a tendency to keep food in their mouth all the time had significantly lesser ECC as compared to those who had this tendency. This difference was statistically significant (P = 0.001). The reason for this could be increased demineralization due to increased exposure to food substances resulting in higher ECC prevalence. Though these questions appear in the food responsiveness section of CEBQ, it proves the known fact that frequency and quantity of food has role in ECC. It was also observed that those children who did not have a tendency to eat too much had significantly less ECC compared to those who ate too much (P = 0.045).
In response to children enjoying food most of the parents responded positively that their children loved food (72%), they were interested in food (68.4%) although ECC was observed to be highest in children who were not interested in food (39.2%), followed by those who did not look forward to mealtimes (38.6%), but this difference was also not statistically significant. In response to children enjoying food, approximately 60% of the parents said that their children did not look forward to meal times. However, no statistical significant difference was found between children who had ECC and those without ECC. The scale DD reflects the desire of children to have drinks to carry around with them, usually sugar sweetened drinks. The study population did not show any heightened DD as has been found in other studies, which is also a major cause of obesity in those children. [17] DD sweetened carbonated drinks was not observed in the study population and this factor was not significantly associated with ECC.
The scales emotional overeating and EUE can be characterized by either increase or a decrease in eating in response to a range of negative emotions, such as anger and anxiety. Emotional overeating was not observed in the sample population and it was not significantly associated with ECC. This was in contrast with other studies where most of the children had a tendency to eat more during stress or when they are anxious or annoyed. [5] The differences can be attributed to cultural and social differences between Indian population and western population. In response to factor 6, EUE was not observed in the study population However in response to factor 7, it was observed that prevalence of ECC was significantly high in children who ate more when they had nothing else to do compared to those who did not eat more (P = 0.008).
Prevalence of ECC was highest (41.6%) in children who ate more when they had nothing else to do (52.6%). Also, approximately 84.8% of the children did not have a tendency to eat more when they had nothing to do and 69.3% of these children were caries free. This difference was found to be statistically significant (P = 0.008).
Problematic eating behavior in children was observed as early as 46 months of age. ECC was more prevalent in children who had the tendency to keep food in their mouth all the time, who ate excessively and who ate more when they had nothing else to do.
| Acknowledgment | | |
Dr. Nandakumar and Mr. Shivaraj, Department of Community Medicine, M S Ramaiah Medical College, Bengaluru for help in Biostatistics.
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Correspondence Address:
Latha Anandakrishna
Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, MSRUAS, Bengaluru, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.147101
[Table 1], [Table 2], [Table 3], [Table 4] |
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