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Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 306-312

Association between healthy eating index, body mass index, and early childhood caries in schoolchildren of Sakaka, KSA: A case–control study

1 Department of Preventive Dentistry, College of Dentistry, Jouf University, Sakaka, KSA
2 Department of Oral Medicine and Radiology, College of Dentistry, Jouf University, Sakaka, KSA

Date of Submission19-Mar-2019
Date of Decision14-Jul-2019
Date of Acceptance11-Oct-2019
Date of Web Publication12-Dec-2019

Correspondence Address:
Dr. Sudhakar Vundavalli
College of Dentistry, Jouf University, Sakaka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_34_19

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Background: Early childhood caries (ECC) was observed in children worldwide, and it adversely affects the oral health-related quality of life. ECC is multifactorial, and the concepts of poor nutrition and inappropriate feeding bottle habits as its risk factors could not provide sufficient evidence. Aim: The study aimed to assess the relation between Healthy Eating Index (HEI), body mass index (BMI), and ECC in the age group of 5–6 years children. Materials and Methods: A case–control study was carried out among 350 schoolchildren of Sakaka, KSA. Caries experience was recorded using decayed, missing, and filled teeth (dmft) index (WHO criteria 1997); various anthropometric measures such as weight, BMI, and height were recorded as per the standard guidelines. The Pearson's correlation coefficient and unpaired t-tests were used as bivariate tests; ANOVA with Tukey's post hoc for multivariate analysis. Results: A total of 350 male participants participated in the study, with the age range of 5–6 years and the mean age being 5.4 ± 0.7. The prevalence of ECC in the study population was 87%. The mean dmft values for each BMI category among the underweight, normal, overweight, and obese children were 4.73, 7.8, 9.4, and 10.8, respectively. The mean intake of grains was 1.9, vegetables 0.61, fruits 1.31; milk 1.78, meat/dal 4.8, total fat 9.9, saturated fat 9.9, cholesterol 10 refined carbohydrates 10, and variety 0.17 in children with severe ECC (S-ECC). Overall mean HEI score was significantly higher in children with S-ECC compared to simple ECC low (43.25 ± 3.44 vs. 57.46 ± 4.12), and HEI and dmft values were negatively correlated (−0.932). Conclusion: There is a negative relationship between ECC and HEI scores and positive correlation between BMI scores and ECC. Diet is again proved as a common risk factor for dental caries and obesity. Hence, the Nutritional Education Program is the need of an hour for these children and parents.

Keywords: Body mass index, dental caries, dietary habits, early childhood caries, healthy eating index

How to cite this article:
Vundavalli S, Nagarajappa AK, Doppalapudi R, Alhabarti AS, Aleiadah AS, Alruwili MN. Association between healthy eating index, body mass index, and early childhood caries in schoolchildren of Sakaka, KSA: A case–control study. J Indian Assoc Public Health Dent 2019;17:306-12

How to cite this URL:
Vundavalli S, Nagarajappa AK, Doppalapudi R, Alhabarti AS, Aleiadah AS, Alruwili MN. Association between healthy eating index, body mass index, and early childhood caries in schoolchildren of Sakaka, KSA: A case–control study. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2022 Jun 30];17:306-12. Available from: https://www.jiaphd.org/text.asp?2019/17/4/306/272789

  Introduction Top

Saudi Arabia stands at a better place in terms of health indicators among Gulf cooperation countries, and lifestyle-related health problems were the leading causes of mortality like any developed nations.[1] Good oral health is an integral component of good general health, although enjoying good oral health includes more than just having healthy teeth, many children have inadequate oral and general health because of active and uncontrolled dental caries.[2] Dental caries is the most common oral disease that affects a significant number of the Saudi Arabian population.[3]

Dental caries is a multifactorial infectious disease resulting from interactions among a susceptible host, cariogenic bacteria, and cariogenic diet.[4] It affects almost all age groups, but the presence of caries in young children is an important concern than that of elderly people. Early childhood caries can rapidly destroy the primary dentition of toddlers and small children affecting their general health, growth patterns, and quality of life, and if left untreated can lead to pain, acute infection, and premature loss of deciduous teeth, malocclusion, nutritional insufficiencies, and speech problems.[4]

The study of dental caries in primary dentition is important not only for the resulting deterioration in the quality of life of young children but also because dental caries in primary dentition is one of the best predictors of caries in the permanent dentition.[5] There are numerous risk factors significantly related to early childhood caries (ECC), the most important are probably certain feeding practices, such as bedtime bottle feeding, “at will” breastfeeding, and frequent intake of sugary snacks and drinks contribute to the development of ECC. Failure to eat breakfast daily and eating fewer than six servings of fruits or vegetables a day were also associated with dental caries in very young children.[5]

Diet plays an important role in the causation of caries; various dietary assessment methods such as oral questionnaire (24 h recall) method, food frequency questionnaire, and food diary method were commonly used. The Healthy Eating Index (HEI) is one index of overall diet quality based on the food pyramid where 24 h dietary recall is used, and it is comprised 10 component scores, each ranging from 0 (poor) to 10 (good).[6] Nutrition is one of the basic requirements of any living organism to grow and sustain life.[7] There were minimal data available proving a correlation between HEI and ECC in children. Hence, this study tested the hypothesis that there is no association between HEI, body mass index (BMI), and ECC in Saudi Arabian children.

  Materials and Methods Top

Study design

A case–control study was conducted to assess the association between HEI and ECC in school children. Children who are diagnosed with ECC were considered as cases and children without ECC as controls.

Settings and participant selection

This study was conducted in a school setting in Sakaka, capital of Aljouf province, KSA during the period from January 2018 to March 2018. The study participants were selected through systematic random sampling methods. The age group of the study participants ranged from 5 to 6 years old. Ethical clearance was obtained from the Institutional Review Board before the start of the study, and all the procedures followed are in accordance with the World Medical Association Declaration of Helsinki. The inclusion and exclusion criteria were as follows.

Inclusion criteria

  • 5–6-year-old children who had at least one decayed, missing (due to caries) or filled primary teeth
  • Parents who were willing to give written informed consent for the study.

Exclusion criteria

  • Medically compromised children
  • Children with physical and mental disabilities
  • Uncooperative children/children without parental consent.

The sample size was determined by taking the studies done by the previous researchers [7] on the prevalence of ECC which was found to be 37.3%. n = Z2 × p (1 − p)/E2. The size of the sample required was 323 which were rounded off to 350 children. Participants were selected using stratified cluster sampling; initially, Sakaka town is divided geographically into three zones, one school was selected as a cluster through simple random (lottery) method from the list of the schools, and children were selected through systematic random sampling until the desired number was achieved from each school.

Training and calibration of investigators

The examiner was trained under the guidance of a dietitian to record the HEI. HEI was recorded by the examiner on five participants who were not included in the study. Then, the index was recorded by the dietitian on the same individuals and the interexaminer variability was calculated. The κ = 0.86 was obtained for interobserver agreement.

For the collection of data, a specially designed pretested pro forma was used. The pro forma consisted of demographic questions such as age, sex, address, oral hygiene practices, and 24-h dietary recall chart.

Measuring healthy eating index

The United States Department of Agriculture's (USDA) center for nutrition policy and promotion developed the HEI.[6] This index was known for its reliability in assessing dietary quality, which is essential for this study. In this study, HEI was modified as per daily recommended dietary allowance (RDA) of Saudi children. The HEI is composed of ten components, each representing different aspects of a healthful diet: components 1–5 measure the degree to which a person's diet conforms to the USDA's food guide pyramid serving recommendations for the five major food groups (grains, vegetables, fruits, milk, and meat); as expressed in servings per day. The next four components of the HEI assess the degree of adherence to the dietary guidelines recommendations regarding several nutrients [6] (total fat, saturated fat, cholesterol, and sodium), and the final component examines the varieties of foods in a person's diet. Overall, the HEI is a sum of the components with a possible score of 0-–100. Each of the ten dietary components has a scoring range of 0–10.[6] Individuals with an intake at the recommended level received a maximum score of ten points. A score of zero was given when no foods in a particular group were eaten. Intermediate scores were calculated proportionately. High component scores indicate intakes close to recommended ranges or amounts; low component scores indicate less compliance with recommended ranges or amounts.

An HEI score over eighty implies a “good” diet, an HEI score between 51 and 80 implies a diet that “needs improvement,” and an HEI score <51 implies a “poor” diet.[6]

Scoring is given based on the amount of servings per day; numbers of servings were taken based on the RDA for Saudi Arabian children drawn up by the Ministry of Health (MOH).[8] Since children require fewer calories (1800 kcal for 5–6-year-old children) than adults, the minimum numbers of servings were kept to reflect the Food Guide Pyramid recommendations, and the serving sizes were adjusted. Dietary assessment was made by 24-h recall method where mothers or caregivers were asked to remember and report all the foods and beverages consumed in the past 24 h by the child.

Body mass index measurement

Height and weight measurements were recorded for all the children who participated in the study. Weight of each child on barefoot with light clothing was measured to the nearest 0.1 kg using a portable glass digital electronic personal weighing scale (Nova BGS-1238) which was calibrated before use. Each child was instructed to stand still, with mass equally distributed between feet, until the scale reading stabilized. The reading was then recorded. Height was measured to the nearest 0.1 cm using a mobile stadiometer. For the calculation of BMI, the following formula was used.

The value obtained was then plotted on age- and gender-specific percentile curves given by the Centers for Disease Control and Prevention, and children were categorized into four groups based on their BMI percentiles as follows:[9]

  • Underweight group children with BMI for age <5th percentile
  • Normal group children with BMI for age ≥5th percentile and <85th percentile
  • Overweight group children with BMI for age ≥85th percentile and <95th percentile
  • Obese group children with BMI ≥95th percentile.

Dental caries assessment

The examination for dental caries was carried out on the dental chair, and the caries were recorded based on the WHO criteria (1997); decayed, missing, and filled teeth (dmft) scores were used to calculate caries experience.[10] For the purpose of this study, ECC cases were defined using the American Academy of Pediatric Dentistry, criteria that are, the presence of 1 or more decayed (noncavitated or cavitated lesion), missing (due to caries), or filled tooth surfaces in any primary teeth in a child of 72 months age or younger constitutes simple ECC.

In children younger than 3-years of age, any sign of smooth-surface caries is indicative of severe ECC (S-ECC). From ages 3 through 5, one or more cavitated, missing teeth (due to caries), or filled smooth surfaces in primary maxillary anterior teeth, or decayed, missing, or filled score of ≥4 (ages 3–<4), ≥5 (ages 4–<5), or ≥6 (ages 5–<6) surfaces constitutes S-ECC.[11]

Statistical analysis

All statistical analysis was performed using the SPSS software (20.0, SPSS Inc., Chicago, IL, USA). Descriptive statistics were done using mean ± standard deviation and proportions with 95% confidence interval. Normality of data was assessed with KS test before performing inferential statistics. The Chi-square test was done for assessing the differences between qualitative variables. Pearson correlation test was used to evaluate the relation between BMI and dmft values and unpaired t-test for comparison between mean HEI scores in two categories of ECC. ANOVA was used for multivariate analysis with Tukey's honestly significant difference as post hoc test. The odds ratio was obtained from multiple binomial logistic regression analyses with ECC as dependent variable and age, brushing frequency, BMI category, and HEI scores as independent variables. Variables with P < 0.5 were included in multinomial model. P < 0.05 was considered statistically significant.

  Results Top

A total of 350 participants with the age range of 5–6 years were included in the study, and the mean age being 5.4 ± 0.7. [Table 1] shows the distribution of children according to age.
Table 1: Distribution of children according to age and gender

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[Table 2] shows the distribution of children based on mean dmft in various BMI for age categories. The mean dmft values for each BMI category among the underweight, normal, overweight, and obese children were 4.73 ± 1.9, 7.8 ± 3.3, 9.4 ± 3.08, and 10.8 ± 4.09, respectively, which was statistically significant (P = 0.000) and post hoc analysis identified mean dmft is significantly higher in obese children compared to other groups [Table 3].
Table 2: Distribution of children based on mean decayed, missing, and filled teeth in various body mass index categories

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Table 3: Post hoc analysis (Tukey's HSD)

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The mean intake of grains was 1.9 ± 0.87, vegetables 0.61 ± 0.86, fruits 1.31 ± 3.32; milk 1.78 ± 1.55, meat/dal 4.8 ± 3.5, total fat 9.9 ± 0.23, saturated fat 9.9 ± 0.19, cholesterol 10 ± 0.0, sodium 10 ± 1.1, and variety 0.17 ± 1.05 in children with S-ECC. A statistically significant difference was found between mean intake of grains and meat/dal to the types of ECC (P = 0.001) [Table 4].
Table 4: Distribution of participants based on healthy eating index to early childhood carry

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The frequency of sugar intake of the children to the early childhood caries was compared, and a statistically significant association was found between the frequency of intake of added sugar to the S-ECC (P = 0.001) [Table 5]. There was no statistically significant difference between brushing frequencies and mean dmft [Table 6]. HEI scores were negatively correlated with dmft scores in the participant children (Pearson correlation = −0.932, P = 0.000] [Graph 1]. Logistic regression analysis showed none of the independent variables was statistically significant in predicting ECC [Table 7].
Table 5: Comparison between the frequencies of sugar intake of the children to the early childhood caries

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Table 6: Comparison between the frequencies of tooth brushing with mean decayed, missing, and filled teeth

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Table 7: Multinomial logistic regression

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  Discussion Top

The present study was conducted to assess the relation between dietary quality and early childhood caries in 5–6-year-old children. Factors affecting the onset of carious lesions include oral hygiene, diet composition and frequency, socioeconomic status, salivary immunoglobulin, bacterial load, and fluoride intake.[12] ECC can be a particularly virulent form of caries beginning soon after tooth eruption, developing on smooth surfaces progressing rapidly, and having a lasting detrimental impact on the dentition.[4] All untreated dental caries may not be detrimental to the general health; however, it significantly influences the quality of life and dietary intake of children, especially when it is associated with pain and discomfort.[4] In the present study, the final sample comprised 350 children with the age group of 5–6-year-old. According to the WHO, affected eating pattern can rapidly manifest in younger children of 4–6 years of age.[12] Hence, this age group was selected for the study.

In the present study, the maximum number of participants was with normal BMI for age which is similar to the study done by Farsi et al.[13] and a study conducted by Bhayat et al. in the Medina region of Saudi Arabia.[14] The current study showed a positive relationship between nutritional status and early childhood caries among the study participants which was dissimilar to the studies done by Liang et al.,[15] Bansal et al.,[16] and Quadri et al.;[17] similar to the studies done by Davidson et al.,[18] Ashour et al.,[19] and Alghamdi and Almahdy [20] which showed a positive relationship between nutritional status and caries. Mitrakul et al. found that in S-ECC, the BMI percentile was not correlated with dmft or the sugar consumption patterns and negatively associated with iron consumption in 3–5-year-old Thai children.[21]

As diet plays a major role in the causation of caries, our study investigated the relationship of dietary guidelines in the food pyramid as measured by the HEI to the early childhood caries. The HEI is a measure of diet quality, independent of quantity that can be used to assess compliance with the US dietary guidelines for Americans and monitor changes in dietary patterns.[10] It is also used to examine the relationships between diet and health-related outcomes, and it is a valuable tool for epidemiologic and economic research and can be used to evaluate nutrition interventions programs.

This index provides a picture of foods people are eating, the amount of variety in the diet and compliance with specific dietary guidelines recommendations. Currently, there are two commonly used diet scores: the HEI and the Revised Diet Quality Index.[22] Both of these are based on the U.S. dietary guidelines and include both food- and nutrient-based indicators. Although they have been adapted for use in other countries by altering the cutoffs, there has been little adaptation of these indices in other countries.

Saudi Arabia is a vast country and is unique in the entire world with diverse culture and food habits.[8] Improper dietary patterns in children are more common in Saudi Arabia. The average Saudi diet mainly consists of cereals and pulses; it remains largely deficient in green leafy vegetables, fruits, milk, and milk products.

There is no separate component of sugar in the HEI, but since our study relates to dental caries, we have added sugar as a separate component, and it was found to be significantly associated with ECC.

The relationship between sugar and dental caries remains complex because other risk factors such as plaque status, saliva, bacteria level, and host factor also play roles in caries formation. Because of the exposure to fluoride in the modern age (dentifrice), the relationship between sugar consumption and caries is much weaker than it was historically.

There are very few studies to link HEI to the ECC, this kind of index is not reported in Saudi Arabia. Hence, we made an attempt to fit this index into the Saudi Arabian scenario based on the dietary guidelines for Saudis given by the MOH.[8] As most of the diet taken by Saudis is custom-made, it is difficult to assess the calorific value of such diet, which might give an exact picture of the diet's influence on caries.

In this study, number of servings was compared with the RDA for Saudis drawn up by the MOH,[8] where participant's consumption in certain food groups such as grain group, fat, and sodium group met the recommendation while the consumption of milk, fruits, and vegetables was below the RDA.

In the present study, high score for grain, meat/dal was associated with reduced S-ECC, and similar findings were reported by İnan-Eroǧlu et al. in the Turkish population.[23] This might be due to the high fiber and less sugar present in grains which would have been the reason for less caries in the grain group. In addition, meat/dal contains adequate protein and has low cariogenic potential which replaces the fermentation of refined carbohydrate and relatively are protected from dental caries. In the present study, there is no variety component among the study participants which was dissimilar to the study done by Nunn et al.[22] A variety of component gives us the different kinds of food items in a food group consumed in a day by a person, Saudi diet is predominantly meat based and this different kind of varieties are not seen regularly, and the age group of participants was only 5–6 years; hence, no variety component was seen in the study.

The overall HEI score was significantly higher in simple ECC (57.4) and lesser in S-ECC (43.2), and the majority of the participant's diet falls in the needs improvement category (HEI score ranging in-between 51 and 80) which is again similar to the findings from the Turkish study.[23] However, the present study had some limitations: Since the data were cross-sectional, causal relationships cannot be established, and the observed association could be due to other unexplored factors (hereditary). Caries detection was carried out visually, without taking radiographs, regarding HEI a perfect score of 10 is given when the minimum recommended number of servings in each food group is consumed, but it may also include children with excess consumption, such as excess fruit juice, and there is no separate component for sweets as there is in the food guide pyramid, which might result in better discrimination between healthy children and those with ECC. 24-h dietary recall approach is that individuals may not report their food consumption accurately for various reasons related to knowledge, memory, and the interview situation. Deriving detailed and accurate information from the parents regarding the eating practices, composition of snacks consumed, and weaning may not be totally reliable. Hence, future research should include obtaining dietary history through 7-day dietary records.

  Conclusion Top

There is a negative relationship between ECC and HEI scores and a positive correlation between BMI scores and ECC. Diet is again proved as the common risk for dental caries and obesity; hence, nutritional educational intervention is a need of an hour for both children and parents.


We would like to thank the children and their parents who participated in this study. No funding was obtained from any organization or individuals.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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