The impact of dietary behaviors and food consumption and their relation to oral health are significant public health issues. Women and men exhibit different dietary behaviors. Understanding the influences of dietary behaviors on oral health from the perspective of gender disparities, however, is limited. This article provides the intersections of dietary factors and oral-systemic health for which women are at greater risk than men. Topics include the effect of dietary choices on oral health disparities seen in female patients. Interventional strategies at the local and community level that are designed to influence the balance between dietary habits and oral-systemic health are discussed.
Key points
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Specific dietary behaviors and food consumption significantly affect oral health.
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Compared with men, women tend to report more weight-related unhealthy eating behaviors, including those of eating disorders.
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Certain food consumption and dietary behaviors are known risk factors for both obesity and dental disease.
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Oral health care providers (OHPs) must have an active role in early diagnosis, oral treatment, and referral of patients with unhealthy dietary behaviors because they are often the first health providers to observe overt health effects.
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The impact of OHPs is enhanced with their taking an active role combating a broad spectrum of weight-related disorders and oral diseases by providing preventive strategies at the personal and community levels.
Introduction
The impact of specific dietary behaviors and food consumption is evident and of increasing importance in obesogenic and cariogenic food arenas. Generally, studies conclude that women and men have different dietary behaviors. Understanding the influences of dietary behaviors on oral health from the perspective of gender disparities is limited, however, calling for review to shed some light on these complex interactions. This article provides the intersections of dietary factors and oral-systemic health that are at greater risk for women than men. Additionally covered are US government initiatives and leadership structures that are set to address oral health disparities. Lastly, current efforts on dental office–based and community-based interventions that designed to directly or indirectly influence dietary oral-systemic health are discussed.
Introduction
The impact of specific dietary behaviors and food consumption is evident and of increasing importance in obesogenic and cariogenic food arenas. Generally, studies conclude that women and men have different dietary behaviors. Understanding the influences of dietary behaviors on oral health from the perspective of gender disparities is limited, however, calling for review to shed some light on these complex interactions. This article provides the intersections of dietary factors and oral-systemic health that are at greater risk for women than men. Additionally covered are US government initiatives and leadership structures that are set to address oral health disparities. Lastly, current efforts on dental office–based and community-based interventions that designed to directly or indirectly influence dietary oral-systemic health are discussed.
Weight-preoccupied society and obesity
According to the World Health Organization, overweight (body mass index [BMI] ≥25) and obesity (BMI ≥30) compose the 5th leading risk for deaths globally. In the United States, approximately 2 in 3 adults and 1 in 3 children are reported to be overweight or obese. The percentage of obese adults increases with age, especially among women. Although an estimated 32% of women between 20 and 39 years of age are obese, the percentage climbs to 36% between ages 40 and 59 and tops 42% for women ages 60 and older. The rate of obesity, however, is similar between girls (15%) and boys (18.6%). Moreover, 2.8% of men and 6.9% of women are reported to be morbidly obese; significant differences also exist by ethnicity, with lower rates of obesity among white adults than black or Hispanic adults. In the United States, approximately 60% of non-Hispanic black women 20 years of age and older are obese compared with slightly more than 40% of Hispanic women and approximately 35% of non-Hispanic white women. Models predict that by the year 2015, three-quarters of adults in the United States will be overweight and 40% obese.
Girls and young women face different developmental stages and challenges in childhood, adolescence, and pregnancy. Weight concerns and dieting behaviors are more common among women than men. Among social factors, social pressure for thinness has been widely accepted as an explanatory factor that contributes to gender disparities in distorted body image, weight preoccupation, and, in consequence, dieting and eating disorders. Compared with men, women tend to report more unhealthy eating behaviors, such as dieting and eating disorders. The general consensus is that weight concern is a powerful medium that distorts body image, which, in turn, contributes to distorted eating behaviors, particularly more for women than men. These unhealthy eating behaviors make individuals susceptible to health risks. Less attention is given, however, to whether dieting or eating disorders are directly related to oral health.
Cariogenic food consumption and dietary behaviors
Certain food consumption and dietary behaviors are known risk factors for both obesity and dental caries. During the past 3 decades, Americans have dramatically increased their consumption of sugar-sweetened beverages (SSBs), including soda, fruit drinks and punches, and sport drinks. Since the 1970s, soda consumption has approximately tripled. Concurrently, the rates of weight gain, obesity, type 2 diabetes mellitus, and cardiovascular disease (CVD) have risen. SSBs are the largest source of refined sugar consumed in the United States. In 2004, adolescents consumed an average of 300 calories per day from SSBs, accounting for 13% of their daily caloric intake. The high consumption of SSBs is a significant determinant of dental caries, obesity, bone mineral density (BMD), anxiety, and poor sleep.
High consumption of SSBs, when combined with gingival plaque deposits, is a significant risk factor for dental caries among low-income youth and adults. A longitudinal cohort study from birth to preschool age by Marshall and colleagues confirmed that regular soda consumption, including 100% fruit juice or powdered beverages, was the strongest risk factor for dental caries among dietary factors. The increased consumption of SSBs with a concurrent reduced intake of milk during the teenage years may increase the risk of osteoporosis in older women.
Recent focus has extended to other deleterious dietary behaviors, including snacking on chips and sugar-dense foods as well as the frequency of processed starch consumption. Dietary habits, such as skipping breakfast and eating inadequate fruits or vegetables, were also associated with dental caries in children. Furthermore, inappropriate feeding practices, such as at-will feeding and bedtime bottle feeding, contribute significantly to the development of dental caries. In summary, poor dietary choices, such as these, combined with SSB consumption are common indicators of obesity and dental caries, making consideration of food environment and choice in relation to oral health essential.
Oral-systemic dietary connections
Although oral-systemic connections have been documented since the seventeenth century, only recently have medicine and dentistry become confluent with respect to the overall health and well-being of the patient population. Several reviews have outlined the many oral-systemic connections that have been studied or theorized. Several mechanisms have linked how oral-systemic connections are made throughout the body, including oral manifestations of systemic diseases, oral causes of systemic diseases, and, in some cases, simply correlations between oral health and systemic health issues. As an example, severe generalized periodontitis may negatively affect the control of underlying systemic diseases.
A growing body of research points to the relationship between oral health and systemic diseases, such as heart diseases, diabetes, and poor pregnancy outcomes. Oral health has been declared as 1 of the 12 Leading Health Indicators in Healthy People 2010 . The oral-systemic women’s health issues that have dietary connections are discussed.
Diabetes
In the United States, approximately 25.8 million people have diabetes and approximately 35% of adults, ages 20 and older, are considered prediabetic, with conditions that are exacerbated by being overweight or obese. Similarly, hyperinsulinemia and the insulin-resistant state are related to increased weight, which, in combination, contribute to diabetes and kidney disease–related deaths. As the 7th leading cause of death in the United States, the lifetime risk of developing diabetes for an individual born in 2000 is 33% for men and 39% for women. Although the all-cause mortality rate among diabetic men has decreased over the past 4 decades, the rates of all-cause mortality among diabetic women have shown no reduction.
A bidirectional relationship exists between periodontitis and diabetes. Diabetes has an adverse effect on periodontal health, and periodontal disease is a widely accepted complication associated with type 2 diabetes mellitus. Periodontal disease may contribute to systemic inflammation that generates inflammatory cytokines, which can lead to worsening insulin resistance and type 2 diabetes mellitus. At the same time, diabetes can have adverse effects of the periodontium, including decreased collagen turnover, impaired neutrophil function, and periodontal destruction. In a study among Pima Indians with and without type 2 diabetes mellitus, diabetes increased the risk of developing periodontitis 3-fold. Moreover, studies have shown that diabetes increases the risk of alveolar bone and attachment loss. There is strong evidence to suggest that the incidence and severity of periodontitis are influenced by the presence of type 2 diabetes mellitus and, among individuals with type 2 diabetes mellitus, that the incidence and prevalence of periodontitis are affected by patient control. Diabetes patients, especially those with poorly controlled diabetes mellitus or hyperglycemia, are more susceptible to loss of periodontal attachment.
Diabetes is a risk factor for other oral pathologies as well. Diabetes is associated with increased risk of gingivitis; candidiasis; oral lichen planus; premalignant lesions, like leukoplakia; and oral malignancies. Oral symptoms commonly associated with type 2 diabetes mellitus include dry mouth, gingival bleeding and swelling, and advanced pocket formation. Diabetes-associated xerostomia may make oral tissue more susceptible to damage by trauma and opportunistic infections, such as candidiasis. It can also lead to accumulation of bacterial plaque and food debris, which are associated with increased risk for dental caries and periodontitis. Prolonged xerostomia increases the risk of local accumulation of plaque and debris, which can increase the risk of opportunistic infections, altered taste, oral malodor, and oral mucosal soreness.
Additionally, glycemic control and disease duration seem to have different effects on oral health. Poor control and duration of diabetes are both associated with more severe periodontal disease and individuals with poor glycemic control have higher prevalence and severity of gingival inflammation and periodontal destruction. Xerostomia and parotid gland enlargement may also be related to the degree of glycemic control. Similarly, poorly controlled diabetes mellitus may increase the risk of developing superficial and systemic fungal infections ; the clinical course of oral candidosis may be more severe among patients with type 2 diabetes mellitus than in healthy patients and exacerbated most among type 2 diabetes mellitus patients with poor glycemic control. It is unclear whether improved oral hygiene improves glycemic control. Evidence suggests that improvements in oral hygiene among diabetics can improve diabetes control and may reduce Hemoglobin A1c.
Cardiovascular Disease
Women represent an increasingly larger proportion of patients with coronary artery disease due to their living longer than their male counterparts. The incidence of heart disease throughout their life span poses an increased financial burden on the health care system. Oral health has been associated with CVD since as early as 1989, when Mattila and colleagues reported an association between poor dental health and acute myocardial infarction. Periodontal disease specifically has been linked to CVD since 1996, when the newly formed area of periodontal medicine paved the way for looking at oral-systemic links, such as CVD. Since that time, there have been several research studies connecting CVD and periodontitis. This literature has grown to the extent that 6 meta-analyses have been conducted, all showing that patients with periodontitis are at increased risk for developing CVD. Furthermore, a systematic review demonstrated that periodontitis is associated with systemic concentrations that are linked to atherosclerosis—raised concentrations of C-reactive protein, fibrinogen, and cytokines.
Although these connections have been made extensively, some studies have found mixed results, particularly in connections to coronary heart disease. Although many studies demonstrate increased risk of CVD with periodontitis, epidemiologic studies cannot establish causality, and the question of the mechanism is being investigated. Four potential mechanisms that foster this oral-systemic connection have also been posited: common susceptibility to infections (causing both periodontitis and atherosclerosis), systemic inflammation, infection from periodontitis entering the blood, and immune response to periodontitis, causing inflammation.
Excess weight is associated with an increased risk of CVD and a woman’s risk of coronary heart disease is graded: as more excess weight is accumulated, the risk of coronary heart disease increases. In a large prospective cohort study conducted among women in the United States, researchers found that after controlling for obesity, even mild-to-moderate weight gain increased a middle-aged woman’s risk of coronary disease.
Reproductive Complication
Pregnancy has been linked to some of the most significant hormonal-oral changes. Oral manifestations include increased caries, acid erosion, and increased salivation from vomiting as well as xerostomia, increased tooth mobility, and tooth loss. Research has suggested several potential risk factors that periodontal disease may carry for adverse pregnancy outcomes. Correlations were established between periodontitis and preterm low-birth-weight infants, and a direct relationship between the severity of periodontitis and the risk of preterm birth was established. These connections have been researched extensively enough for the conduct of 4 meta-analyses, 3 that concluded a positive association between pregnant women with periodontal disease and risk of preterm birth and 1 that demonstrated indications of this association but with a lack of conclusive evidence.
A systematic review of 25 studies reported that 18 of the reviewed studies demonstrated an association between periodontal treatment and a reduction in preterm birth and preterm low-birth-weight babies. In 2009, a meta-analysis conducted by Polyzos and colleagues demonstrated a significantly lower rate of preterm birth but only a borderline significantly lower rate of low-birth-weight infants when pregnant women were treated for periodontal disease with scaling and root planning. (For a review of this topic, see the article by Steinberg and colleagues elsewhere in this issue.) Given the varied results, more research is needed to understand how periodontal treatment may have an impact on adverse birth outcomes.
Excess weight also puts women at risk for experiencing an array of pregnancy-related complications, mainly due to elevated rates of chronic hypertension and diabetes prior to conception. Compared with women with normal BMI, obese pregnant women are more likely to develop gestational diabetes mellitus and pregnancy-induced hypertension. While giving birth, they face increased rates of labor induction, delivery by cesarian section, and wound infection.
Osteoarthritis
Osteoporosis has been associated with increased rates of bone loss, accelerated alveolar bone resorption, and periodontitis. Overweight women are at greater risk of developing osteoarthritis and tend to suffer more from its effects than similarly overweight or obese men. The prevalence of osteoarthritis increases with additional severity of overweight and obesity. Additionally, some medications used to treat osteoporosis may cause osteonecrosis of the teeth. Osteoporosis is not believed to cause periodontitis but may increase the severity of already existing periodontitis ; this relationship, however, remains unclear.
Other osteopathic conditions, such as osteoporosis and osteopenia, are common among competitive female athletes and those with some types of disordered eating. Disordered eating is associated with menstrual irregularity and menstrual irregularity is correlated with low BMD. A study among young competitive female distance runners found that disordered eating was associated with low BMD even in the absence of menstrual irregularity. Anorexia nervosa (AN) that begins during the teenage years can also cause deficiencies in bone mass accrual and short stature as well as increase the likelihood of being osteopenic, even after years of weight and menstrual recovery.
Grocholewicz and Bohatyrewicz reported a negative correlation between lumbar BMD and periodontal disease as well as between the radius BMD and papillary bleeding index.
Eating disorders and disordered eating
Girls and women are disproportionately affected by eating disorders and disordered eating. Studies have consistently reported higher rates of AN, bulimia nervosa (BN), and binge-eating behaviors among girls and women, with the lifetime prevalence of AN and BN 1.75 to 3 times higher among women. It is suggested that dieting may be a precursor to disordered eating behaviors. Moreover, mounting evidence suggests that obesity, disordered eating behaviors, and eating disorders are interrelated, often occurring in the same individuals.
Although eating disorders are defined as psychiatric diagnoses, they are associated with nutritional, medical, and dental problems. AN is often practiced by severe food restriction or starving oneself, thus leading to underweight status. BN is characterized by binge eating and inappropriate compensatory behaviors, such as vomiting, laxative use, and excessive exercise, in order to control body weight. Eating disorders are associated with psychological disorders and systemic diseases, including oral health. AN and BN have both been associated with increased oral health problems, and some cases are linked to dental caries and periodontal diseases. Compared with AN patients, BN patients reported worse oral health status, especially dental erosion, dry or cracked lips, and burning tongue syndrome.
Disordered eating includes a broad range of behaviors that elude clear definitional boundaries. In practice, disordered eating is often used to describe a wide array of irregular eating behaviors that do not collectively meet the clinical criteria for diagnosis as eating disorders. Unhealthy eating behaviors may include excessive dieting, fasting, extreme body dissatisfaction, binge eating, compulsive exercising, and purging. Boutelle and colleagues found that overweight adolescents were more likely than peers with healthy weights to partake in unhealthy weight control measures, such as using laxatives or diet pills or vomiting. Similarly, obese children are 3 times more likely than healthy controls to develop BN. In a longitudinal study of adolescents, researchers found that those who used unhealthful weight control behaviors at baseline (including using diet pills, food substitutes, cigarettes, diet pills, vomiting, or laxatives to control weight) increased their BMI more than those who did not engage in any weight control behaviors. Five years later, these youth were also at increased risk for binge eating with loss of control and extreme weight control behaviors.
Even though oral health problems are secondary conditions in eating disorder patients, the true problems of dental diseases are often not recognized or are hidden by patients, remaining undetected by dental professionals. Oral health education and training in the association between eating disorders and oral health is a great necessity because dental care professionals can play an important role in early detection and diagnosis of eating disorders, thus promoting oral health.
Preventive public health activities
Government Initiatives
In 2000, the surgeon general’s first report on oral health, Oral Health in America, addressed the need of public health efforts to improve oral health disparities in the United States. By building on the recommendations of the surgeon general’s report, Healthy People 2010 and Healthy People 2020 provided the specific goals and objectives to work with national and state public health agencies. For the first time, in Healthy People 2020 , the US Department of Health and Human Services included “oral health” as 1 of the 12 Leading Health Indicators and introduced the importance of oral-systemic diseases. To prevent oral-systemic diseases, Healthy People 2020 recommends increasing regular dental care visits, which is 1 of the 17 oral health objectives: “Persons aged 2 years and older who used the oral health care system in the past 12 months.”
Among the objectives, increasing the proportion of site-specific access to preventive care with an oral health component was clearly stated along with increasing the proportion of the population who use the oral health care system and preventive dental service. The access to site-specific public health channels such as schools, local health departments, and Federally Qualified Health Centers, was listed as a separate objective for preventive oral health services where comprehensive oral-systemic health screening and interventions can be incorporated ( Box 1 ). In particular, increasing access to preventive dental care service for low-income children and adolescents was a separate objective, reflecting the need to address disparities of populations at risk. Given the problems of reproductive complications and their health implications to children, women in poverty may be a special population in need as well.
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OH–7: Increase the proportion of children, adolescents, and adults who used the oral health care system in the past 12 months.
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OH–8: Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year.
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OH–9: Increase the proportion of school-based health centers with an oral health component.
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OH–10: Increase the proportion of local health departments and Federally Qualified Health Centers that have an oral health component.
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OH–11: Increase the proportion of patients who receive oral health services at Federally Qualified Health Centers each year.
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OH–14: (Developmental) Increase the proportion of adults who receive preventive interventions in dental offices.
Abbreviation: OH, Oral health.
The Oral Health Initiative 2010 was announced to support and enhance current public health efforts to improve the oral health of the public. The key message is, “oral health is integral to overall health,” and a systems approach is proposed that focuses on 4 areas: (1) emphasize oral health promotion/disease prevention, (2) increase access to care, (3) enhance oral health workforce, and (4) eliminate oral health disparities. Among the 9 new initiatives, there were no initiatives that can be directly connected to oral-systemic diseases or dietary factors; in fact, none of the initiatives used the words oral-systemic disease ( Box 2 ). It is encouraging, however, to have “oral health as part of women’s health across the lifespan” as one of the initiatives. The last initiative in Box 2 presents a developmental perspective on women’s oral health issues from infancy to the postmenopausal period to medical and dental care services.
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Head Start Dental Home Initiative (Administration for Children and Families)
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National Oral Health Surveillance Plan (Centers For Disease Control and Prevention and National Institutes of Health)
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Review of Innovative State Medicaid dental Programs (Centers for Medicare and Medicaid Services)
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National Study on Oral Health Access to Services (Centers for Medicare and Medicaid Services)
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Early Childhood Caries Initiative (Indian Health Service)
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Clinical and Translational Science Program (National Institutes of Health)
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A Cultural Competency E-learning Continuing Education Program for Oral Health Professionals (Office of Minority Health)
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Oral Health as Part of Women’s Health Across the Lifespan (The Office on Women’s Health)
Community Interventions on SSB Consumption
Community-based nutrition interventions aimed at curve obesity epidemics have been tested and placed at different levels. Among those recent efforts, there is no question that community interventions focused on SSBs may present a valuable opportunity in preventive oral health interventions. The recent increases in soft drink consumption among children and youth not only reflect the recent advertisement and business advances by manufacturers of these beverages but also the widespread availability within communities, including school settings.
SSBs represent the most frequent purchase among youth. The recommendation that reducing these added dietary sugars might be feasible by reducing the availability of vending machines in school settings. Cullen conducted a school interventional study to investigate whether school food environment changes influenced soda purchases in a middle school in Texas. She found that healthier alternatives, such as increasing access to bottled water and whole fruit juices, can be made available to youth with favorable uptake. This study demonstrated that vending machine changes (including soda machines) can be implemented in school setting. In efforts to curb high rates of SSB consumption, researchers suggest reducing soda bottle sizes and adding more water bottles as an alternative.
Banning all SSBs in schools was recommended by the Institute of Medicine in 2007 to establish healthy school environments. Many state school beverage policies, however, focused only on soda bans yet allowed other sweetened beverages, such as sports drinks and fruit juices. Tabera conducted an evaluation study on children’s access to, purchase of, and consumption of SSBs. They found that policies banning all SSBs may reduce access and purchase of SSBs but not consumption. Also, they reported that there were no differences detected between states having only a soda ban and those with no policy. The results indicated no positive effect of school beverage policies on children’s SSB consumption. Thus, more a comprehensive approach is desired in the development of school-based beverage policy interventions.
As an example of community-wide intervention on SSB consumption, New York City became the first major metropolitan city to enact a ban on the size of soda cans and bottles. The intent of such a ban is to reduce excess caloric intake by the city’s residents in hopes to help curb the increasing obesity epidemic and improve overall community health. This ban essentially limits soda larger than 16 ounces in size to be sold at restaurants, fast food chains, theaters, delis, and office cafeterias. This revolutionary city-wide stipulation is the first of its kind in the United States, although the city of New York has passed previous bans on smoking in bar settings, removed whole milk selections from city schools and trans fat additives in food, and required calorie labeling in restaurants.
Although community-based food ban policies are in their infancy, their basis is justifiable to improving the community health of residents of all. Currently, community-level efforts are discussed only regarding obesity prevention and do not include the angle of oral health. There is well-established evidence that high SSB consumption poses serious potential harm to oral health. Therefore, community-based interventions aimed at targeting dietary behaviors at various levels (schools, restaurants, and so forth) may provide the optimal opportunity in regards to oral-systemic diseases prevention.
From research to practice
Diabetes
Greenberg and colleagues conducted a national random sample of general dentists in the United States in order to assess attitudes, willingness, and perceived barriers regarding chairside medical screening in the dental office. The majority of dentists believed it was important to screen for hypertension (85.8%), CVD (76.8%), type 2 diabetes mellitus (76.6%), hepatitis (71.5%), and HIV (68.8%). Likewise, the majority of dentists were willing to refer patients for consultation with physicians (96.4%), collect oral fluids for salivary diagnostics (87.7%), and conduct medical screenings that yield immediate results (83.4%).
In a cross-sectional survey of 265 randomly selected dentists in 3 states, researchers found 61% believed that addressing diabetes was an important responsibility. Athough the vast majority (86%) of dentists advised patients with diabetes about the risk of periodontal disease, only 47% reported that they knew how to assess for diabetes, 42% felt well prepared to intervene with patients with diabetes, and 18% provided diabetic-related services.
Eating Disorders
OHPs (ie, dentists and dental hygienists) have a role in prevention, early diagnosis and oral treatment, and referral of patients who engage in unhealthy weight control behaviors because they are often the first health professionals to observe overt health effects. Oral health issues resulting from unhealthy weight control behaviors present themselves as signs of malnutrition, dehydration, and vomiting.
Failure of OHPs to identify oral signs and oral health issues may lead to irreversible damage to the oral cavity and progression to weight-related disorders and associated systemic health problems. OHPs must learn to provide screening, baseline education, and referrals as part of comprehensive patient care (see American Dietetic Association for specific guidelines ). Despite the growing evidence of the role of nutrition in oral-systemic health issues, nutrition education in dental education has faced challenges. Although the fundamentals of macronutrients and micronutrients in human metabolism and oral health are taught in biochemistry and pathology courses, translation of nutrition and diet into patient care practice is limited. In addition, limited patient contact time and lack of strong evidence-based practice outcomes have contributed to inconsistent integration of health behavior management into oral health practice.
The following components, based on the information–motivation–behavioral skills model, health belief model, and brief motivational interviewing, are part of a training program to increase the capacity of OHPs to practice early identification of disordered eating behaviors among their patients:
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Didactic component: eating disorders and oral findings—describes the main types of eating disorders and associated disordered eating behaviors, characteristics, and health issues. In addition, this component displays the oral findings of disordered eating behaviors and information for differential diagnosis.
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Behavioral skills component: EAT (Evaluate, Assess, Treat) framework and skills—based on the Brief Motivational Interviewing, the EAT framework and skills component is the critical skill–based portion of the intervention. The EAT framework is divided into 3 steps that include (1) evaluating patients presenting signs of disordered eating behaviors and perform differential diagnosis, (2) assessing patient readiness for addressing disordered eating behaviors, and (3) patient-specific treatment strategies based on a patient’s stage of readiness.
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Practice component: EAT case studies—4 interactive case studies provide an opportunity for learners to practice secondary prevention behaviors with 4 different patients (varying in age and gender) at different stages of readiness to address the underlying cause of the various oral health issues identified. The video case studies provide an opportunity for learners to practice secondary prevention behavioral skills, leading to increased self-efficacy.
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Resource and referral components: provide OHPs with the resources necessary for supporting secondary prevention behaviors, including (1) printer-friendly education materials for patients, parents, and dental office staff; (2) printer-friendly patient-specific treatment plan templates available for OHPs; and (3) a Web link to nutrition and disordered eating treatment networks.
A prospective group randomized controlled trial involving 27 dental and dental hygiene classes from 12 accredited oral health education programs in the United States was implemented to assess the efficacy of the Web-based training program on attitudes, knowledge, self-efficacy, and skills related to the secondary prevention of disordered eating behaviors. Mixed-model analysis of covariance indicated large improvements among students in the intervention group on all 6 outcomes of interest.
Obesity
It is imperative that dentists along with other health professional take a leadership role for nutrition/healthy lifestyle counseling of their patients, especially in those with high risks for dental caries. Dovey recommends that dental clinics serve as an important source of health promotion and diseases prevention, suggesting that dentists could screen for obesity, thus offering better integration of children’s dental services and other child health care services.
Incorporating nutrition/healthy lifestyle counseling into pediatric dental practices is reviewed and recommended by Vann and colleagues. After height and weight are recorded, health care providers can easily calculate BMI and establish conversations about nutrition and healthy lifestyle with parents. Vann and colleagues also suggested that by embracing an awareness of the childhood obesity epidemic, pediatric dental providers can serve as community model for healthy lifestyle practices by sponsoring and promoting both office-based and community-based lifestyle programs.
Future/implications for dietary oral-systemic research and practice
Women are disproportionately affected by diet-related oral and systemic health issues. Growing evidence shows that many of the same factors contribute to both oral health and obesity. Dental practitioners are in a pivotal position to provide guidance for the prevention and reduction of both. The American Academy of Pediatric Dentistry policy on nutrition points out that discussions relative to diet and dental caries should be the essential components of oral health anticipatory guidance for children and that dietary discussions are central in providing counseling for caregivers of children with increased caries risk. An American Dietetic Association 2007 position report states, “oral health and nutrition have a synergistic bidirectional relationship.” The American Academy of Pediatric Dentistry revised a policy on dental homes in 2004 that is similar to the medical homes proposed by the American Academy of Pediatrics: dental homes offer patient-centered comprehensive, continuous, coordinated, and prevention-based care. There is a clear consensus across the multiple health care professions that the integration of oral health with nutritional and medical services, education, and research is necessary. Literature on implementation and evaluation of this new model of care, however, is scarce.
The oral health community continues to recognize the importance of looking at the ways to understand and improve oral health disparities and associated social environmental conditions. Oral health professionals and government agencies need to expand their efforts synergistically in office settings and education institutions. Public health interventions targeting obesity prevention can be strategically incorporated with oral health interventions in a congruent way. How and whether these scientific findings would be translated in the development of programs and policies for dental office and oral health programs remain to be determined.
By acknowledging the infancy stage of oral-systemic disease research and practice, this article attempts to emphasize the importance of a gendered perspective on diet-related oral health issues. There is scarce information, however, in the literature for women-centered research and practices that would be responsive to the increased diseases and illness associated with diet. Failure to identify and address the need of women, however, would deepen the current health disparities being addressed. Strategies across oral health and all disciplines will provide for a more comprehensive integrative approach to better the health and well-being of the patient population.
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