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pop consumption habits
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Nutrition Research 30 (2010) 27 – 31 www.nrjournal.com
A group of Midwestern university students needs to improve their oral hygiene and sugar/pop consumption habits Tami E. Luebke, Judy A. Driskell⁎ Department of Nutrition and Health Sciences, University of Nebraska, Lincoln, NE 68583-0806, USA Received 9 September 2009; revised 10 November 2009; accepted 13 November 2009
Abstract Poor oral hygiene and sugar/pop consumption practices are detrimental to one's overall health. College women were hypothesized to have better oral hygiene habits and to consume less sugar/pop than men and that the students' habits would be different from those the students had before college. These habits of students at a Midwestern university were evaluated by sex. The volunteers included 105 men and 91 women. Three quarters of the students reported brushing their teeth at least the recommended twice daily, with women brushing their teeth more often. About a third of the students flossed at least the recommended once daily. Not quite a third of the students reported brushing and flossing their teeth more often than they did before college. More than a third reported using mouth rinses 4 or more times weekly, with 13% reporting using a fluoride-containing mouth rinse. More than 60% reported using fluoride-containing toothpaste. Slightly more than a third reported drinking fluoridated water in their younger years. A larger percentage of women than men reported that diet pop was their pop of choice. More than two thirds of the students that drank pop indicated that regular pop was their favorite. Most of the students reported consuming sugary foods more than once daily, but they indicated that most of these sugars were not sticky. Few differences were observed in oral hygiene and sugar/pop consumption habits of these college students by sex. Nutritionists and other health professionals should work cooperatively in helping individuals improve their oral hygiene and sugar/pop consumption habits. © 2010 Elsevier Inc. All rights reserved. Keywords: Abbreviations:
College students; Tooth brushing and flossing habits; Fluoride exposure; Sugar consumption habits; Pop consumption habits CDC, Centers for Disease Control and Prevention; NHANES, National Health and Nutrition Examination Survey; ADA/Crest/Oral-B, American Dental Association in collaboration with Crest and Oral-B.
1. Introduction Oral hygiene is critical to everyone's health and overall wellbeing. Some dental health issues such as peridontal disease are silent onset diseases. It has long been known that poor oral hygiene is associated with periodontal disease [1]. According to the Centers for Disease Control and Prevention (CDC), 19% of adults 25 to 44 years of age have signs of periodontal diseases [2]. Poor dental hygiene, tobacco use, and diet are risk factors associated with periodontal disease [3,4]. The CDC ⁎ Corresponding author. Tel.: +1 402 472 8975; fax: +1 402 472 1587. E-mail address: [email protected] (J.A. Driskell). 0271-5317/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.nutres.2009.11.001
recommends tooth brushing and flossing to help remove plaque from the teeth in order to prevent gingivitis and other oral diseases [2]. A link has been reported to exist between periodontal disease and cardiovascular disease, stroke, diabetes mellitus, human immunodeficiency virus infection, overweight and obesity, oral and pharyngeal cancers, and osteoporosis [5,6]. The American Dental Association recommends consumption of a “well-balanced” diet, limiting between meal snacking, brushing twice daily with fluoride toothpaste, and flossing daily to maintain oral health [7]. Leading health organizations support fluoridation of community water as it helps prevent tooth decay [8]. Fluoridation of public water supplies is recommended by
28
T.E. Luebke, J.A. Driskell / Nutrition Research 30 (2010) 27–31
the Surgeon General [9]. In a study involving 972 individuals, Grembowski et al [10] reported that fluoridated water consumption did reduce oral disease. In the US population, the intake of fluoride from fluoridated dental products is considerable [11]. The CDC also recommends the use of fluoridated toothpaste [2]. Fluoride mouth rinses are recommended by many dentists as these rinses help reduce and prevent tooth decay [12]. High sugar consumption has long been linked to dental caries [13,14]. Dietary sugar has been reported to be a major factor in the etiology of coronal (above the gum line) caries [15]. Sugars should be limited to less than 10% energy (kcal) according to a report by the World Health Organization [16]. The CDC recommends that individuals should avoid snacks high in sugars and starches [2]. High frequency and duration of consuming sugars and starches increases one's exposure to these cariogenic substrates [17]. When dietary sugars are restricted, the number of cariogenic Streptococcus mutans found in dental plaque is limited [18]. Restriction of “sticky” sugars, in particular, can help prevent caries formation [15]. The mean intake of added sugar by Americans is 15.8% energy (kcal), and the largest source of these added sugars is pop (also referred to as soda or soft drinks) [19]. The 2005 Dietary Guidelines for Americans recommends that individuals consume drinks without added sugar [17]. The Institute of Medicine, National Academy of Sciences [20], indicates that added sugars should be consumed at no more than 25% energy (kcal). Regular pop contains an average of about 17 g sugar, whereas diet pop contains sugar substitutes [21]. The consumption of sugar-sweetened beverages can influence dental health, particularly when these beverages are sipped continuously throughout the day. Few if any studies have examined the oral hygiene habits of college students. The objectives of the present study was to assess the oral hygiene and sugar/pop consumption habits of college students by sex and if the students' habits would be different from those the students had before college. College women were hypothesized to have better brushing and flossing habits and to consume less sugar/pop than males and these habits would be different from those the students had before college. 2. Methods and materials 2.1. Subjects The study was approved by the University of NebraskaLincoln's institutional review board; all subjects gave informed consent. The subjects, undergraduate students ranging from 18 years of age and above, were recruited from 11 AM to 1:30 PM during January 2009 at the 2 university unions. Participants received nominal gifts for completing the questionnaires. 2.2. Questionnaire An 18-item questionnaire fashioned after that used in surveys by the American Dental Association [5] and
National Health and Nutrition Examination Survey (NHANES) [22] was developed to obtain demographic, oral hygiene, and sugar and pop consumption habits of the subjects. The questionnaire was evaluated by 6 nutrition and dental professionals for content validity. Afterwards, the questionnaire was evaluated by 6 undergraduate students for readability. Minor changes were made on the questionnaire after each of these evaluations. 2.3. Statistical analyses Sample size was determined using the Pearson χ2 test implemented in SAS version 9.1.3 software (SAS Institute, Inc, Cary, NC) with 80% power detecting a difference of 20% at α = .05 between the 2 sex groups. All data were evaluated by sex using χ2 analyses [23] implemented in SAS software. Differences were considered significant at P b .05.
3. Results and discussion This is the first time that oral hygiene and sugar/pop consumption habits of university students have been evaluated. This group of university students needs to improve both their oral hygiene and their sugar/pop consumption habits. A few differences in these habits were observed by sex. The self-reported oral hygiene and sugar/ pop consumption habits of these university students are given in Table 1. The volunteer participants included 105 men and 91 women; 11.7% were freshmen; 25.5%, sophomores; 23.0%, juniors; and 39.8, seniors. Of the students surveyed, 12.8% reported living at home with family; 30.6%, in a dormitory, fraternity, or sorority; and 56.6%, in a house/apartment with friends, significant other, or themselves. The subjects in the current study were representative of undergraduate students at the University with regard to sex and their living situation; however, a larger percentage of seniors and a smaller percentage of freshmen were included in the study than is representative of the University's undergraduate enrollment [24]. In most cases, university freshmen live and eat in the dormitories. University seniors are more often involved in activities that take place in the unions where the surveys were conducted in the present study. Eighty percent of the subjects reported brushing their teeth the recommended [2,7] 2 or more times daily. A significant difference (P = .0131) in response distribution was observed by sex, with women reporting brushing their teeth more often than men. According to a 1997 survey, 56% of US adults brushed their teeth more than once daily [25]. According to a 2008 survey conducted by the American Dental Association (ADA) in collaboration with Crest and Oral-B (ADA/Crest/Oral-B), 80% of US adults admitted brushing twice daily [5]. This represents a considerable increase from the 1997 survey.
T.E. Luebke, J.A. Driskell / Nutrition Research 30 (2010) 27–31 Table 1 Self-reported oral hygiene and sugar/pop consumption of university students (given as percent of students) Parameter How often students brushed their teeth on average bOnce daily Once daily Twice weekly NTwice daily How often students flossed on average Never Once monthly Once weekly Once daily NOnce daily Brushing and flossing habits different from before college More often As often Less often Use mouth rinses 4+ times weekly Yes No Use fluoride mouth rinses b 4+ times weekly Yes No Use fluoride-containing toothpaste majority of time Yes No Do not know/unsure Typically drank fluoridated water while growing up Yes No Do not know/unsure Frequency of drinking 12 oz (usual can size) of pop Never 1-3 times monthly 1-3 times weekly 1 time daily N1 times daily Favorite type of pop (for those reporting drinking pop) Regular pop Diet pop Pop drinking habits different from before college Much more pop now Little more pop now Same amount Little less pop now Much less pop now Habits changed from drinking regular or diet pop Drink same type of pop as before college Changed from regular to diet pop Changed from diet to regular pop
All students a
P by sex .0131
1.9/0.0 23.8/12.1 70.5/74.7 3.8/13.2 .2522 19.9 24.5 27.5 27.6 0.5 .0563
35.6/20.9 56.7/65.9 7.7/13.2
29
Table 1 (continued) All students a
Parameter c
Rating of amount of sugar in diet No sugar Sugary foods 1-3 times weekly Sugary foods about once daily Sugary foods 1-3 times daily Sugary foods 4+times daily Generally eat a lot of sticky sugars d Most of sugars consumed are sticky sugars Most of sugars consumed are not sticky sugars Never eat sugars Sugar consumption different from before college Much more sugar Little more sugar About the same Little less sugar Much less sugar
P by sex .7651
4.1 34.7 35.2 23.4 2.6 .1887 16.9 81.6 1.5 .0338 4.8/11.0 11.5/7.7 49.1/58.2 20.2/19.8 14.4/3.3
a
Percentages for men/women. ACT, Crest Fluoride, Natural Dentist Fluoride rinses, and others. c Includes sugar in food/drink, such as candies, pop, juices, doughnuts, jellies, and others. d Caramel, taffy, candies, raisins/dried fruits, and others. b
.3914 37.2 62.8 .6950 13.3 86.7 .3554
61.7 11.2 27.1 .0920 36.2 33.2 30.6 .2263 10.7 24.5 39.3 14.3 11.2 .0001 83.3/53.3 16.7/46.7 .0515 13.6/8.9 11.7/20.0 25.2/38.9 26.2/17.8 23.3/14.4 .1071 79.1 16.6 4.3 (continued on next page)
Twenty percent of the subjects in the present study reported never flossing, whereas 28.1% reported flossing the recommended [2,7] 1 or more times daily. No significant difference was observed by sex with regard to how often the subjects reported flossing their teeth. According to a 1997 survey, about 25% of US adults floss daily [25]. The 2008 ADA/Crest/Oral-B survey [5] indicated that 49% of US adults flossed at least once daily and 10% never flossed. A 2008 survey indicated that 80% of US adults agreed that taking care of one's mouth, teeth, and gums is absolutely essential, yet only 33% claimed to do an excellent job of taking care of their teeth [5]. Perhaps this is due to a lack of or insufficient health education. With regard to the question “are your brushing and flossing habits different now than they were before college,” a difference (P = .0563) was observed by sex in the present study. Almost two thirds of these students indicated that their brushing and flossing habits were similar to those before their enrolling in college. Apparently, the brushing and flossing habits that the majority of these students developed earlier in life were maintained. However, some of the students did brush and/or floss more often. Perhaps, this was out of the desire to attract or please peers. Slightly more than one third of students in the current study reported using mouth rinses 4 or more times a week and 12.9% reported using a mouth rinse containing fluoride (ACT, Crest Fluoride, Natural Dentist Fluoride, etc) 4 or more times a week with no differences by sex. According to the ADA/Crest/Oral-B survey, 52% of US adults reported not believing that mouth rinses have any health benefit even though it is recommended by dentists [5]. More than half
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T.E. Luebke, J.A. Driskell / Nutrition Research 30 (2010) 27–31
of the subjects in the present study reported using a toothpaste containing fluoride most of the time. Around a third of the subjects in the present study reported typically drinking fluoridated water while they were growing up; however, almost a third reported not knowing or being unsure whether they drank fluoridated water in their younger years. Nearly 70% of the US population was served by community water systems containing fluoridated water in 2006 [26]. A focus area goal of Healthy People 2010 [27] is that 75% of US population reside in areas having fluoridated water. No significant difference was observed by sex in the present study with regard to how often students drank 12 oz of pop, with almost two thirds reporting drinking pop 1 to 3 times weekly or 1 to 3 times monthly. A significant difference (P b .0001) was observed by sex in the responses of the 89.3% of students who reported drinking pop with regard to whether their pop of choice was regular or diet, with a larger percentage of women choosing diet pop. Sixtynine percent of the students that drank pop selected regular pop as their favorite as opposed to diet pop. The findings of the present study are in agreement with a 2004 survey at our university, which indicated that 41% of male undergraduates ordered regular pop when eating fast food meals or snacks as compared to 21% of females, and 31% of females typically ordered diet pop as compared with 14% of men [28]. The findings of the current study are also similar to those of the 1999 to 2004 NHANES survey that men 20 to 44 years old consumed significantly greater quantities of sugar-sweetened beverages than women [29]. Most of the students in the present study indicated not changing their drinking habits as far as drinking diet or regular pop since starting college. In regard to the question “are your pop drinking habits different now than they were before college,” a difference (P = .0515) was observed by sex. When participants in the present study were requested to rate the amount of sugar in their diets (including foods and drinks, such as candies, pop, juices, doughnuts, jellies, etc), no significant differences were observed by sex. Most of these students reported eating sugary foods 1 to 3 times weekly or once daily. Eighty-two percent of the students indicated that when they consumed sugars, most of these sugars were not sticky (caramel, taffy, candies, raisins/dried fruits, etc) sugars. A significant difference (P = .0338) was observed by sex as to how current sugar consumption compared to that before college, although more than half the students reported consuming about the same amount of sugar as they used to. US adults included in the 2005 National Health Interview Survey were reported to have “excessive” intakes of added sugars [30]. Adult intakes of added sugars have been estimated to be nearly 17% energy (kcal) daily [31]. The mean total sugar intakes of the US men and women 20 years of age and above included in NHANES 2005 to 2006 were 141 and 100 g/d, respectively, whereas the carbohydrate intakes were 310 and 217 g/d, respectively [32]. A quarter of the students in the present study reported eating sugary foods
more than once daily. Likely these students should decrease their intakes of sugary foods. The frequency of sugar intake has been linked with cariogenesis [2]. All of the participants in this study were undergraduates. Most undergraduate students at this university during spring semester 2009 were white and 80% were from Nebraska [24]. Oral hygiene and sugar/pop consumption habits of undergraduate students living in different geographic regions of the US may be different. Similar studies at universities in different regions of the US are needed, especially at universities with more ethnically diverse undergraduate student populations. The data obtained in this study were also self reported and frequently self perceived by the students, and may not always be accurate. Around a quarter of the students in the present study reported not brushing their teeth the recommended twice daily and more than two thirds did not floss the recommended once daily. College women reported brushing their teeth more often than men. A larger percentage of the women than men gave diet pop as their pop of choice. Almost half of the students of both sexes reported consuming sugary foods more than once daily. Pop and other sugarsweetened beverages provide little nutritional benefit and do increase the risk of dental caries. The hypothesis that university women had better oral hygiene and sugar/pop consumption habits than men was shown to be correct some of the time; these students generally reported having oral hygiene and sugar/pop consumption habits that were different from their habits before their enrolling in college. Health professionals should help individuals develop behavioral patterns such that they brush and floss their teeth more often as well as decrease their consumption of sugarcontaining foods and beverages. Oral health, diet, and nutrition topics should be incorporated into clinical and community health education endeavors. Acknowledgment We thank the subjects for their participation in the study. The use of the facilities of the two university unions for recruitment purposes is appreciated. We also appreciate the help of Tuirma V. Sinaga and Eliza Halim in administering and coding the surveys and David W. Giraud in conducting the statistical analyses. The study was funded in part by the Nebraska Agricultural Research Division. References [1] Podshadley AG, Haley JV. A method for evaluating oral hygiene performance. Public Health Rep 1968;83:259-64. [2] Centers for Disease Control and Prevention. Oral health for adults. Atlanta (Ga): Centers for Disease Control and Prevention, Division of Oral Health; 2006. [3] Al-Zahrani MS, Borawski EA, Bissada NF. Periodontitis and three health-enhancing behaviours: maintaining normal weight, engaging in recommended level of exercise, and consuming a high-quality diet. J Periodontol 2005;76:1362-6.
T.E. Luebke, J.A. Driskell / Nutrition Research 30 (2010) 27–31 [4] Pihlstrom B, Michalowicz B, Johnson N. Peridontal diseases. Lancet 2005;366:1809-21. [5] American Dental Association. The public speaks up on oral health care: an ADA and Crest/Oral-B survey. Chicago (Ill): American Dental Association; 2008. [6] American Dietetic Association. Position of the American Dietetic Association: oral health and nutrition. J Am Diet Assoc 2007;107: 1418-28. [7] American Dental Association. Healthy mouth, healthy body: for the dental patient. J Am Dental Assoc 2006;137:563. [8] American Dental Association. Fluoride: nature's tooth decay fighter. J Am Dent Assoc 2009;140:126. [9] U.S. Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville (Md): U.S. Department of Health and Human Services; 2000. [10] Grembowski D, Fiset L, Milgrom P, Conrad D, Spadafora A. Does fluoridation reduce the use of dental services among adults? Med Care 1997;35:454-71. [11] Burt BA. The changing patterns of systemic fluoride intake. J Dent Res 1992;71:1228-37. [12] American Dental Association. For the dental patient. J Am Dent Assoc 2000;131:1095. [13] Walker AR, Cleaton-Jones PE. Sugar intake and dental caries. Br Dent J 1992;172:7. [14] Papas AS, Joshi A, Palmer CA, Giunta JL, Dwyer JT. Relationship of diet to root caries. Am J Clin Nutr 1995;61(Suppl):423S-9S. [15] Newbrun E. Sugar and dental caries: a review of human studies. Science 1982;217:418-23. [16] World Health Organization. Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO Expert Consultation. Geneva, Switzlerland: World Health Organization; 2003. [17] U.S. Departments of Health and Human Services and Agriculture. Dietary guidelines for Americans. 6th ed. Washington (DC): U.S. Government Printing Office; 2005. [18] Newbrun E, Hoover C, Mettraux G, Graf H. Comparison of dietary habits and dental health of subjects with hereditary fructose intolerance and control subjects. J Am Dent Assoc 1980;101:619-26. [19] Guthrie JF, Morton JF. Food sources of added sweeteners in the diets of Americans. J Am Diet Assoc 2000;100:43-51.
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[20] Institute of Medicine, National Academy of Sciences. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National Academies Press; 2002/2005. [21] Nestle M. “Soft drink pouring rights”: marketing empty calories to children. Pub Health Rep 2000;115:308-9. [22] Blicher B, Joshipura K, Eke P. Validation of self-reported periodontal disease: a systematic review. J Dent Res 2005;84:881-90. [23] Dowdy S, Wearden S, Chilko D. Statistics for research. 3rd ed. Hoboken (NJ): John C. Wiley and Sons, Inc.; 2004. [24] Institutional Research and Planning. University of Nebraska-Lincoln (NE). University of Nebraska-Lincoln fact book 2008-2009. Lincoln (Neb): University of Nebraska-Lincoln; 2009. [25] Hersch J. Smoking, seat belts, and other risky consumer decisions: differences by gender and race. Manag Decision Econ 1996;17:471-81. [26] Centers for Disease Control and Prevention. Populations receiving optimally fluoridated public drinking water—United States, 1992-2006. MMWR 2008;57(27):737-41. [27] U.S. Department of Health and Human Services. U.S. Department of Health and Human Services. Healthy People 2010 (Conference Edition, vol. 2). Washington (DC): U.S. Department of Health and Human Services; 2000. [28] Driskell JA, Meckna BR, Scales NE. Differences exist in the eating habits of university men and women at fast-food restaurants. Nutr Res 2006;26:524-30. [29] Bleich SN, Wang YC, Wang Y, Gortmaker SL. Increasing consumption of sugar-sweetened beverages among US adults: 19881994 to 1999-2004. Am J Clin Nutr 2009;89:372-81. [30] Thompson FE, McNeel TS, Dowling EC, Midthune D, Morrissette M, Zeruto CA. Interrelationships of added sugars intake, socioeconomic status, and race/ethnicity in adults in the United States: National Health Interview Survey, 2005. J Am Diet Assoc 2009;109:1376-83. [31] Cook A, Friday JE. Pyramid serving in the United States 1999-2002, 1 day. Beltsville (Md): United States Department of Agriculture; 2005. [32] U.S. Department of Agriculture. Agricultural Research Service. Nutrient intakes from food: mean amounts consumed per individual, one day, 2005-2006. Beltsville (Md): U.S. Department of Agriculture; 2008.
Nutrition Research 30 (2010) 27 – 31 www.nrjournal.com
A group of Midwestern university students needs to improve their oral hygiene and sugar/pop consumption habits Tami E. Luebke, Judy A. Driskell⁎ Department of Nutrition and Health Sciences, University of Nebraska, Lincoln, NE 68583-0806, USA Received 9 September 2009; revised 10 November 2009; accepted 13 November 2009
Abstract Poor oral hygiene and sugar/pop consumption practices are detrimental to one's overall health. College women were hypothesized to have better oral hygiene habits and to consume less sugar/pop than men and that the students' habits would be different from those the students had before college. These habits of students at a Midwestern university were evaluated by sex. The volunteers included 105 men and 91 women. Three quarters of the students reported brushing their teeth at least the recommended twice daily, with women brushing their teeth more often. About a third of the students flossed at least the recommended once daily. Not quite a third of the students reported brushing and flossing their teeth more often than they did before college. More than a third reported using mouth rinses 4 or more times weekly, with 13% reporting using a fluoride-containing mouth rinse. More than 60% reported using fluoride-containing toothpaste. Slightly more than a third reported drinking fluoridated water in their younger years. A larger percentage of women than men reported that diet pop was their pop of choice. More than two thirds of the students that drank pop indicated that regular pop was their favorite. Most of the students reported consuming sugary foods more than once daily, but they indicated that most of these sugars were not sticky. Few differences were observed in oral hygiene and sugar/pop consumption habits of these college students by sex. Nutritionists and other health professionals should work cooperatively in helping individuals improve their oral hygiene and sugar/pop consumption habits. © 2010 Elsevier Inc. All rights reserved. Keywords: Abbreviations:
College students; Tooth brushing and flossing habits; Fluoride exposure; Sugar consumption habits; Pop consumption habits CDC, Centers for Disease Control and Prevention; NHANES, National Health and Nutrition Examination Survey; ADA/Crest/Oral-B, American Dental Association in collaboration with Crest and Oral-B.
1. Introduction Oral hygiene is critical to everyone's health and overall wellbeing. Some dental health issues such as peridontal disease are silent onset diseases. It has long been known that poor oral hygiene is associated with periodontal disease [1]. According to the Centers for Disease Control and Prevention (CDC), 19% of adults 25 to 44 years of age have signs of periodontal diseases [2]. Poor dental hygiene, tobacco use, and diet are risk factors associated with periodontal disease [3,4]. The CDC ⁎ Corresponding author. Tel.: +1 402 472 8975; fax: +1 402 472 1587. E-mail address: [email protected] (J.A. Driskell). 0271-5317/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.nutres.2009.11.001
recommends tooth brushing and flossing to help remove plaque from the teeth in order to prevent gingivitis and other oral diseases [2]. A link has been reported to exist between periodontal disease and cardiovascular disease, stroke, diabetes mellitus, human immunodeficiency virus infection, overweight and obesity, oral and pharyngeal cancers, and osteoporosis [5,6]. The American Dental Association recommends consumption of a “well-balanced” diet, limiting between meal snacking, brushing twice daily with fluoride toothpaste, and flossing daily to maintain oral health [7]. Leading health organizations support fluoridation of community water as it helps prevent tooth decay [8]. Fluoridation of public water supplies is recommended by
28
T.E. Luebke, J.A. Driskell / Nutrition Research 30 (2010) 27–31
the Surgeon General [9]. In a study involving 972 individuals, Grembowski et al [10] reported that fluoridated water consumption did reduce oral disease. In the US population, the intake of fluoride from fluoridated dental products is considerable [11]. The CDC also recommends the use of fluoridated toothpaste [2]. Fluoride mouth rinses are recommended by many dentists as these rinses help reduce and prevent tooth decay [12]. High sugar consumption has long been linked to dental caries [13,14]. Dietary sugar has been reported to be a major factor in the etiology of coronal (above the gum line) caries [15]. Sugars should be limited to less than 10% energy (kcal) according to a report by the World Health Organization [16]. The CDC recommends that individuals should avoid snacks high in sugars and starches [2]. High frequency and duration of consuming sugars and starches increases one's exposure to these cariogenic substrates [17]. When dietary sugars are restricted, the number of cariogenic Streptococcus mutans found in dental plaque is limited [18]. Restriction of “sticky” sugars, in particular, can help prevent caries formation [15]. The mean intake of added sugar by Americans is 15.8% energy (kcal), and the largest source of these added sugars is pop (also referred to as soda or soft drinks) [19]. The 2005 Dietary Guidelines for Americans recommends that individuals consume drinks without added sugar [17]. The Institute of Medicine, National Academy of Sciences [20], indicates that added sugars should be consumed at no more than 25% energy (kcal). Regular pop contains an average of about 17 g sugar, whereas diet pop contains sugar substitutes [21]. The consumption of sugar-sweetened beverages can influence dental health, particularly when these beverages are sipped continuously throughout the day. Few if any studies have examined the oral hygiene habits of college students. The objectives of the present study was to assess the oral hygiene and sugar/pop consumption habits of college students by sex and if the students' habits would be different from those the students had before college. College women were hypothesized to have better brushing and flossing habits and to consume less sugar/pop than males and these habits would be different from those the students had before college. 2. Methods and materials 2.1. Subjects The study was approved by the University of NebraskaLincoln's institutional review board; all subjects gave informed consent. The subjects, undergraduate students ranging from 18 years of age and above, were recruited from 11 AM to 1:30 PM during January 2009 at the 2 university unions. Participants received nominal gifts for completing the questionnaires. 2.2. Questionnaire An 18-item questionnaire fashioned after that used in surveys by the American Dental Association [5] and
National Health and Nutrition Examination Survey (NHANES) [22] was developed to obtain demographic, oral hygiene, and sugar and pop consumption habits of the subjects. The questionnaire was evaluated by 6 nutrition and dental professionals for content validity. Afterwards, the questionnaire was evaluated by 6 undergraduate students for readability. Minor changes were made on the questionnaire after each of these evaluations. 2.3. Statistical analyses Sample size was determined using the Pearson χ2 test implemented in SAS version 9.1.3 software (SAS Institute, Inc, Cary, NC) with 80% power detecting a difference of 20% at α = .05 between the 2 sex groups. All data were evaluated by sex using χ2 analyses [23] implemented in SAS software. Differences were considered significant at P b .05.
3. Results and discussion This is the first time that oral hygiene and sugar/pop consumption habits of university students have been evaluated. This group of university students needs to improve both their oral hygiene and their sugar/pop consumption habits. A few differences in these habits were observed by sex. The self-reported oral hygiene and sugar/ pop consumption habits of these university students are given in Table 1. The volunteer participants included 105 men and 91 women; 11.7% were freshmen; 25.5%, sophomores; 23.0%, juniors; and 39.8, seniors. Of the students surveyed, 12.8% reported living at home with family; 30.6%, in a dormitory, fraternity, or sorority; and 56.6%, in a house/apartment with friends, significant other, or themselves. The subjects in the current study were representative of undergraduate students at the University with regard to sex and their living situation; however, a larger percentage of seniors and a smaller percentage of freshmen were included in the study than is representative of the University's undergraduate enrollment [24]. In most cases, university freshmen live and eat in the dormitories. University seniors are more often involved in activities that take place in the unions where the surveys were conducted in the present study. Eighty percent of the subjects reported brushing their teeth the recommended [2,7] 2 or more times daily. A significant difference (P = .0131) in response distribution was observed by sex, with women reporting brushing their teeth more often than men. According to a 1997 survey, 56% of US adults brushed their teeth more than once daily [25]. According to a 2008 survey conducted by the American Dental Association (ADA) in collaboration with Crest and Oral-B (ADA/Crest/Oral-B), 80% of US adults admitted brushing twice daily [5]. This represents a considerable increase from the 1997 survey.
T.E. Luebke, J.A. Driskell / Nutrition Research 30 (2010) 27–31 Table 1 Self-reported oral hygiene and sugar/pop consumption of university students (given as percent of students) Parameter How often students brushed their teeth on average bOnce daily Once daily Twice weekly NTwice daily How often students flossed on average Never Once monthly Once weekly Once daily NOnce daily Brushing and flossing habits different from before college More often As often Less often Use mouth rinses 4+ times weekly Yes No Use fluoride mouth rinses b 4+ times weekly Yes No Use fluoride-containing toothpaste majority of time Yes No Do not know/unsure Typically drank fluoridated water while growing up Yes No Do not know/unsure Frequency of drinking 12 oz (usual can size) of pop Never 1-3 times monthly 1-3 times weekly 1 time daily N1 times daily Favorite type of pop (for those reporting drinking pop) Regular pop Diet pop Pop drinking habits different from before college Much more pop now Little more pop now Same amount Little less pop now Much less pop now Habits changed from drinking regular or diet pop Drink same type of pop as before college Changed from regular to diet pop Changed from diet to regular pop
All students a
P by sex .0131
1.9/0.0 23.8/12.1 70.5/74.7 3.8/13.2 .2522 19.9 24.5 27.5 27.6 0.5 .0563
35.6/20.9 56.7/65.9 7.7/13.2
29
Table 1 (continued) All students a
Parameter c
Rating of amount of sugar in diet No sugar Sugary foods 1-3 times weekly Sugary foods about once daily Sugary foods 1-3 times daily Sugary foods 4+times daily Generally eat a lot of sticky sugars d Most of sugars consumed are sticky sugars Most of sugars consumed are not sticky sugars Never eat sugars Sugar consumption different from before college Much more sugar Little more sugar About the same Little less sugar Much less sugar
P by sex .7651
4.1 34.7 35.2 23.4 2.6 .1887 16.9 81.6 1.5 .0338 4.8/11.0 11.5/7.7 49.1/58.2 20.2/19.8 14.4/3.3
a
Percentages for men/women. ACT, Crest Fluoride, Natural Dentist Fluoride rinses, and others. c Includes sugar in food/drink, such as candies, pop, juices, doughnuts, jellies, and others. d Caramel, taffy, candies, raisins/dried fruits, and others. b
.3914 37.2 62.8 .6950 13.3 86.7 .3554
61.7 11.2 27.1 .0920 36.2 33.2 30.6 .2263 10.7 24.5 39.3 14.3 11.2 .0001 83.3/53.3 16.7/46.7 .0515 13.6/8.9 11.7/20.0 25.2/38.9 26.2/17.8 23.3/14.4 .1071 79.1 16.6 4.3 (continued on next page)
Twenty percent of the subjects in the present study reported never flossing, whereas 28.1% reported flossing the recommended [2,7] 1 or more times daily. No significant difference was observed by sex with regard to how often the subjects reported flossing their teeth. According to a 1997 survey, about 25% of US adults floss daily [25]. The 2008 ADA/Crest/Oral-B survey [5] indicated that 49% of US adults flossed at least once daily and 10% never flossed. A 2008 survey indicated that 80% of US adults agreed that taking care of one's mouth, teeth, and gums is absolutely essential, yet only 33% claimed to do an excellent job of taking care of their teeth [5]. Perhaps this is due to a lack of or insufficient health education. With regard to the question “are your brushing and flossing habits different now than they were before college,” a difference (P = .0563) was observed by sex in the present study. Almost two thirds of these students indicated that their brushing and flossing habits were similar to those before their enrolling in college. Apparently, the brushing and flossing habits that the majority of these students developed earlier in life were maintained. However, some of the students did brush and/or floss more often. Perhaps, this was out of the desire to attract or please peers. Slightly more than one third of students in the current study reported using mouth rinses 4 or more times a week and 12.9% reported using a mouth rinse containing fluoride (ACT, Crest Fluoride, Natural Dentist Fluoride, etc) 4 or more times a week with no differences by sex. According to the ADA/Crest/Oral-B survey, 52% of US adults reported not believing that mouth rinses have any health benefit even though it is recommended by dentists [5]. More than half
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of the subjects in the present study reported using a toothpaste containing fluoride most of the time. Around a third of the subjects in the present study reported typically drinking fluoridated water while they were growing up; however, almost a third reported not knowing or being unsure whether they drank fluoridated water in their younger years. Nearly 70% of the US population was served by community water systems containing fluoridated water in 2006 [26]. A focus area goal of Healthy People 2010 [27] is that 75% of US population reside in areas having fluoridated water. No significant difference was observed by sex in the present study with regard to how often students drank 12 oz of pop, with almost two thirds reporting drinking pop 1 to 3 times weekly or 1 to 3 times monthly. A significant difference (P b .0001) was observed by sex in the responses of the 89.3% of students who reported drinking pop with regard to whether their pop of choice was regular or diet, with a larger percentage of women choosing diet pop. Sixtynine percent of the students that drank pop selected regular pop as their favorite as opposed to diet pop. The findings of the present study are in agreement with a 2004 survey at our university, which indicated that 41% of male undergraduates ordered regular pop when eating fast food meals or snacks as compared to 21% of females, and 31% of females typically ordered diet pop as compared with 14% of men [28]. The findings of the current study are also similar to those of the 1999 to 2004 NHANES survey that men 20 to 44 years old consumed significantly greater quantities of sugar-sweetened beverages than women [29]. Most of the students in the present study indicated not changing their drinking habits as far as drinking diet or regular pop since starting college. In regard to the question “are your pop drinking habits different now than they were before college,” a difference (P = .0515) was observed by sex. When participants in the present study were requested to rate the amount of sugar in their diets (including foods and drinks, such as candies, pop, juices, doughnuts, jellies, etc), no significant differences were observed by sex. Most of these students reported eating sugary foods 1 to 3 times weekly or once daily. Eighty-two percent of the students indicated that when they consumed sugars, most of these sugars were not sticky (caramel, taffy, candies, raisins/dried fruits, etc) sugars. A significant difference (P = .0338) was observed by sex as to how current sugar consumption compared to that before college, although more than half the students reported consuming about the same amount of sugar as they used to. US adults included in the 2005 National Health Interview Survey were reported to have “excessive” intakes of added sugars [30]. Adult intakes of added sugars have been estimated to be nearly 17% energy (kcal) daily [31]. The mean total sugar intakes of the US men and women 20 years of age and above included in NHANES 2005 to 2006 were 141 and 100 g/d, respectively, whereas the carbohydrate intakes were 310 and 217 g/d, respectively [32]. A quarter of the students in the present study reported eating sugary foods
more than once daily. Likely these students should decrease their intakes of sugary foods. The frequency of sugar intake has been linked with cariogenesis [2]. All of the participants in this study were undergraduates. Most undergraduate students at this university during spring semester 2009 were white and 80% were from Nebraska [24]. Oral hygiene and sugar/pop consumption habits of undergraduate students living in different geographic regions of the US may be different. Similar studies at universities in different regions of the US are needed, especially at universities with more ethnically diverse undergraduate student populations. The data obtained in this study were also self reported and frequently self perceived by the students, and may not always be accurate. Around a quarter of the students in the present study reported not brushing their teeth the recommended twice daily and more than two thirds did not floss the recommended once daily. College women reported brushing their teeth more often than men. A larger percentage of the women than men gave diet pop as their pop of choice. Almost half of the students of both sexes reported consuming sugary foods more than once daily. Pop and other sugarsweetened beverages provide little nutritional benefit and do increase the risk of dental caries. The hypothesis that university women had better oral hygiene and sugar/pop consumption habits than men was shown to be correct some of the time; these students generally reported having oral hygiene and sugar/pop consumption habits that were different from their habits before their enrolling in college. Health professionals should help individuals develop behavioral patterns such that they brush and floss their teeth more often as well as decrease their consumption of sugarcontaining foods and beverages. Oral health, diet, and nutrition topics should be incorporated into clinical and community health education endeavors. Acknowledgment We thank the subjects for their participation in the study. The use of the facilities of the two university unions for recruitment purposes is appreciated. We also appreciate the help of Tuirma V. Sinaga and Eliza Halim in administering and coding the surveys and David W. Giraud in conducting the statistical analyses. The study was funded in part by the Nebraska Agricultural Research Division. References [1] Podshadley AG, Haley JV. A method for evaluating oral hygiene performance. Public Health Rep 1968;83:259-64. [2] Centers for Disease Control and Prevention. Oral health for adults. Atlanta (Ga): Centers for Disease Control and Prevention, Division of Oral Health; 2006. [3] Al-Zahrani MS, Borawski EA, Bissada NF. Periodontitis and three health-enhancing behaviours: maintaining normal weight, engaging in recommended level of exercise, and consuming a high-quality diet. J Periodontol 2005;76:1362-6.
T.E. Luebke, J.A. Driskell / Nutrition Research 30 (2010) 27–31 [4] Pihlstrom B, Michalowicz B, Johnson N. Peridontal diseases. Lancet 2005;366:1809-21. [5] American Dental Association. The public speaks up on oral health care: an ADA and Crest/Oral-B survey. Chicago (Ill): American Dental Association; 2008. [6] American Dietetic Association. Position of the American Dietetic Association: oral health and nutrition. J Am Diet Assoc 2007;107: 1418-28. [7] American Dental Association. Healthy mouth, healthy body: for the dental patient. J Am Dental Assoc 2006;137:563. [8] American Dental Association. Fluoride: nature's tooth decay fighter. J Am Dent Assoc 2009;140:126. [9] U.S. Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville (Md): U.S. Department of Health and Human Services; 2000. [10] Grembowski D, Fiset L, Milgrom P, Conrad D, Spadafora A. Does fluoridation reduce the use of dental services among adults? Med Care 1997;35:454-71. [11] Burt BA. The changing patterns of systemic fluoride intake. J Dent Res 1992;71:1228-37. [12] American Dental Association. For the dental patient. J Am Dent Assoc 2000;131:1095. [13] Walker AR, Cleaton-Jones PE. Sugar intake and dental caries. Br Dent J 1992;172:7. [14] Papas AS, Joshi A, Palmer CA, Giunta JL, Dwyer JT. Relationship of diet to root caries. Am J Clin Nutr 1995;61(Suppl):423S-9S. [15] Newbrun E. Sugar and dental caries: a review of human studies. Science 1982;217:418-23. [16] World Health Organization. Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO Expert Consultation. Geneva, Switzlerland: World Health Organization; 2003. [17] U.S. Departments of Health and Human Services and Agriculture. Dietary guidelines for Americans. 6th ed. Washington (DC): U.S. Government Printing Office; 2005. [18] Newbrun E, Hoover C, Mettraux G, Graf H. Comparison of dietary habits and dental health of subjects with hereditary fructose intolerance and control subjects. J Am Dent Assoc 1980;101:619-26. [19] Guthrie JF, Morton JF. Food sources of added sweeteners in the diets of Americans. J Am Diet Assoc 2000;100:43-51.
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[20] Institute of Medicine, National Academy of Sciences. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National Academies Press; 2002/2005. [21] Nestle M. “Soft drink pouring rights”: marketing empty calories to children. Pub Health Rep 2000;115:308-9. [22] Blicher B, Joshipura K, Eke P. Validation of self-reported periodontal disease: a systematic review. J Dent Res 2005;84:881-90. [23] Dowdy S, Wearden S, Chilko D. Statistics for research. 3rd ed. Hoboken (NJ): John C. Wiley and Sons, Inc.; 2004. [24] Institutional Research and Planning. University of Nebraska-Lincoln (NE). University of Nebraska-Lincoln fact book 2008-2009. Lincoln (Neb): University of Nebraska-Lincoln; 2009. [25] Hersch J. Smoking, seat belts, and other risky consumer decisions: differences by gender and race. Manag Decision Econ 1996;17:471-81. [26] Centers for Disease Control and Prevention. Populations receiving optimally fluoridated public drinking water—United States, 1992-2006. MMWR 2008;57(27):737-41. [27] U.S. Department of Health and Human Services. U.S. Department of Health and Human Services. Healthy People 2010 (Conference Edition, vol. 2). Washington (DC): U.S. Department of Health and Human Services; 2000. [28] Driskell JA, Meckna BR, Scales NE. Differences exist in the eating habits of university men and women at fast-food restaurants. Nutr Res 2006;26:524-30. [29] Bleich SN, Wang YC, Wang Y, Gortmaker SL. Increasing consumption of sugar-sweetened beverages among US adults: 19881994 to 1999-2004. Am J Clin Nutr 2009;89:372-81. [30] Thompson FE, McNeel TS, Dowling EC, Midthune D, Morrissette M, Zeruto CA. Interrelationships of added sugars intake, socioeconomic status, and race/ethnicity in adults in the United States: National Health Interview Survey, 2005. J Am Diet Assoc 2009;109:1376-83. [31] Cook A, Friday JE. Pyramid serving in the United States 1999-2002, 1 day. Beltsville (Md): United States Department of Agriculture; 2005. [32] U.S. Department of Agriculture. Agricultural Research Service. Nutrient intakes from food: mean amounts consumed per individual, one day, 2005-2006. Beltsville (Md): U.S. Department of Agriculture; 2008.