Health Promotion International, Vol. 14, No. 4, 329-335,
December 1999
© Oxford University Press 1999
Effects of dietary guidelines on sugar intake and dental caries in 3-year-olds attending nurseries in Brazil
1 Department of Epidemiology and Public Health, Royal Free and University College Medical School, University College London, London WC1E 6BT, UK and 2 Departamento de Odontologia Preventiva e Social, Faculdade de Odontologia, Universidade de Pernambuco, Av. Gen. Newton Cavalcanti 1650, Tabatinga, Camaragibe, PE, CEP 50.740-000, Brazil
Address for correspondence: Aubrey Sheiham, Department of Epidemiology and Public Health, Royal Free and University College Medical School, University College London, London WC1E 6BT, UK
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SUMMARY |
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The health outcomes of food and health policies are seldom evaluated. The objective of this study was to assess the effect of adoption of dietary guidelines on sugars by nurseries on levels of sugar consumption and 1-year dental caries increments in low-socio-economic 3-year-old children. Twenty-nine nurseries out of the 50 largest nurseries in Recife, Brazil were randomly selected. Five hundred and ten children (78% of those approached were examined); 245 children attending 12 nurseries adopting guidelines on reduction of sugar intake, and 265 at 17 nurseries without guidelines were assessed. The children's sugar intakes at nursery and at home were assessed by measuring 6 days weighed food intakes at the nursery and a food inventory completed by the children's mothers. Dental caries were examined using standard WHO criteria. There were statistically significant differences in frequency and weight of sugar intake between children attending nurseries adopting and those not using dietary guidelines (p < 0.001). Children at nurseries adopting guidelines consumed less than half of the amount of sugar consumed in a day by children at non-adopting nurseries; 22.9 versus 53.5 g. Children attending nurseries without guidelines on reduction of sugar intake were 4.87 times more likely to develop caries in 1 year than those attending nurseries with guidelines. Children who had a daily sugar intake of more than 32.6 g had nearly three times the risk of developing a high caries increment than those consuming less than 32.6 g. Dietary guidelines for sugar for nurseries are effective in providing menus with lower levels of sugar. Children consuming such menus are much less likely to develop dental caries.
Key words: caries; dietary guidelines; nurseries; sugar
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSFINDINGSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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An increasing number of preschool children spend some time being cared for outside the family home, in nurseries (Caroline Walker Trust, 1998
). Nurseries therefore supply an increasing proportion of the total food eaten by children in their care. Healthy eating and drinking are essential for proper growth and development in childhood (Caroline Walker Trust, 1998). Those who provide child care in nurseries are in a good position to influence not only the nutritional intake of the children but also the children's knowledge and attitudes on dietary matters (Caroline Walker Trust, 1998). Among the shortcomings of diets of preschool children in many countries is that they contain too much of the types of sugars that contribute to tooth decay and lower the nutrient density of the diet. The international recommendation of sugar intake is that non-milk extrinsic sugars should not exceed 10% of total energy intake; ~32.6 g for a 3-year-old child (WHO, 1990). Although a number of international and national expert committees have recommended guidelines on reduction of sugar intake (Department of Health, 1989; WHO, 1990), very little research has been conducted to assess the effect of the adoption of such guidelines. In Australia, the effect of adoption of a recommendation to restrict the sale of sweets in school canteens on caries increment of schoolchildren was assessed (Fanning et al., 1969; Roder, 1973). Both studies found lower caries increment in schools not selling sweets. In England, a study reported positive associations between selling biscuits in schools and caries in incisor teeth (Pengelly and Smith, 1972). There are no controlled studies of the dental health effects of implementing dietary guidelines in nurseries. Dental caries in preschool children is common in most countries, and causes considerable pain and suffering. In developing countries, particularly those that produce sugar, e.g. Brazil, dental caries in young children is a major public health problem (Freire et al., 1996). The objective of this study is to test the effect of adoption of dietary guidelines on sugars by nurseries on levels of sugar consumption and 1-year dental caries increments in low-socio-economic 3-year-old children. The hypothesis is that children attending nurseries which have adopted dietary guidelines on sugars would have a lower intake of dietary sugars and lower caries increments in their primary teeth than children attending nurseries without dietary guidelines. The study was designed in Recife, Brazil where a group of nurseries had implemented guidelines and offered an excellent opportunity of assessing the effects of the policy.
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METHODS |
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There were 99 non-fee-paying nurseries with 7776 children enrolled in Recife's metropolitan area (Assessoria 5, 1991
). These non-fee-paying nurseries are managed by governmental (34%) and non-governmental (66%) organizations (Assessoria 5, 1991). In Brazil, the governmental organizations are directly linked to Federal, State or Municipal level. As the objective of the study was to assess the effect of dietary guidelines on children with relatively high dental caries levels, fee-paying nurseries were not included as the children attending them had lower caries levels. To obtain a sample of ~250 children aged 3 years in each type of nursery, 29 out of the 50 largest nurseries were randomly selected; 12 nurseries with and 17 nurseries without dietary guidelines. Part-time operated nurseries were excluded. The sample size was calculated to give a 95% power of demonstrating between the two groups of children at the 1% level. The nurseries with guidelines were under separate control by two non-governmental (Lar Fabiano de Cristo and CAS) and one governmental (State Secretariat of Health) organizations. Nurseries without guidelines were controlled by two governmental and two non-governmental organizations. The nurseries to be compared were roughly matched prior to selection for the social class background of the parents sending children to the nursery.
To assess whether guidelines on reduction of sugar intake had been adopted or not by the sampled nurseries, elite interviews (Kinkade and Leone, 1992) were conducted among seven decision-makers involved in the planning and organizational issues of the selected nurseries. All the decision-makers contacted agreed to participate. The interview schedule had items on whether the nursery had any recommendations regarding nutrition and what they were. On sugars, they were asked ‘Does this nursery have any recommendations regarding sugar in nursery meals and snacks? Does this nursery follow the recommendations regarding sugar in nursery meals?’
All 1005, 3-year-old children aged 36–47 months attending the selected nurseries were eligible to participate in the study, except children with learning difficulties. The initial sample size comprised 650 3-year-old children. Five hundred and ten children were examined on two occasions, ~1 year apart, to assess the effects of the nursery policy on new caries. Permission to carry out the research was obtained from the organizations responsible for the management of the nurseries and the Legiao Brasileria de Assistencia. All parents of the selected children agreed to their participation.
The baseline investigation commenced in September 1993, with caries examination among the sampled children. The time interval between the first and second dental examination averaged ~12 months, with the follow-up clinical examination performed in September–November 1994. The WHO (WHO, 1987) caries diagnostic criteria were used to assess caries status (Rodrigues and Sheiham, 1999). The measurement of sugar intake at the nurseries was based upon a weighed inventory method in which an independent observer weighed all sugary food and drinks consumed by children during three non-consecutive days. In this method, the food is prepared and/or cooked and only weighed immediately before consumption, and any plate waste is weighed at the end of the meal (Marr, 1971). The measurements at each nursery were repeated at an interval of 6 months. Thus, for each child there were two sets of 3-days weighed inventory between September 1993 and November 1994; or a total of 6 days dietary intake over 1 year. All food and drink consumed by each child participating in the survey was weighed by the same independent observer.
Daily frequency of sugar intake, at home, at nursery and overall, was calculated by counting the number of daily eating occasions in which sugary food and drinks were consumed. An eating occasion is defined as an ingestion of food or beverage items no more than 20 min apart (Burt et al., 1988). The variables related to daily frequencies of sugar intake were stratified in such a way as to allow comparisons between children having the lowest frequencies and those having higher sugar frequencies. Daily frequency and weight of sugar intake at the nursery were calculated as an average of the 6-days weighed inventory. Daily weight of sugar intake was calculated in grams. It was decided that this variable would be dichotomized to obtain the odds ratios of those who had the highest sugar intake versus the remainder with lower sugar intake. The information on the children's dietary intake at home was collected by interviews with the mothers. Mothers were asked to recall their children's past intake in terms of food, drink and confectionery actually eaten during the last 24-h period.
The effectiveness of the guidelines on reduction of sugar intakes was assessed by comparing the daily frequency and daily total weight of sugar intake of the 3-year-old children attending the nurseries adopting and those not using guidelines on sugar intake.
Odds ratios and their 95% confidence intervals were calculated using logistic regression. Statistical significance of the observed differences was assessed through the likelihood ratio test. When appropriate, tests for linear trend were calculated by unfactoring ordered variables. The multivariate analysis took into account the hierarchical relationships between proposed risk factors. The data were processed and analysed using a multilevel modelling program (Goldstein, 1987).
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FINDINGS |
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Dietary guidelines
For most organizations, guidelines on nutrition were set locally by the nutritionist of the organization or by volunteers, based upon guidelines recommended by a group of expert nutritionists at the Legi, o Brasileira de AssistÍncia (LBA), a Federal body linked to Ministry of Social Affairs in Brasilia. The nursery menu was worked out by a qualified nutritionist. All food items had a ‘per capita’ recommendation for use. The nursery menu also worked as a guide for the purchasing of food items, which was done centrally every week for all nurseries. The directors of nurseries followed strictly the menu recommended by the organization where they worked because the quantities of foods and drinks were controlled and there was no other alternative sources of supplies. The nursery menu also worked as a guide for food preparation, including provision of sugars. The children spent from 07.00 h to 17.00 h at the nursery. The provision of meals was seen as one of the major functions of the nursery along with educational activities.
The prevention of dental caries was the most common reason for adopting guidelines on sugars. The decision-makers emphasized that dental caries was a common and serious disease among children, and that in some cases caries was so severe that it affected the child's nutritional status. Masked undernutrition and hyperactivity were other reasons given for adopting the guidelines.
Sample characteristics
A total of 510 children completed all aspects of the research (78% of those approached); 245 children were attending 12 nurseries adopting guidelines on reduction of sugar intake, and 265 attended 17 nurseries that did not have guidelines.
The educational levels of the parents of the children was low. Thirty-one per cent of parents of children attending nurseries adopting guidelines were illiterate compared to 27% of those from non-adopting nurseries. The educational level, family income, employment status, family structure, social classes of the parents of adopting and non-adopting nurseries were not significantly different (p = 0.48–0.93). The age and sex of children in the two groups were similar. There were significant differences in the household sizes and number of siblings between nursery types. Children from adopting nurseries tended to come from larger households and have more siblings.
Impact of guidelines on caries levels
The baseline caries levels (dmfs) did not differ significantly between children at the two types of nurseries. The mean baseline dmfs in children attending nurseries adopting guidelines was 2.75 (SD 5.39), compared to 3.21 (SD 6.44) in those at nurseries without guidelines. Similar percentages of children at the two types of nurseries were caries free at the baseline; 51 and 54%. Neither was the nutritional status different nor the percentages of children taking medicines.
The nurseries adopting guidelines on reduction of sugar intake effectively reduced the sugar intake at their nurseries compared with those nurseries not using guidelines. The daily average weight of sugar intake at nursery for all nurseries was 38.7 g. However, the range of daily sugar intake at nurseries was wide; from 8.6 to 89.9 g. There were statistically significant differences in frequency and mean sugar intake between children attending the nurseries adopting and those not using dietary guidelines. Children at nurseries adopting guidelines had one less intake of sugars a day (2.57 versus 3.85, p < 0.001, Table 1), and consumed less than half the amount of sugar a day than children at non-adopting nurseries; 22.9 (SD 6.2) versus 53.5 (SD 17.7) g (p < 0.001, Table 2). Ninety-seven per cent of children attending nurseries adopting guidelines on sugar consumed 32.6 g or less of sugar per day compared to 16% of children attending nurseries without guidelines (Table 3).
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Attendance at nurseries adopting guidelines on reduction of sugar intake was strongly associated with lower 1-year caries increment in primary. Children attending nurseries not using guidelines on reduction of sugar intake had a higher caries risk, with an odds ratio of 4.87 compared to those attending nurseries with guidelines (Table 4
). A higher caries increment was related to higher daily frequency and weight of sugar intake at nursery, overall daily frequency of sugar intake (sugar intake at home plus nursery), past caries experience, use of fluoride, and habits related to toothbrushing. Attending nurseries not using guidelines on reduction of sugar intake, increased by 3.6 times the risk of developing a high caries increment.
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The effect of daily average weight of sugar intake at nursery on dental caries was clear. The caries levels after 1 year at the nursery were significantly different between children at the nurseries following dietary guidelines and those without (p < 0.001); 3.72 compared to 5.66. This significant difference was also apparent when comparing the percentages of children who did not develop any new cavities during the follow-up period. Two-thirds (65.3%) of children attending nurseries using guidelines on reduction of sugar did not develop any new cavities compared to 38.5% of children at nurseries without guidelines. The effect of daily overall sugar intake on caries increment remained highly significant after adjusting for all the variables. Those children with the highest overall sugar intake (five or more times per day) were 4.29 times (OR = 4.29, 95% CI = 1.72–10.71) more likely to have a high caries increment (Table 3
). This variable also showed a dose–response trend with the risk of high caries increment (Rodrigues and Sheiham, 1999). Irrespective of the type of nursery attended, children who consumed sugar at nursery amounting to more than 10% of their total energy intake were more likely to have a high caries increment. After adjusting for confounding factors, children who consumed more than 32.6 g of sugar per day, the recommended upper limit, at the nursery, were 2.75 times more likely to have high caries increment compared to those who consumed up to 32.6 g (OR = 2.75; 95% CI = 1.29–5.85, Table 3). The confidence intervals were wide. Nevertheless, there was at least a 29% higher risk of high caries increment among children who consumed more than 32.6 g of sugar daily at nursery.
The adoption of guidelines by nurseries did not have much effect on the mother's behaviour and attitude in relation to her child's sugar intake at home. And guidelines did not influence children's sugar intake at home. In fact, children attending nurseries using guidelines on sugar had a higher daily frequency of sugar intake at home than children from nurseries without guidelines (Table 4). Despite that, the children from nurseries with guidelines developed less caries over the 1-year observation period.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSFINDINGSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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This study assessed the effects of policies on diet at nurseries which were implemented by one governmental and two non-governmental organizations. Whilst attempts were made to control for socio-demographic differences, the children attending the nurseries which were compared had significant differences in the household sizes and number of siblings between nursery types. Nevertheless, when that factor and all other confounding factors were controlled and entered into a multivariate analysis model, the positive effects of dietary guidelines persisted (Rodrigues and Sheiham, 1999
).
Children at nurseries with guidelines on sugar consumed less sugars and did that less frequently at the nursery than 3-year-old children attending nurseries without guidelines. Almost all children attending nurseries adopting guidelines on sugar consumed 32.6 g or less of sugar per day compared to one-sixth of children attending nurseries without guidelines. There was a positive relationship between daily frequency and daily weight of sugar intake at the nurseries. These findings are consistent with those of Rugg-Gunn et al. (Rugg-Gunn et al., 1984) and Cleaton-Jones et al. (Cleaton-Jones et al., 1987), and highlight the importance of guidelines including recommendations on weight as well as on frequency of sugars intake.
The adoption of guidelines for reducing sugar intake in nurseries for low-socio-economic children was associated with lower caries increments in primary teeth. Children attending nurseries not using guidelines on sugar were 4.8 times more likely to have higher caries increments than those attending nurseries using guidelines. A higher caries increment was related to higher daily frequency and weight of sugar intake at nursery, overall daily frequency of sugar intake (sugar intake at home plus nursery), past caries experience, use of fluoride, and habits related to toothbrushing. These findings highlight the importance for dental health of dietary interventions at a community level and at an early age.
The main implication of this study is that public health measures, e.g. dietary guidelines, should be used in preference to more individually oriented preventive approaches. Indeed, a need for a combined approach is indicated. This is particularly relevant for poor marginalized populations living under considerable levels of social material deprivation. Public health interventions to improve dental health of nursery school children through a health promotion dietary programme could consider adoption of guidelines on reduction of sugar intake by nurseries taking into account the levels recommended by WHO (WHO, 1990). To ensure the implementation of such guidelines, courses should be arranged to increase awareness among nursery staff and families about the health damaging effects of sugar intakes above 10% of total calories. Administrative guidelines to promote adherence to the guidelines among the nursery staff should be developed with staff, parents and nutritionists. Dietary recommendations on sugar should be directed especially towards nurseries dealing with very young children.
In most developing countries and in sections of populations in developed countries, dental caries in primary teeth is a major dental public health problem. These trends highlight the importance of the main causative factor for caries, i.e. non-milk extrinsic sugars (Department of Health, 1989). The findings from this study give strong supportive evidence for continued emphasis of non-milk extrinsic sugars as a major dietary cause of dental caries.
In countries where dietary guidelines are being developed for nurseries, guidelines on the amount, type and frequency of sugar intake should be incorporated. This is consistent with recommendations to increase the consumption of complex carbohydrates from vegetables and fruit, and decreasing the amount of non-milk extrinsic sugars (WHO, 1990; Caroline Walker Trust, 1998). The findings from this study can be used as an argument for inclusion of guidelines on sugar for children attending nurseries.
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ACKNOWLEDGEMENTS |
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CAPES provided financial support for this research. We would like to thank the organizations and the nursery staff for their co-operation with this study. Special thanks to Leopoldina Sequera, Sonia Andrade and Zelita Fernandes of the Instituto de Nutricao of the Universidade Federal de Pernambuco for their technical support with the fieldwork and analysis of the dietary data.
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REFERENCES |
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Assessoria 5 (1991) Creches em Pernambuco. Recife. Unpublished, Mimeo.
Burt, B. A., Eklund, S. A., Morgan, K. J., Larkin, F. E., Guire, K. E., Brown, L. O. and Weintraub, J. A. (1988) The effects of sugars intake and frequency of ingestion on dental caries increment in a three year longitudinal study. Journal of Dental Research, 67, 1422–1429.
Caroline Walker Trust (1998) Eating Well for Under-5s in Child Care. The Caroline Walker Trust, PO Box 17621, London SW10 9WT, pp. 6–18.
Cleaton-Jones, P., Richardson, B. D., Sreebny, L. M., Fatti, P. and Walker, A. R. (1987) The relationship between the frequency and the total consumption of sucrose among four South African ethnic groups. Journal of Dentistry for Children, 54, 251–254.[Medline]
Department of Health (1989) Dietary sugars and human disease. Report on the Panel on Dietary Sugars of the Committee on Medical Aspects of Food Policy (COMA). Report No. 37. HMSO, London.
Fanning, E. A., Gotjamanos, T. and Vowles, N. J. (1969) Dental caries in children related to availability of sweets at school canteens. Medical Journal of Australia, 1, 1131– 1132.[Web of Science][Medline]
Freire, M. C. M., Melo, R. B. and Silva, S. A. (1996) Dental caries prevalence in relation to socioeconomic status of nursery school children in Goiania-GO, Brazil. Community Dentistry Oral & Epidemiology, 24, 357–361.
Goldstein, H. (1987) Multilevel Models in Educational and Social Research. Griffin, London.
Kinkade, P. T. and Leone, M. C. (1992) The effects of tough drunk driving laws on policing: a case study. Crime & Delinquency, 38, 239–257.[Abstract]
Marr, J. W. (1971) Individual dietary surveys: purposes and methods. World Review of Nutrition and Dietetics, 13, 105–164.[Medline]
Pengelly, J. P. B. and Smith, F. J. A. (1972) Incisor caries and primary schools tuckshops. Public Health London, 86, 183–188.
Roder, D. M. (1973) The association between dental caries and the availability of sweets in South Australian school canteens. Australian Dental Journal, 18, 174–182.[Medline]
Rodrigues, C. and Sheiham, A. (1999) Relationship between dietary guidelines, sugar intake and caries in primary teeth in low income Brazilian 3-year-olds: a longitudinal study. International Journal of Paedodontics (in press).
Rugg-Gunn, A. J., Hackett, A. F., Appleton, D. R., Jenkins, G. N. and Eastoe, J. E. (1984) Relationship between dietary habits and caries increment assessed over two years in 405 English school children. Archives of Oral Biology, 29, 983–992.[Web of Science][Medline]
WHO (1987) Oral Health Surveys. Basic Methods. World Health Organization, Geneva.
WHO (1990) Diet, Nutrition and Prevention of Chronic Diseases. Technical Report Series No. 797. World Health Organization, Geneva.
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