|Year : 2015 | Volume
| Issue : 3 | Page : 285-291
Association of maternal food choices with caries status and sugar consumption among preschool children in Vikarabad town
Md Shakeel Anjum, P Parthasarathi Reddy, M Monica, K Yadav Rao, Irram Abbas, Kistigari Poornima
Department of Public Health Dentistry, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
|Date of Web Publication||14-Sep-2015|
Department of Public Health Dentistry, Sri Sai College of Dental Surgery, Vikarabad - 501 101, Telangana
Source of Support: None, Conflict of Interest: None
Introduction: Children choose sweet, energy dense foods in preference to more nutritious options. Despite being aware about healthy food, mothers regularly purchase, prepare and allow their children to eat unhealthy food. Aims: To explore the association between the knowledge of mothers of preschool children about making food choices and oral health of their children and to assess the association with their children's sugar consumption and caries status. Materials and Methods: A cross-sectional study was conducted on 358 mother and child pairs from preschools and Anganwadi centers in the Vikarabad town of Ranga Reddy district in Telangana using simple random sampling. Data were collected using a questionnaire filled by their mothers who gathered their views on choices about food; a 3-day diet chart and clinical assessment of the children's caries status. Chi-square, t-test and ANOVA were used. Results: Majority of mothers were motivated by their child's preferences (51%), availability and accessibility of food products (19%) and affordability (15%) when making food choices for their children. Though, mothers had a favorable knowledge regarding food choices for their children and about oral health, it was not found to be associated with caries status of their children. However, the association between the sweet scores of the children and their caries status was significant. Conclusion:Though the mothers had favorable knowledge about providing healthy foods to their children, it did not reflect in their behavior when choosing foods. Higher sugar consumption of the children was associated with more dental caries.
Keywords: Caries, children, food choices, mothers, sugar intake
|How to cite this article:|
Anjum MS, Reddy P P, Monica M, Rao K Y, Abbas I, Poornima K. Association of maternal food choices with caries status and sugar consumption among preschool children in Vikarabad town. J Indian Assoc Public Health Dent 2015;13:285-91
|How to cite this URL:|
Anjum MS, Reddy P P, Monica M, Rao K Y, Abbas I, Poornima K. Association of maternal food choices with caries status and sugar consumption among preschool children in Vikarabad town. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2019 Nov 13];13:285-91. Available from: http://www.jiaphd.org/text.asp?2015/13/3/285/165276
| Introduction|| |
Nutritional intake during childhood is important for growth as well as the development of lifelong eating habits.  Children, nowadays, are prone to poor dietary habits that do not meet the dietary requirements of the body. 
Children under the age of 5 years generally spend most of their time with parents and guardians, especially mothers, even when they attend preschools or nurseries. These early years involve "primary socialization" during which the earliest childhood routines and habits are acquired. These include dietary habits and healthy behaviors, established as norms in the home and are dependent on the knowledge and behavior of parents and elder siblings.  Eating habits and body weight of children are linked to the nutritional habits of other family members - in particular, parents.  Family nutritional habits and food environment can both positively and negatively influence children's dietary intakes.  Food preferences are established early in life and are learned through experiences with food and eating. Preferences for sweet, energy dense foods are well developed by the time children attend school, and if made available, children have a tendency to choose such high sugar snack foods over other healthier options.  Dietary habits are formulated early in life, and a mother's choice of foods is a strong determinant of her offspring's dietary habit. Food choice may be defined as "the selection of foods for consumption, which results from the competing, reinforcing, and interacting influences of a variety of factors." 
Dental caries (DC) is a major public health problem among school children. , It is a multi-factorial microbial disease in which diet plays a significant role. There has been an enormous amount of experimental research published worldwide, linking fermentable carbohydrate (sugar) with DC. , A study by Rodrigues et al. showed that children who had a daily sugar intake of more than 32.6 g had nearly 3 times the risk of developing a high caries increment than those consuming <32.6 g.  Parental involvement in deciding their children's diet can ensure that their children are caries free. Parents, especially mothers help children learn and develop both eating habits and food choices; this may act through their personal preferences, attitudes to food and their knowledge and understanding of the benefits of a healthy diet.
As the food choices of preschool children are largely determined by parents, attention must be paid to the factors shaping parents' decisions.  Parenting style, time pressures as well as a cultural and socioeconomic background have been found to be important. There exists an apparent paradox in parents' food choices: That is, why do parents who are aware of what represents "healthy" food regularly purchase, prepare and allow their children to eat "unhealthy" food? 
Many behavioral theories such as the Health Belief Model and Theory of Reasoned Action have confirmed the major role of knowledge and attitudes in explaining behavioral changes.  These aspects are especially emphasized when the role of parents' knowledge of and attitudes toward health behavior and status of their offspring is assessed. Parents play a central role in giving children the information and encouragement needed for healthy lives. Despite changing roles and areas of responsibility within the family, in the child's oral health-related lifestyle, the mother still seems to play the key role. 
Mothers play a significant role in taking decisions on matters that affect their children's health. Opinions and beliefs of mothers are valuable considerations in forays into children's oral health initiatives.  As mothers have the greatest influence on children, this study attempted to explore the association of knowledge among mothers about making food choices for their children, with their children's caries status and sugar consumption, from preschools and Anganwadi centers of Vikarabad town.
| Materials and methods|| |
A cross-sectional study was conducted on mother and child pairs from preschools and anganwadi centers in the Vikarabad town of Ranga Reddy district in Telangana. The ethical clearance for the study was taken from the Institutional Review Board of the dental college. Permission from the authorities of the selected preschools and anganwadi centers was obtained prior to the start of the study. The sample size was determined using the following formula: n = (Zα + Zβ) 2 × rpq/Δ2
Where Z0α = 1.96 = 95% confidence interval (value of selected alpha level), Zβ = 0.84 = 80% power (value of selected beta level); RP = 15% (relative precision).
q = 1 − p; Δ = 0.05 = 5% (acceptable margin for error); n = required return sample size.
The sample size was calculated to be 399.84, which was rounded off to 400. For the purpose of the study, the town of Vikarabad was geographically divided into four Zones - North, South, East and West Zones. A subsample of 100 was taken from each zone. The complete lists of the private schools (total - 28) and anganwadi centers (total - 32) were obtained, respectively, from the Mandal educational officer and Child Development Project Officer, Vikarabad. Using simple random sampling, four private and four anganwadi centers were randomly selected, with each zone comprising one private school and one anganwadi center. If the sample required from one school was not obtained, another school from the same zone was randomly chosen till the desired sample was attained.
The study was conducted over a period of 1-month from June 25 th , 2014 to July 24 th 2014. Prior to conducting the study, the investigator was calibrated and trained to record the def index by Gruebbel,  under the guidance of a staff member of the institution (k = 0.88). The oral health checkup for all the 3-5-year-old children in each of these four schools and anganwadi centers was done. A total of 527 children were found to be in the age group of 3-5 years. Children who were present on the day of the study; those cooperative and medically fit were included in the study. Mothers willing to participate and giving informed consent were included. Mothers who had undergone previous dental treatment and children with teeth missing for reasons other than caries were excluded. About 496 children were eligible for the study. From this list of eligible children, the final sample of 400 was selected randomly.
Data were collected in three parts: A questionnaire filled by their mothers which gathered their views on choices about food; a 3-day diet chart and the clinical assessment of the children's caries status. Prior to the main study, the semi-structured questionnaire was validated (item content validity = 0.79). It was also checked for internal consistency using Cronbach's alpha coefficient during a test-retest procedure, conducted in one of the preschools, on a convenient sample of 30 mother and child pairs, at a 7-day interval and it was found to be satisfactory (α = 0.68).
The basic version of the questionnaire was written in English. Prior to the main study, a standardized procedure of translation and backwards-translation was followed to translate the questionnaire into Telugu with the help of a person well-versed in both languages. The questionnaire consisted of demographic details of the mother and child, eight questions enquiring about the eating habits of the child and 11 questions assessing the maternal knowledge about food choices and oral health of their children.
Before starting with the clinical examination, the procedure was briefed to the mother. Caries status of the child was recorded using plane mouth mirror and an explorer in the school premises in front of the mother under natural light with child sitting on a chair with high backrest, seated comfortably and the examiner standing behind the chair. The examiner herself entered the codes on a sheet of paper. After examination, mothers were informed regarding the caries status of their children. The child who required any emergency dental procedure was referred to the dental college for the treatment.
After obtaining caries status of the children, data on dietary intake of children for 3 days (including 2 weekdays and a day of the weekend) was obtained by distributing a diet chart to their mothers either directly or through the school authorities. The pattern of the child's food consumption was assessed using this diet chart in which each mother had to record all items eaten or drunk along with the time of consumption on three consecutive days. Mothers were asked to record all details in their vernacular language. The amount of food item eaten was to be recorded in terms of household measurements such as one cup or one teaspoon. The investigator clarified any uncertainties about the charts and encouraged their completion. On the 4 th day, the diet charts were collected and assessed individually to calculate their sweet scores. Of the 3 days, the day with maximum sugar consumption was considered for the analysis.
Data were entered into a Microsoft excel sheet. Descriptive statistics was done in number and percentage for each of the responses to the knowledge based questions. The knowledge-based questions were coded, and their mean knowledge scores and standard deviation were calculated. The level of significance was set at P < 0.05. Data were analyzed using the statistical package SPSS version 21.0 (SPSS Inc; Chicago, IL, USA). The Chi-square test was used for examining the maternal knowledge about food choices and oral health of their children. ANOVA was used to assess the association between maternal knowledge (independent variable) and categories of sweet scores (dependent variable) of their children. Statistically significant difference between maternal knowledge and caries status of their children was assessed using independent sample t-test. Statistically significant difference between categories of sweet scores (dependent variable) and caries status of the children was assessed using ANOVA, followed by Bonferroni correction. Association between maternal demographic characteristics with sugar consumption and caries status of their children were also done using Chi-square test.
| Results|| |
Out of 400, only 358 questionnaires and diet charts were returned completely filled giving a response rate of 89.5%. Thirty-one percent of the children were of the age 3 years, 32% were 4-year-old and 37% were 5-year-old. Boys (52%) were more in number than girls (48%). 56% of them belonged to private schools, and the remaining belonged to anganwadi centers [Table 1].
When in doubt about feeding food to their children, more than half of the mothers took the advice of their family members (57%), followed by doctors (21%). Three-fourth of the mothers reported that their children finished the entire food irrespective of what was packed for lunch. Half of the mothers reported that their children were influenced by their friends when buying foods. The majority of the mothers (47%) were concerned about their child's oral health while 37% were not. Sixteen percent of the mothers were of the view that milk teeth are not important as they will be replaced with permanent teeth anyway. [Table 2] shows the distribution of mothers, according to their views about their children's eating habits. [Table 3] shows the responses of mothers to knowledge based questions.
Mothers of children belonging to the excellent category had higher mean knowledge scores (14.74 ± 2.42) than the other two categories ("good" category - 14.65 ± 2.61; watch out zone category - 14.38 ± 2.51). Though not significant, higher mean knowledge scores among mothers were associated with less sugar consumption of their children [Table 4]. [Table 5] shows the difference between maternal knowledge and the caries experience of the children. Though not significant, mothers of caries-free children (14.58 ± 2.42) had higher mean knowledge scores than those with DC (14.52 ± 2.60). [Table 6] shows that higher sugar consumption of the children was associated with more DC and it was highly statistically significant (P < 0.001). The majority of the children who were caries free had "excellent" sweet scores (54%). The majority of them who had caries belonged to the watch out zone (72%).
|Table 4: Association between maternal knowledge and sugar consumption of their children |
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|Table 5: Association between maternal knowledge and caries experience of their children |
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|Table 6: Association between sugar consumption levels and caries experience of the children |
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Considering the association between maternal demographic characteristics with sugar consumption and caries status of their children, it was found that only the mother's education was found to be statistically significant with the caries experience of their children (P < 0.001). Remaining variables did not show any statistically significant difference (P > 0.05).
| Discussion|| |
Food choice is a complex process which involves many different factors. The many attempts made to illustrate the factors influencing this process are the physical properties and nutrient content of food; the individual's previous experience and learning associated with foods, which in turn will lead to different beliefs, values and habits; socioeconomic environment; sensory perceptions, monetary considerations, convenience, health and nutrition, management of relationships and quality. These different factors affecting food choice could be integrated by investigating personal attitudes and beliefs. 
Diet is important in the health and development of children, and can impact on later health outcomes. Establishing and maintaining healthy eating habits is important because habits formed in early life are likely to continue into adulthood. Therefore it is very important to understand influences on children's diets. As a single dietary recall would not capture variations in dietary habits, a 3-day diet chart was chosen.
Parental knowledge and attitude is one of the factors influencing dental disease and health in children. Parents are influential primary role models for healthy eating. As this study was based in a town with low literacy levels, a questionnaire to assess this knowledge was prepared keeping in mind the level of understanding of the mothers.
The majority of the mothers reported that their children preferred confectionaries like cakes, biscuits and chocolates, the most. Children are increasingly consuming high intakes of foods rich in fat, sugar and salt, and low intake of fruits, vegetables, whole grains and calcium-rich foods. Children tend to be attracted to confectionaries which are available in the market rather than the healthier options like fruits. Despite being aware of what constitutes a healthy diet, parents regularly purchase and allow their children to eat such unhealthy foods.  When in doubt regarding food choices, more than half of the mothers took the advice of their family members followed by doctors. Family members especially, elders play a vital role in day to day decision making. 
The majority of the mothers (71%) agreed that adding sweeteners to drinks and foods can be harmful to their children's teeth. This shows that the mothers had adequate knowledge about sugars and its effects on teeth. This finding contrasts with a European study by Elena and Petr where, the level of knowledge among mothers about the harmful effect of hidden sugar was significantly low.  The majority of the mothers were of the view that giving chocolate bars as gifts or rewards to children for their good behavior and academic achievements affected their eating habits. Unfortunately, this deleterious habit pattern once established is difficult to break and persists even after a child becomes older. Effective modification of dietary patterns depends on an understanding of the factors governing food choice.  Despite knowing that the habits are harmful and recognizing it as a means of preventing tooth decay, mothers continued allowing their children to eat chocolates. These contrasting views need to be further explored.
More than three-fourth of the mothers (83%) agreed that parents should decide what their child eats. Results of this study highlight the role of parents in controlling their child's eating habits. This, however, requires that parents need to be more confident in controlling sugar snacking of their children. Perceived control can be increased through the experience of personal mastery by choosing sugar-free snacks for children. 
High percent of mothers regarded healthy milk teeth among children as essential for proper chewing of food, and only negligible percent considered them as not important as they will be replaced with permanent teeth anyway (16%). This is contrary to an Indian study by Bahuguna et al. who found that treatment need for primary teeth was not considered imperative by a large percentage (65%) of parents.  Since many of them are belonging to village community subsisting on low income and more urgent problems to deal with such as food, shelter, general health care, and oral health of the child is neglected.
Likes and dislikes of the child took top priority among various factors because parents do not mind about the content as long as their children are eating food. However, health is clearly not the only factor people take into account when choosing their food and a focus on health may lead to exclusive emphasis on a set of motives that are of limited significance for many people. It is, therefore, important to explore the role of other influences on food choice. It may be that as incomes increase, people are less bound to buy only that food they know about, and can afford to take greater risks with food selection. 
Parents are gatekeepers for food availability within the home.  Consumption of healthful and unhealthful foods is significantly predicted by their home availability. Over the last several decades, families have dramatically increased purchases of convenient, less nutritious away-from-home foods.  There are a number of factors that may influence household food availability, such as household composition, access to food outlets, household income, transportation, income, and refrigeration/storage facilities.  Detailed findings about how to overcome barriers and what parents need to facilitate frequent and healthful family meals are scant in the literature.
A lack of nutritional knowledge cannot be used to explain why some parents purchase unhealthy food for their young children, and why children are allowed to eat meals which parents know are lacking a healthy balance. Price is also an obvious influence on food choice. The cost of food is a much more important element in selection among people with low incomes compared with those that are better off.  In this study, choices made by mothers about food were not found to be associated with sweet scores or caries status of their children. The above findings support the view of other researchers that improving knowledge may be insufficient to achieve behavioral change because nutritional knowledge and behavior are often poorly related.  Given that lack of knowledge is not the issue, identifying the issues surrounding the purchase, preparation and consumption of "unhealthy" and "healthy" foods have significant implications for future interventions. 
A significant difference, however, was found between the sweet scores of the children and their caries status (P < 0.001). Children come equipped with a biological set of taste predispositions: They like sweet and salty tastes and energy-dense foods, and they dislike bitter and sour tastes.  However, they develop most of their food habits through exposure and repeated experience. Though nonsignificant, the mothers of caries-free children had higher mean knowledge scores than those of children with caries. In a Nigerian study, the maternal attitude was significantly correlated with the oral health of their children.  Another study supports this finding that parents of caries-free children had more positive beliefs and attitudes than those with caries when studied over a period of time. 
The association of maternal demographic factors with the caries status of their children was also tested in this study. Only mother's education was found to be statistically significant with the caries experience of their children. This implies that mothers who were uneducated or attained low levels of education that is, up to tenth standard, were more likely to have children with DC. It has been suggested that maternal education may play a key role in the quality of children's diets. Parents, especially mothers, help children learn and develop both eating habits and food choices; this may act through their personal preferences, attitudes to food and their knowledge and understanding of the benefits of a healthy diet.
This study did have certain shortcomings. Not all possible DC risk and protective factors were assessed and controlled for in this study (e.g., use of fluoridated toothpaste, saliva flow rate). Furthermore, children included in this study were generally from the low socioeconomic background. In order to generalize the results, more number of studies should be carried out in a wider area covering urban and rural areas covering mothers of all socioeconomic backgrounds. Although this study offers insights into the characteristics of mothers' food choices, they fall short in explicating the particular role of mothers and the intricacies of the mother-child feeding relationship in making food choices for their children and the significant role that complex, interacting social and environmental factors play in this process. The findings of this study confirm that mothers face growing complexities in their food choice practices, this problem will require comprehensive and multi-factorial approaches that attend to both individual behaviors and socio-environmental factors and conditions.
When parents provide early exposure to nutritious foods, even fruits, and vegetables, children begin to like and eat more of such foods. Successful intervention efforts must involve and work directly with parents from the earliest stages of child development to support healthful practices both in and outside of the home. Reducing children's risk of developing caries is a significant component of tackling the complex public health problem. Addressing this problem will require comprehensive and multi-factorial approaches that attend to both individual behaviors and socio-environmental factors and conditions. Furthermore, parents with low educational attainment should be targeted by messages appropriate to their social context, literacy and level of understanding. Initiatives are required to promote early preventive visits of children by dentists and other health professionals, who come into contact with new mothers if goals of healthier mouths among children are to be realized.
| Conclusion|| |
Though the mothers had favorable knowledge about providing healthy foods to their children, it did not reflect in their behavior as they tended to consider, among various factors, the likes and dislikes of their children, affordability and accessibility of food products when choosing foods. It can thus, be concluded that mothers face growing complexities in their food choice practices.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]