University of Ghana http://ugspace.ug.edu.gh ASSOCIATION BETWEEN OBESITY AND ORAL HEALTH IN GHANAIAN SCHOOL CHILDREN: THE ROLE OF DIETARY AND ORAL HYGIENE PRACTICES BY NDANU, THOMAS AKUETTEH (10325597) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF DOCTOR OF PHILOSOPHY (PHD) NUTRITION DEGREE JULY, 2015 i University of Ghana http://ugspace.ug.edu.gh DECLARATION I, NDANU, THOMAS AKUETTEH, author of this dissertation do hereby declare that, with the exception of references to other people’s work which has been duly cited, this work has entirely resulted from my personal original research under the supervision of Prof. Anna Lartey assisted by other senior members: Dr. Richmond Aryeetey, Dr. Josephine Sackeyfio and Dr. Gloria Otoo and has not been presented for another degree elsewhere. ………………… ………… Ndanu, Thomas Akuetteh (Student) This dissertation has been submitted for examination with our approval as members of the Supervisory Committee: …… …………………………. Prof. Anna Lartey (Supervisor, Department of Nutrition and Food Science Faculty of Sciences, University of Ghana, Legon) ………………… …………......... Dr. Richmond Aryeetey School of Public Health, College of Health Sciences, University of Ghana, Legon Dr. Josephine Sackeyfio (Department of Community and Preventive Dentistry, School Medicin and Dentistry, College of Health Sciences, Korle Bu, University of Ghana, Legon) …………………..… Dr. Gloria Otoo (Supervisor, Department of Nutrition and Food Science Faculty of Sciences, University of Ghana, Legon) ii University of Ghana http://ugspace.ug.edu.gh DEDICATION I wish to dedicate this work to my wonderful wife and children for their encouragement and support. I also wish to dedicate it to Prof. Anna Lartey who gave me the first lecture in nutrition and got me hooked onto the nutrition profession and has always been there to encourage me. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I wish to acknowledge and express my gratitude to Prof. Anna Lartey for the immense support, her supervision and encouragement that saw the completion of this work. I will also like to express my profound gratitude to IDRC for providing the financial support for this thesis work. My thanks also go to all the dental surgeons who were involved in the data collection for this work; Dr. Alice Cornellia Sackey, Dr. Waltraud Dromo Quartey, Dr. Kakra Bonsu, Dr. Indra Wadwani Kwesi, Dr. Ablah Ofosuhemaa Nsiah, Dr. Edwin Kwame Aryee and the research team which included, Rudolf Pobee, Edmond Agyeman Kyei, Elizabeth Asare, Mrs. Georgina Ndanu, Elorm Ndanu for helping in the data collection and capture. I also thank the various school heads and school children and their parents who participated in this study. My special thanks go to the University of Ghana Dental School for offering their equipment and special tools for the field work without which oral examination would have been impossible. iv University of Ghana http://ugspace.ug.edu.gh Table of content Item Page Title page i Dedication ii Declaration iii Acknowledgement iv Table of contents v List of abbreviations ix Abstract x Chapter One; Introduction 1 Problem statement 9 Rationale 10 Conceptual framework 12 Objectives 13 Working hypothesis 13 Chapter Two; Literature Review 14 Chapter Three; Methodology 34 Chapter Four; Results 46 Association between dietary habits and oral health practices of obese 48 and non-obese children Prevalence of caries and gum diseases and associated dietary factors 69 Oral bacterial infection in the school children and relation with caries 71 and gum disease Results and analysis of public school data 74 v University of Ghana http://ugspace.ug.edu.gh Chapter Five; Discussions, Conclusion and Recommendation 91 References and Appendices 118 List of tables Table 4.1, Background characteristics of the school children 47 Table 4.2, Dietary habit among obese and non-obese children 49 Table 4.2.1, Reasons for skipping meals 51 Table 4.3, Snacking habits among obese and non- obese children 52 Table 4.4, Frequency and type of snacking during TV watching among obese 53 and non-obese children Table 4.5, Mean consumption of selected food items by school children in 54 private schools Table 4.6, Mean weekly frequency of consumption of various food groups 55 between obese and non-obese children Table 4.7, Physical activities among obese and non-obese children in private 56 schools Table 4.8, Oral hygiene habits among obese and non-obese children 57 Table 4.9, Table 4.9, Dental visit and reported history of oral conditions 58 Table 4.10, Oral hygiene Status among obese and non-obese school children 60 Table 4.11, Oral health status (Prevalence of caries, gum disease and mean 61 DMFT) Table 4.12, Oral cleaning habits and prevalence of caries in the two groups 62 Table 4.13 Other oral hygiene habits and prevalence of caries among obese 63 and non-obese vi University of Ghana http://ugspace.ug.edu.gh Table 4.14, Possible effect of maternal educational level, nutrient intake and 65 toothpick use on the oral conditions Table 4.15, Association between puberty and oral diseases among respondent 66 groups Table 4.16, Periodontal risk levels among obese and non-obese and pubertal age 68 groups Table 4.17, Association between dietary factors and oral health status 70 Table 4.18, Multivariate analysis of possible risk factors for caries 71 Table 4.19, Prevalence of oral microbial infections among obese and non-obese 72 children Table 4.20, Association between streptococcus mutans and caries experience 73 among the obese and non-obese children Table 4.21, Demographic characteristics of the public school children studied 75 Table 4.21a Socio-economic background of parents of public school children 76 Table 4.22, Weight status among the sexes 77 Table 4.23, Comparison of Caries prevalence among the weight categories 77 Table 4.24, DMFT score for obese and non-obese children by sex 78 Table 4.25, Prevalence of gum infections among the weight categories 79 Table 4.26, Prevalence of Oral conditions among the Primary and JHS school 79 children Table 4.27, Prevalence of oral disease among the weight categories and 80 possible risk associations Table 4.28, Comparisons of mean Silness and Lӧe plaque score among the 83 weight categories Table 4.29, Association between oral hygiene status and weight categories 83 Table 4.30, Gingival index by child weight categories 84 vii University of Ghana http://ugspace.ug.edu.gh Table 4.31, Dietary practices between obese and non-obese public school 85 children Table 4.32, Dietary habits by child oral infection status 86 Table 4.33, Association between oral infection and breakfast intake among 88 obese and non-obese Table 4.34, Snacking behavior among obese and the non-obese by oral 89 infection status List of charts Figure 4.1, Meal times skipped by respondents 50 Figure 4.2, Caries prevalence among the age group of respondents 64 Figure 4.3. CPITN scores among obese and non-obese school children 67 Figure 4.4, overall distribution of healthy sextants in the school children. 69 Figure 4.5, Plaque score for the children 81 Figure 4.6, Calculus score 81 Figure 4.7, Overall distribution of Silness and Lӧe plaque score 82 Figure 4.8, Eight commonest food eaten at breakfast in school 87 Figure 4.9 Oral health conditions school among public school children 90 List of appendices Appendix 1, Index teeth probed for caries and gum disease 145 Appendix 2, Questionnaire 146 Appendix 3, Parent’s informed consent 157 Appendix 4, Child informed consent 160 Appendix 5, Summary for lay people 163 Appendix 6, Permission letter to GES 165 viii University of Ghana http://ugspace.ug.edu.gh Appendix 7, Permission to heads of Selected schools 166 Appendix 8, Sample size calculation equations 168 Appendix 9, Descriptive summary of weekly consumption of foods 170 Appendix 10, Ethical approval for modification of study design Appendix 11, Approval letter form GES Appendix 12, Published article from the Study List of Abbreviations aa Actinobacillus actinomycetemcometans CI Calculus index CPITN Community periodontal index of treatment need DMFT Decayed, Filled and Missing Teeth GI Gingival Index IDRC International Development Research Center IOTF International Obesity Task Force JHS Junior High School NMIMR Noguchi Memorial Institute for Medical Research PI Plaque Index WHO World Health Organization UR Upper Right UL Upper Left LR Lower Right LL Lower Left GES Ghana Education Service SHEP School Health and Education Programme ix University of Ghana http://ugspace.ug.edu.gh Abstract Background: Obesity is associated with diabetes, hypertension, cardiovascular diseases, caries and periodontal diseases, and other morbidities. The association between childhood obesity and oral disease is, however, not well defined. This study examined the association between obesity and oral health in school children and explored possible dietary and oral hygiene risk factors. The study hypothesized that there was poorer oral hygiene status and higher caries and gum disease among the obese than the non-obese. Also oral bacteria associated with caries and gum diseases would be more common in obese than the non-obese school children. Method: The first phase of the study consisted of a single cross-sectional survey of 547 school children from private schools in Accra made up of 233 obese and 314 non-obese schools children between the ages of 9 and 15 years. Dietary and oral hygiene information were collected and respondents were orally examined by two dental surgeons. The second phase was a case-control design of 493 public school children made of 210 cases of caries and gum diseases, and 283 controls. Bacteria samples were cultured from oral plaque samples collected from 75 obese and 75 non-obese children. Results: Mean age of the school children from the private school was 11.5 ±1.7. Dietary habits and oral hygiene practices as well as caries and gum disease prevalence were similar in the obese and non-obese children. Caries prevalence among the obese was 14.9% and among the non-obese was 15.1%. The caries experience among the 12 years old (WHO index age for caries) obese children was 15.4% and among the non-obese was 8.2%. Gum disease prevalence among the obese was 3.7% and among the non-obese was 5.5%. None of these differences was significant, p>0.05. The overall oral disease (caries and gum disease) prevalence among the children was 19.2% and not different by obesity status. x University of Ghana http://ugspace.ug.edu.gh In the public schools, caries experience among the obese children was 33.3% and non-obese was 19.4%. Gum disease among the obese was 38.9% and the non-obese was 33.3%, p=0.620. None of the dietary and oral hygiene factors showed any significant association with the oral conditions in the two groups. Only breakfast intake among the children in the public school was associated with low caries prevalence (p=0.0314). Streptococcus infection was significantly higher in the obese (41.3%) than the non-obese (26.0%) but this did not show any significant association with the caries experience in the two groups. Lactobacillus species was very low (1.3%) but Actinobacillus actinomycetemcometans (aa) among the non-obese was 15.6% and the obese 6.7% but was not significantly different, (p=0.068). Conclusion: Dietary and oral hygiene practices were similar between the obese and the non- obese school children, whether in private or public schools. Similarly, caries and gum disease prevalence were not significantly different in the children irrespective of weight category and obesity status and whether they are in private or the public schools. Oral microbial infections of the four bacteria investigated (Lactobacillus species, P. gingivalis, aa) were similar except for streptococcus mutans which was significantly higher in the obese but was not significantly associated with caries prevalence. Obesity in Ghanaian children was not associated with oral health status. xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 INTRODUCTION Growth and development in children are influenced by their nutrient intake and other health promoting habits such as clean environment, good oral hygiene practices and physical activity. Deficiency in energy and nutrient intakes results in deficiency symptoms while excess energy intake leads to either overweight or obesity in both adults and children. Oral manifestation of certain nutrient deficiencies and some oral diseases may be indicative of poor dietary habits and poor oral hygiene practices. Obesity in general has become a worldwide scourge with its attendant health complications (Dietz, 1998; Ebbeling et al., 2002; Pischon et al., 2007). Childhood obesity in particular is of grave concern because there is an increase in incidence (Allison et al., 2004; Han et al., 2010). Childhood obesity tracks into adulthood (Srinivasan et al., 1996; Owens et al., 1998; Parson et al., 1999; Singh et al., 2008). Poor dietary practices and oral hygiene habits of children expose them to both obesity and poor oral health conditions. For example, high sugar intakes and vitamin C deficiencies are associated with oral diseases (Al- Zahrani et. al., 2003, Genco et al., 2005). Oral health conditions have also been linked to certain chronic conditions especially among obese adults (Douglass, 2003; Al-Ansari, 2006) so there is increasing interest in the link between obesity in childhood and oral health risks. Obesity results from the excessive accumulation of body fat which increases body weight and body mass index (BMI) beyond 30 kg/m2, (Expert Panel, 1998; WHO, 2000). It is often associated with disease conditions and the degree of the health challenges it imposes are dependent on the total fat, its distribution in the body (Arcaro et al., 1999) and presence of co-morbidities (Ferguson et al., 1998). Obesity has been shown to be a risk factor for many chronic diseases such as diabetes, hypertension, arthritis and asthmatic conditions in 1 University of Ghana http://ugspace.ug.edu.gh adults. (Gidding, 1996; Ebbeling et al, 2002,) Sometimes there is an early onset of these cond itions in some children as a result of childhood obesity (Ebbeling et al., 2002; Batch and Baur, 2005) 1.1 Childhood obesity Child obesity is diagnosed as BMI-for-Age z-score for boys or girls greater than 3SD or percentile greater than 95% (WHO/IASO/ IOFT, 2000). Childhood obesity has become a worldwide problem because of the possibility of obese children growing up as obese adults (Srinivasan et al., 1996; Whitaker et al., 1997). Overweight adolescents have a 70% chance of becoming overweight or obese adults (Owens et al., 1998). The first problems faced by obese children are usually emotional or psychological (Must et al., 1992). Childhood obesity however can also lead to life- threatening conditions including diabetes, high blood pressure, heart disease, sleep problems and some cancers (Shina et al., 2002; Pinhas-Hamiel et al.,1996; Freedman et al., 1999). About 61% of children between 5 and 15 years who are overweight have one or more risk factors (Freedman et al., 1999; Strauss et al., 2000) for cardiovascular disease, and 27% of these children have two or more risk factors. Greater numbers of children are being diagnosed with type 2 diabetes, conditions earlier thought to have an adult-onset and is related to obesity (Freedman et al., 1999; Strauss et al., 2000; Batch and Baur, 2005). Obesity and diabetes increase the risk of periodontal conditions at least in adults (Genco et al., 2005; Hein and Small, 2006) but the associations has not been conclusively demonstrated in children. 2 University of Ghana http://ugspace.ug.edu.gh 1.2 Worldwide Trend in Child Obesity In children obesity is affected by age and sex hence the diagnosis of obese children takes into account these factors. Child obesity is therefore diagnosed as BMI-for-Age z-score for boys or girls greater than 3SD or percentile greater than 95% (WHO/IASO/ IOFT, 2000; Srinivasan et al., 1996; Dorsey et al., 2005; de Onis et al., 2007; WHO 2006). Increasing trends in the prevalence of childhood obesity have been reported throughout the developed and developing world. The distribution of body mass index has shifted so that the average overweight child has rather fallen into the obese group, thus further compounding the potential physical and psychosocial consequences of child obesity (Flegal and Troiano, 2002). In a report showing the global impact of obesity epidemics on children, the International Obesity Task Force (IOTF) reported that one in ten children are overweight. Also, 2-3 per cent of the world's children aged 5-17 are obese. It further reported that 22 million young children are either overweight or obese worldwide (IOTF, 2004). In South Africa, for example, some 25% of girls and 7% of boys in the 13-19 year age range were found to be overweight or obese (Armstrong et al., 2006; Kruger et al., 2006) In some developing countries childhood obesity is common in higher social groups; however, it is also rising among the urban poor possibly due to changing local diet towards western diets in the presence of under-nutrition (Kruger et al, 2006; Goyal, et al., 2010). Children in poor families in developed countries are particularly at a higher risk because of poor diet and limited opportunities for physical activity. In the US, overweight doubled in Hispanic and African-American pre-teenage children as compared to white children during the 1990s (Allison et al., 2004; IOTF report, 2004). The number of overweight and obese children in the UK rose steadily in the past 20 years. In 2004 it was estimated that 3 University of Ghana http://ugspace.ug.edu.gh 14% of boys and 17% of girls aged 2 to 15 were obese (Summerbell et al., 2008). In Ghana the prevalence of obesity among 3-5 years olds was reported to be 2.4% in 1998 but rose to 8% by 2003 (GSS et al, 1998; GSS et al, 2003). A study carried out among about 3000 school children in Ghana also reported overall overweight and obesity prevalence of 15.0%. The prevalence among private schools was higher (21%) than that among public school (11%); the prevalence for girls was 20% and for boys was 9% (Lartey, 2012). 1.3 Risk factors for childhood obesity Both genetic and environmental factors have been implicated in the increasing incidence of childhood obesity (Samaras et al., 1998; Kruger et al., 2006; Hans et al., 2010; Hasselbalch, 2010; Hasselbalch, et al., 2010). It is known that children whose parents are overweight or obese also have higher risk of becoming overweight or obese as well (Kruger et al., 2006). Increased intakes of junk foods coupled with low physical activity are major reasons for childhood obesity. Reduced physical activity is attributed to increase in the use of cars to and from school. This reduces the opportunities for walking or cycling to school. The growth in the number of TV channels and internet games played by children and the aggressive promotion and marketing of energy-dense foods have all contributed to the children obesity epidemics (IOTF report, 2004). 1.4 Dietary factors in child obesity Practice of unhealthy dietary habits, lack of exercise and increasing sedentary lifestyles, such as hours of TV watching have been shown to be the main causes of childhood obesity (Hills et al., 2007; Lob-Corzilius, 2007; Flynn et al., 2007; Hans et. al., 2010). High-calorie foods such as chocolates, sweets and fast food are cheap and readily available to school children. Choice of snacks high in sugar and fat have also contributed to the overweight in the school children. Most children in schools are exposed to and therefore are choosing 4 University of Ghana http://ugspace.ug.edu.gh pastries, carbonated and fruit drinks instead of raw fruits as snacks (Jahns et al., 2001; O'Connor et al., 2006). The intakes of these sugar loaded snacks are also associated with oral health problems. 1.5 Factors influencing oral health status of children Oral hygiene is a basic factor for good oral health especially in children. Poor oral hygiene leads to dental plaque formation which in turn can cause gingivitis eventually leading to periodontal diseases. Dental plaque, the soft adherent materials deposited on the tooth surface may consist of bacteria, desquamated epithelial cells and migrated polymorphonuclear leukocytes (Harold et al., 1998). Lack of oral cleanliness allows the bacteria in the plaque to ferment sugars in foods to produce acid that leads to tooth decay or dental caries. 1.6 Common oral health problems in school children and risk factors The two most common oral diseases in children are caries and periodontal conditions. Caries occur when plaque pH levels drop below 5.5 due to increased acid production in the dental plaque from the fermentation of sugars in the foods consumed (Riva et al., 2003). The acid produced causes demineralization of the tooth enamel exposing the softer underlining dentin to further bacteria invasion. Factors affecting the onset of carious lesions include poor oral hygiene, diet composition and frequency of intake, salivary immunoglobulins, bacterial load and fluoride intake (Caufield et al, 2005). Other conditions that favor caries occurrence include, the host oral environment; that is, the tooth surface, salivary flow and immunity; the presence of a substrate, which must be a fermentable carbohydrate and finally the bacteria load. Socioeconomic status of the children also contribute to the caries risk due to the exposure 5 University of Ghana http://ugspace.ug.edu.gh to cariogenic foods such as candies, soft drinks and other high sugary foods (Oliveira et al., 2008, Jahns et al., 2001). 1.7 Periodontal disease prevalence in children Oral hygiene status defined by plaque score was found to be higher in 6 year olds than the older children 7-9 year olds in a study carried out on peri-urban school children in Accra, Ghana. More than 90% of the six year olds had plaque accumulation as against 54% for the 7-9 year olds (Bruce et al., 2002). Plaque and calculus formation often precede periodontal conditions. It begins with the inflammation of the gum (gingivitis) and when not checked worsens to be become periodontitis (Wilson et al., 1985; Califano et al., 1996; Califano et al., 1997; Albandar et al., 1997). The plaque is made up of the soft tissues while the calculus is the hardened calcified deposit on the tooth surface. The subgingival calculus causes irritation of the gum sparking inflammation. 1.8 Types of periodontal diseases in children and adolescents There are three major forms of periodontal conditions in children. i) Chronic gingivitis where the condition persist for a long time. ii) Localized aggressive periodontitis where it occurs in some parts of the mouth iii) Generalized aggressive periodontitis where it affects most part of the mouth (American Periodontology Association (APA) Position paper, 2003). The chronic gingivitis a common condition in children is characterized by swollen gum tissues, which look red and sometime bleed on brushing or probing. The continuous accumulation of plaque and calculus at the gingival margin tend to initiate the condition. 6 University of Ghana http://ugspace.ug.edu.gh Chronic gingivitis can be prevented and easily treated by regular and proper brushing and effective use of floss as well as regular checkups. When the condition is left untreated it will eventually worsen to serious periodontal disease. The localized aggressive periodontitis is often associated with teenagers and young adults, who are otherwise healthy. It mainly affects the first molars and incisors. It leads to severe loss of alveolar bone in patients who generally have very little dental plaque or calculus. (Davies et al, 1978; Gjermo et al, 1984; American Periodontology Association (APA) Position paper, 2003). The generalized aggressive periodontitis may begin around puberty and involve the entire mouth. It is marked by inflammation of the gums and heavy accumulations of plaque and calculus. Eventually it can cause the teeth to become loose and then fall off (Gjermo et al., 1984; APA Position paper, 2003). 1.9 Prevalence of caries and periodontal diseases in obese children Increasingly significant links have been made between obesity and oral diseases. Obesity as a risk factor for periodontal diseases in children has been reported (Al-Ansari et. al., 2006; Mathus-Vliegen et al., 2007; Karels, and Cooper, 2007). Al-Ansari et al., (2006), reported that obese children demonstrated high DMFT (Decay, Missing and Filled Teeth) scores than normal weight children. Willershausen and others found strong correlation between overweight and increased caries among German elementary school children (Willershausen et al., 2004). Karp and Al-Ansari in separate studies observed that increased obesity rates were associated with increased caries rates (Karp, 1998; Douglass 2003; Al-Ansari, 2006; Karels and Cooper, 2007). 7 University of Ghana http://ugspace.ug.edu.gh 1.10 Dietary factors in obesity and oral health link Decreased intake of fresh fruits, high in vitamin C needed for the integrity of the oral mucosa, leads to high oral infections (Al- Zahrani et al, 2003). A study that assessed the dietary practices of 11-to-18 year old children in the general population found significant decrease in raw fruit and vegetables intakes, and a decrease in the intake of calcium-rich foods (Al- Zahrani et al., 2003). In addition the children were drinking more sodas and non-citrus juice (Dennison et al., 1998; Al- Zahrani et al., 2003; Story et al., 2008; Lorson et al., 2009). 1.11 Oral bacteria associated with dental caries and periodontal diseases The oral environment has significant impact on the risk of oral conditions. Tooth decay is caused by oral bacteria that produce acid from fermentable carbohydrates. The contact of the acid with the tooth surface initiates demineralization leading to the erosion of the tooth enamel. If this process is not halted there is further invasion of other bacteria leading to worse dental problems. Also the bacteria in the plaque often cause inflammation of the gingiva (gum) which may progress into periodontal conditions. Therefore the oral microflora is very important in the incidence of oral infections. Several bacteria are associated with oral infections but the commonest associated with caries are the streptococcus mutans and lactobacillus species (Brandshaw and Marsh, 1994, Brandsahaw et al., 2002). Those associated with periodontal conditions include actinobacillus actinomycetemcomatans and porphyromonas gingivalis. The levels of these bacteria in obese and non-obese children have been shown to be higher among the obese adults than the non-obese (More and More, 1994; Socransky et al, 1998; Socransky et al., 2000; Ximénez-Fyvie et al., 2000). 8 University of Ghana http://ugspace.ug.edu.gh Some studies have suggested that the composition of salivary bacteria changes in overweight women (Goodson et al, 2009). It seems that these bacterial species could serve as biological markers of developing overweight or obese condition. Some other studies have also suggested that oral bacteria may contribute to the pathology of obesity in both adults and children. (Goodson et al, 2009; Barkeling et al., 2001). Studies also seem to suggest a relationship between periodontal disease, obesity and insulin resistance. Grossi, et al, in 2009 found that overweight adults with high insulin- resistance index were nearly 50 percent more likely to have severe periodontal disease compared with those who had a high BMI and low insulin resistance. They concluded that bacteria from gum disease may interfere with fat metabolism, leading to elevated low- density lipoprotein (LDL) cholesterol and total cholesterol. They also suggested that it is possible that periodontal disease contributes to increased morbidity in overweight or obese individuals (Genco, 2005; Grossi et al, in 2009). This has not yet been proven in children. 1.12 Problem statement Obesity is a condition that predisposes individuals to various health challenges. Since obesity is related to dietary practices it also can affect the oral cavity. The oral cavity can be exposed to extreme chemical and temperature changes as well as mechanical stress. Studies have shown that obesity effect on health also include changes in the teeth and the gum (Douglass 2003; Al-Ansari, 2006). This has been well established in adults. Gum disease such as periodontitis in obese adults has been linked to cardiovascular disease (Wood et al., 2003; Saito et al., 2005). In children the association between obesity and oral disease is inconclusive but has not be investigated in the Ghanaian obese children. If these condition also exists in obese children these might increase the risk of early onset of heart problems for the obese child. Therefore establishing the association between child obesity 9 University of Ghana http://ugspace.ug.edu.gh and oral health in Ghanaian children will be the first step in understanding the nature of the association and identifying those factors involved. This will provide relevant information for reducing the risk by monitoring dietary practices and oral hygiene habits. This may in the end delay or prevent the early onset of heart problems in the obese child. 1.13 Rationale for the study There is increasing rate of obesity among children and the effect on oral health needs to be examined for appropriate interventions. Obesity in itself is a nutritional challenge. If caries and periodontal conditions worsen in obese children there may be multiple health risks to grapple with. A study on oral health status of Peri-urban school children 4-16 years in Accra in 2002 showed that the prevalence of plaque was higher in the younger children than in the older ones. Similarly prevalence of calculus which is calcified plaque was also higher in the younger children (Bruce et al, 2002). Studies on oral health and nutritional status among school children carried out by the Department of Community and Preventive Dentistry, Dental School showed that caries prevalence was higher among stunted children than non-stunted children. The DMFT score for stunted children was 3.0 as against 1.9 for normal height children (Ndanu et al., 2007). The possible link between overweight/obesity and dental health among Ghanaian children has not been studied. The association between diet and oral health among Ghanaian children has not been examined either. Though some studies have shown that obese children have increased risk of oral conditions than normal weight children (Douglass 2003; Al-Ansari, 2006; Karels and Cooper, 2007) other studies showed otherwise (Dalla Vecchia et al, 2005). 10 University of Ghana http://ugspace.ug.edu.gh This study therefore sought to demonstrate whether or not an association exists between obesity and oral conditions in Ghanaian obese children and to identify possible factors associated with it. There is paucity of data on the prevalence of oral diseases among Ghanaian obese adults and even less on obese children. Child obesity prevalence is rapidly rising among the Ghanaian children (GDHS, 1998; GDHS, 2003, Lartey, 2012). While it is necessary to investigate other problems that may affect the obese children it is equally important to investigate the association between obesity and oral conditions in the obese Ghanaian children in order to reduce any other possible health risk in the obese child. No data so far has been reported on the overall association of diet, oral hygiene practices and oral diseases among Ghanaian obese children. It will be necessary to examine the association between dietary practices, oral hygiene and obesity on the oral health of obese children. This information will be helpful for intervention programmes to address oral health among at risk children. The study investigated the dietary pattern and snacking behavior of the school children. It examined the oral hygiene habits, oral hygiene status as well as prevalence of oral diseases such as dental caries and gum disease. Finally it investigated the prevalence of specific oral bacteria associated with caries and gum disease. To investigate the association between obesity and oral health in the school children the following conceptual framework was developed. 11 University of Ghana http://ugspace.ug.edu.gh 1.14 Conceptual framework showing the pathway by which nutritional status and dietary habits may be associated with oral health. Genetic, Predisposing factors Environmental, psychosocial for obesity Energy balance, Physical activity Obese Non -obese Respondent category Bad oral habits Poor oral hygiene Bad dietary practices Intervening High level of Snacking factors Nutrient deficiencies Oral infections Outcome Dental variables caries gingivitis Periodontitis (This conceptual framework was the one approved by the Ethical and Protocol Committee for the study to start. The committee insisted that the conceptual framework was simplified as reported from a more complicated one presented to them earlier). The conceptual framework presents the known intervening factors that are directly associated with the disease outcomes in the children. This study examined these factors and their contribution to the possible differences in the oral conditions in obese and the non-obese groups. 12 University of Ghana http://ugspace.ug.edu.gh 1.15 Objectives Three specific objectives were set for this study: Objective 1. To examine the differences in dietary habits and oral health status among obese and non-obese school children (9 - 15 years) This was achieved by conducting dietary and oral health status assessment in a cross- section of selected school children. Dietary intake was assessed using food frequency questionnaire (FFQ) Objective 2. To assess the prevalence and risk of caries and periodontal diseases among obese and non-obese children in the selected schools and evaluate the possible dietary and oral hygiene factors associated with the risk of caries and gum diseases. Objective 3. To assess the oral microflora associated with dental caries and gum disease in both the obese and non-obese school children. 1.16 Working Hypothesis The study hypothesized that: 1. There was a higher prevalence of caries and periodontal disease among obese children than the non-obese children. 2. There was a significant difference in the oral hygiene practices among obese and no-obese children with the obese children having poorer oral hygiene status. 3. The dietary practices among the two groups differ significantly with better practice among normal weight than obese children 4. Oral microflora will differ in obese and in non-obese school children. 13 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Obesity and oral health status Obesity has been demonstrated as a risk factor for many non-communicable diseases such as diabetes, hypertension, stroke and other cardiovascular diseases (Gidding, 1996; Ebbing et al., 2002). Increased interest has shifted to childhood obesity because early detection in the child and its complications in later life can better be monitored and managed. Child obesity is also a good predictor of adult obesity (Parsons et al., 1999; Singh et al., 2008). Owen and others in 1980 showed that about 70% of overweight children grow up to become overweight or obese adults with possible health complications (Owens, et al., 1980). Studies by Gidding, (1996) and Ebbing et al., (2002) all confirmed that obesity is a risk factor for many chronic diseases such as diabetes, hypertension, Arthritis, and Asthmatic conditions in adults. Some of these conditions associated with obesity in adult have been demonstrated to occur in obese children as well (Freedman et al., 1999). Obesity has also been shown to be a risk factor for periodontal (gum) diseases and other oral conditions including caries in adult (Amy, 2003, Dietrich et al., 2005; Al-Ansari et al., 2006; Pischon et al., 2007; Sunitha et al., 2010). The oral cavity consists of several structures including, the teeth, the gums (gingiva) and the supporting connective tissues, ligaments, and bone. The tongue and the salivary glands form part of the oral cavity. The mucosal lining of the mouth and throat undergoes rapid replacement hence may be affected by nutrient deficiency (Christopher, 2001). Infection of these tissues and organs or defect in any of these structures may result in of loss of function and therefore will compromise the health of the mouth. Exposure to certain oral habits such as smoking and drinking 14 University of Ghana http://ugspace.ug.edu.gh alcohol may also expose the mouth to oral cancers (Surgeon General report, 2000). Risk factors for oral diseases include unhealthy diet, tobacco use, harmful alcohol use, and poor oral hygiene (WHO, 2005). Good oral health as defined by WHO includes being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity (Locker, 1997; Petersen, 2003). In addition optimum state of structure and function of the oral cavity that facilitates food consumption and the performance of other functions of the mouth (Gift et al., 1992; Gherunpong et al., 2004) is most desired. Both infections and nutritional deficiencies may compromise the health of the mouth often resulting in caries (tooth decay), periodontal (gum) diseases and sometimes oral cancers (Christopher, 2001). A thorough oral examination can detect signs of nutritional deficiencies as well as a number of systemic diseases, including microbial infections, immune disorders, injuries, and some cancers. Hence the mouth can be considered as a reflection of changes in the whole body. 2.2 Global trends in childhood obesity The Internationals Obesity Task Force (IOTF) in 2004, reported that 2-3% of the world's children aged 5-17 were obese. They stated that as many as 22 million young children were affected globally. The report indicated that the situation was more prevalent in affluent than poorer countries. There was high vulnerability among urban poor in developing countries. They suggested that poor diet among the urban poor may be associated with the introduction of western diets such as fast foods which are often high in saturated fats, salt and sugar (IOTF, 2004). The IOTF also indicated that there is a race and gender association with obesity. In the US for example, overweight doubled in 15 University of Ghana http://ugspace.ug.edu.gh Hispanic and African-American pre-teenage children compared to white children during the 1990s. In South African children girls were either overweight or obese than boys. Thus 25% of girls and 7% of boys in the 13-19 year age range were found to be overweight or obese (IOTF, 2004). Thus, socioeconomic, environmental, as well as, race factors are independent risk factors for obesity. In another report Summerbell et al., (2004) showed that the number of overweight and obese children in the UK rose steadily over the last 20 years up to 2004 with prevalence of 14% in boys and 17% in girls aged 2 to 15 years. Recent report from Health Survey of England (HSE) data from UK revealed that 17% boys and 15% girls were obese, while 31% boys and 29% girls were classed as either overweight or obese. Children aged 11-15 were more likely to be obese than the 2-10 year-olds, thus 21% of boys and 18% of girls aged 11-15, compared with 14% and 13% respectively aged 2-10. Study of the trend from 2004 to 2008 seem to show a plateau of the prevalence in the children. (Health Survey of England report, 2008) 2.3 Obesity in Ghana In Ghana the prevalence of obesity among 3-5 year olds was reported as 2.4% in 1998 but by 2003, the figure had risen to 8% (GSS et al, 1998; GSS et al., 2003). In a study to investigate socio-demographic variations in obesity among Ghanaian adults, Amoah et al., (2003) reported that obesity prevalence among the adult population was 14.1% with a higher levels among female (20.2%) than males (4.6%). The findings also suggested ethnic differences with Akans and Gas having higher prevalence than the Ewe ethnic groups. The urban high income earners showed higher prevalence than the lower income groups. Prevalence was also higher among people with tertiary education (18.8%) compared to 16 University of Ghana http://ugspace.ug.edu.gh those without (12.5%). These education-related differences may be due to the fact that those with higher levels of education are more likely to have higher incomes and be more able to afford junk foods. (Amoah et al., 2003) Biritwum et al., (2005) reported in a nationally-representative large sample study supported by WHO that obesity was 5.5% in adults 18 years and above. Female prevalence was 7.4% as against 2.8% in males. They reported regional and ethnic variations in obesity. Prevalence of obesity was highest in the Greater Accra region (16.1%) and virtually non- existent in the two upper regions of Ghana. It was highest among Ga-Adamgbes, Ewes and Akans, 14.6%, 6.6% and 6.0% respectively (Biritwun et al., 2005) In a study to investigate associations between obesity and socio-economic status in urban civil servants in Ghana, it was reported that obesity prevalence was 10% in males and 36% among female. However no significant differences in obesity rates were found among the different socio-economic groups in the civil servants (Addo et al., 2009). In a recent study of obesity among 6-12 year old school children in public and private schools in Accra, prevalence was observed to be 3% using BMI –Z-score ≥3 (Nyarko et al., 2012). This was presented as West African College of Physicians (WACP) fellowship paper. Another study under the Ghana Schools Survey in 2012 reported overall obesity prevalence as 15.0%. For the private schools the prevalence was 21% and 11% for public schools. Girls had higher prevalence of 20% as against 9% for boys, (Lartey, 2012) 17 University of Ghana http://ugspace.ug.edu.gh 2.4 Obesity and ill-health Obesity is associated with ill health and the severity of the health challenges depends on three major factors: overall fat deposition; its distribution i.e. viscerally or subcutaneously; and presence of co-morbidities (Burton et al., 1985). Obesity is also a major risk factor for many chronic diseases including diabetes, hypertension, arthritis, and asthmatic conditions in adults (Gidding, 1996, Ebbeling et al., 2002). An early onset of these conditions in some obese children has also been reported (Freedman et al., 1999). Increasing BMI as seen in sedentary and obese individuals is also associated with some cancers and gallstones (Erlinger, 2000). 2.5 Obesity and diabetes In Type 2 diabetics there is a degree of insulin resistance and hyperinsulinaemia (Hotamishligil, 2000; Kern et al., 2001; Gray et al, 2010). The resultant hyperglycaemia accompanied by disorders in lipid and amino acid metabolism produce short, medium and long term harmful effects (Ford et al., 2002; Eckel et al., 2005) unless they are detected early and addressed appropriately. Early symptoms include fatigue and dizziness in the short term; but in the longer term, complications include kidney (renal) damage, retinopathy (Ahmad and Ghani, 2012) and neuropathy (Straub et al., 1994). The evidence for a clear link between diabetes and obesity has been established since nearly 80 percent of people with type 2 diabetes are also obese (Bloomgarden, 2000). More recently, attempts have been made to examine molecular and epigenetic mechanisms which may be passed on to generations and relates to nutritional programming (Gluckman et al., 2009; McAllister et al., 2009; Anne et al., 2011). 18 University of Ghana http://ugspace.ug.edu.gh One current theory of molecular mechanism proposes that defective lipid metabolism may be responsible (Rose et al., 2004). It is thought that fat molecules leak out of adipose cells and are taken up by muscle fibers and hepatocytes (Bastard et al., 2002: Rose et al., 2004). The fat molecules interfere with cell signaling pathways that convey messages from insulin receptors from the cell surface to the nuclear receptors, thus impairing the cell's ability to respond to insulin (Rose et al., 2004). Obesity also triggers an inflammatory responses which may also contribute to diabetes. Levels of tumour necrosis factor α (TNFα), the pro-inflammatory signaling molecule have been known to be raised in diabetes. TNFα is also known to interfere with intracellular signaling in insulin-responsive cells (Hotamisligil et al., 1993; Jean-Philippe et al., 2006; Samad et al., 1997; Fried et al., 1998; Bastard et al., 2002). Adipose tissue used to be thought of as just storage tissue but it is clear that it is much more active than that, and is now thought to possess properties of an endocrine gland, releasing hormones and other signaling molecules (adipocytokines). These chemicals may also be involved in disrupting responses to insulin (Rose et al., 2004). 2.6 Obesity and cancer Obesity increases the risk of cancers of the endometrium, breast, and colon (Bergström et al., 2001; Polednak, 2008). An important factor is the release of hormones or other signaling molecules by adipose cells. These can affect the growth and proliferation of cells, and promote uncontrolled growth of cells which then leads to the cancer (Yin et al., 2004). Breast cancer risk is increased in post-menopausal obese women. Potentially important factors include secretion of the female hormone oestrogen by adipose cells, which stimulates the growth of breast cells (Feigelson et al., 2004). There is some evidence that signaling molecules such as leptin and other adipocytokines may also act on these 19 University of Ghana http://ugspace.ug.edu.gh cells (Yin et al., 2004). Some dietary factors may mediate the obesity and oral cancer link (Bravi et al., 2013). Insulin resistance may also contribute to the development of certain cancers (Yu and Rohan, 2000; Yi et al., 2001; Djiogue, et al., 2013) and the inflammation caused by obesity may also play an important role (Calle et al., 2003; Derick et al., 2013). Both genetic and environmental factors determine whether or not an obese person may develop cancer and the environmental factors include smoking and alcohol consumption. All these factors influence the control of the cell, and the complex interactions may initiate or propagate an uncontrolled cell multiplication leading to cancer (Calle et al., 2003; Roberts et al., 2012). 2.7 Obesity, high blood pressure and heart disease Overweight and obesity has been consistently associated with hypertension and weight loss has resulted in improved blood pressure values (Wolf et al., 1997; Must et al., 1999). The mechanism by which obesity influences blood pressure is not completely understood. The current thinking is that atherosclerosis involving dedposition of fatty materials leading to plaque in arteries and damage to the endothelial walls, are an established risk factors for increased peripheral resistance and hypertension (Wofford and Hall, 2004; Surya et al, 2009) . Although chronic inflammation is implicated (Lavie et al., 2003), endocrine and nervous system factors are also thought to be involved (Klein et al., 2004). In the obese individual some hormone systems are found to be affected especially the renin- angiotensin-aldosterone system. This network of specific factors do control blood volume and hence blood pressure (Wofford and Hall, 2004; Atack et al., 2008). Obesity also interferes with kidney function, which may impact on blood pressure (Rutkowski, 2006). The physical mass of fat tissue may also independently interfere with kidney function (Praga, 2006, Sivestava, 2006, Chertow et al., 2006). 20 University of Ghana http://ugspace.ug.edu.gh 2.8 Obesity and periodontal (gum) disease As early as 1973 periodontal changes were observed by Kolesky and Perlstein in obese rats. They reported that the periodontal changes got worse in the presence of oral bacteria and plaque accumulation (Koletsky, 1973; Perlstein et al., 1977). Recent studies have suggested that obesity is also associated with oral diseases, particularly periodontitis in humans (Saito et al., 2001; Wood et al., 2003; Saito et al., 2005; Genco et al., 2005, Dalla Vecchia et al., 2005). In a systematic review and meta-analysis carried out by Chaffee and Weston it was reported that there is a consistent positive association between prevalence of periodontal disease and obesity across several studies (Chaffee and Weston, 2010). The authors also demonstrated that the obesity-periodontal disease association is stronger among women, non-smokers and younger adults than the general adult population. A common pathway in the pathophysiology of obesity and periodontitis has been proposed (Dalla-Vecchia et al., 2005). Obesity has been suggested to be the second greatest risk factor apart from smoking for inflammatory periodontal disease. Perlstein et al., (1977) observed histopathologic changes in the periodontium in hereditary obese Zucker rats. Using ligature-induced periodontitis, alveolar bone resorption was greater in obese animals than non-obese rats. Also, it seemed that under healthy oral conditions, obesity alone does not promote pathologic periodontal changes but in response to bacterial plaque accumulation, periodontal inflammation and destruction were more severe in obese animals (Perlstein et al., 1977). In 1998, Saito and his team studied 241 healthy Japanese individuals and showed for the first time an association between obesity and periodontal disease in humans. Other studies have indicated that the fat distribution pattern plays a crucial role in the association with periodontitis (Wood et al., 2003; Saito et al., 2005.). Another study by Saito and his 21 University of Ghana http://ugspace.ug.edu.gh team concluded that obesity is associated with deep periodontal pockets, independent of glucose tolerance status. Genco and his team analyzed US National Health and Nutrition Examination Survey (NHANES III) data and demonstrated that BMI was positively correlated with the severity of periodontal attachment loss. They found that this relationship is modulated by insulin resistance (Genco et al., 2005). 2.9 Child Obesity and Caries While obesity association with caries in children have been shown to be significant in some studies (Alm et al., 2008; Gerdin et al., 2008; ) other studies did not show any such significant relationship (Chen et al., 1998; Macek et al., 2006; Kopycka-Kedzierawski et. al., 2008,). Studies in countries such as Sweden, (Alm et al., 2008), Germany, (Willershausen et al., 2007), Brazil (Oliveira et al., 2008), Mexico (Vazquez-Nava, et al., 2010), India (Sharma, et al., 2009) and Thailand (Narksawat et al., 2009), all showed significant association between overweight/obesity with caries among children. On the other hand studies from USA, (Macek et al., 2009; Kopycka-Kedzierawski, et al., 2008), France (Tramini et al., 2009), Brazil (Granville-Garcia et al., 2008) and Iran (Sadeghi, et al., 2007) did not find significant association between obesity and caries experience among the children. A systematic review carried out on published articles from 1980 to 2012 showed that the relationship is still inconclusive (Hayden et al., 2012). In one of the Brazilian studies significant association was observed for higher caries among underweight children than the normal weight children. This they claimed was associated more with socioeconomic factors than mere weight challenges (Oliveira et al., 2008). Caries is the commonest chronic disease in children (Slade, 2001) and often is as a result of poor oral hygiene (Petersen et al., 2005). A study by Palmer and others showed that 22 University of Ghana http://ugspace.ug.edu.gh children with severe early childhood caries had an intake of sugar food and beverages more frequently than those with low caries (Palmer et al., 2010). Factors shown to influence early childhood caries include fluoride use in vanishes (Marinho et. al., 2002) and toothpaste (Marinho et al., 2003), and genetic susceptibility (Wang et al., 2012). 2.10 Periodontal diseases in children Studies in the US have shown that five clinically distinct types of periodontal infection can affect children and young adults. These are: plaque-induced gingivitis; chronic periodontitis; aggressive periodontitis; periodontitis resulting from systemic conditions; and necrotizing periodontal disease (American Periodontology Association (APA) Position paper, 2003). The commonest is the plaque induced gingivitis. Puberty can make children more vulnerable to inflammatory gingivitis (De Pormmereau, 1992; Nakagawa et. al., 1994). Medical problems such as blood or genetic disorders, or diabetes can predispose children to periodontal disease (Nakagawa et al., 1994; Samaras et al, 1998; Kruger et al., 2006; Hans et al., 2010). Mouth breathing results in the drying of the mouth and gums, and can cause gingivitis (Silvia et al., 2010; Walsh, 2007, Brunstrom, 2002; Temmel et al., 2005; Eliasson et al., 2006). Orthodontic appliances make oral hygiene more difficult and this can lead to inflamed gums (Atack et al., 1996; Dersot, 2010; van Gaste et al., 2011). Gum disease that is not related to dental plaque can be caused by viruses (herpes), fungi (candidiasis or thrush) or bacteria. Medications such as anti- epileptic Dilantin, and anti-rejection Cyclosporin can cause gingival overgrowth in children (Nakib and Ashrafi, 2011; Vahabi et al., 2013; Salman et al., 2013). 2.11 Plaque and calculus formation and risk of caries and gum disease There is common factor in the cause of caries and gingivitis. Plaque acid erodes the tooth enamel while the toxic compounds produced by the plaque bacteria may irritate the gum and initiate inflammation response which later leads to plaque induced gingivitis. The 23 University of Ghana http://ugspace.ug.edu.gh plaque a soft deposit on the teeth consist of 80% water and 20% solid material. The solid material consist of 50% bacterial and salivary protein and 20-30% carbohydrates and lipids (Tanaka et al., 1999). The extracellular complex carbohydrates synthesized by bacteria are used as bacterial attachment onto the tooth surface while the rest are used as sources of fermentable substrates. Plaque also contains inorganic components such as Ca, K, Na, Mg, P etc., which are higher than in the saliva. Most of the minerals become ionized when pH drops in the plaque. It is the exchange of these ions within the plaque that leads to demineralization of the tooth enamel resulting in caries (Pearce, 1991; Tanaka et al., 1999; Tanaka et al., 2000) When plaque is not removed and it remains on the teeth over a long period, the chemical reaction within it causes the plaque to be calcified resulting in harden substance called calculus or tartar. It may form above the gingival margin on the tooth (supragingival) or may form below the gingival margin and within the Sulcus (subgingival). When the subgingival calculus is not removed the bacterial toxins irritate the gum resulting in gingivitis. When this is not treated on time it may progress into an acute or chronic periodontitis. This may finally lead to tooth loss in both the young and the adult. 2.12 Mechanisms explaining relationship between obesity and oral health The underlying biological mechanisms for the association of obesity with periodontitis are not currently well understood however, cytokines and hormones produced by adipose tissues are thought to play a key role. The adipose tissues produce vast amount of adipokines or adipocytokines, which are involved in inflammatory responses hence do modulate periodontitis (Kershaw et al, 2004; Chaffee and Weston, 2010; Katz and Bimstein, 2011; Dahiya et al., 2012). 24 University of Ghana http://ugspace.ug.edu.gh 2.13 Links between obesity and oral health: the role of lifestyles The two commonest oral health conditions in children are caries and gum disease (WHO, 2012). The direct link between obesity and oral health is often mediated by the diet of the individual. Positive energy balance resulting from excessive calorie intake at the expense of physical activity is associated with increased BMI and if the extra calories come from fermentable carbohydrates then the risk of both obesity and caries is greatly increased. (Holbrook et al., 1995). The form, content and frequency of consumption of sugary foods containing fermentable carbohydrate all increase the risk of caries. (Holt et al, 1982; Holbrook et al., 1998; Dahiya et al., 2012). High intake of sugary foods, particularly soft drinks; frequency of consumption of such foods, sticky snacks with high levels of fermentable carbohydrates (Gustafsson et al., 1954; Burt and Ismail, 1986; Stecksen and Holms, 1995), lack of adequate raw fruits and vegetables to provide vitamin C are major dietary factors in the risk of oral conditions especially dental caries (Holbrook, et al., 1998; Moynihan, 2005; Puertollano, 2011) 2.14 Factors affecting oral health status in children Children and youth in the US were reported to have received approximately one-third or more of their calories from foods purchased outside of the home, at restaurants and fast food joints that contain higher fat than food consumed at home (McGinnis, 2006). The three major factors that influence the oral health status of children are their dietary habits, oral hygiene and oral health behaviours. 2.15 Dietary habits and oral health status The choice of food, timing of meals (Burt and Ismail 1986), frequency of consumption (Gustafsson et al., 1954) and sometimes the intake of alcohol, have all been associated with oral conditions. Apart from high intake of sugary foods that predispose children to 25 University of Ghana http://ugspace.ug.edu.gh oral health risks, the low intake of fruits and vegetables, good sources of vitamin C may also weaken the defenses of the oral mucosa hence worsening the oral disease state (Moynihan, 2005; Puertollano, 2011) 2.16 Oral hygiene habits The accumulation of plaque and plaque pH below 5.5 is often the starting point of tooth decay. Oral hygiene habits such as the use of tooth cleaning materials including chewing stick, chewing sponge, and toothbrush with fluoride containing tooth paste or gels are the most effective ways of preventing or slowing down the decay process even if it had started (Marinho et al., 2002; Marinho et al., 2003). Alm (2008) showed that the early introduction of child to good oral hygiene practices can influence caries prevalence in later life. His study followed children from age 1 till they were 15 years old and showed that early caries experience had a significant effect on caries prevalence at age 15 years. In addition children who had better oral hygiene status at age three demonstrated lower prevalence of approximal caries at age 15 years (Alm, 2008). Thus good oral hygiene habits formed in early childhood provides a good basis for good oral health in adolescence. 2.17 Oral health behavior Oral health behavior includes the perceptions, attitudes and practices of an individual towards his or her oral health as compared to his general wellbeing. It also includes the measures taken to ensure clean and healthy mouth or good oral health. In many poor developing countries, dental visits are often rare and far between for most people (Vysniauskaité and Vehkalahti, 2006; Bayat et al., 2008; Sugihara et al., 2010; Ajayi and Arigbede, 2012). Oral health is not considered a priority among the poor because of limited access to oral health facilities and a lack of oral health culture in some communities. Dental experts e.g., Academy of General Dentistry, proposed that each person should visit the dentist twice every year to have a dental checkup or for oral cleaning (Kim and Kaste, 26 University of Ghana http://ugspace.ug.edu.gh 2013; Giannobile et al., 2013). This advice is given because regular visits to the dentist will help diagnose oral diseases at their earliest stages to facilitate early treatment and complete cure. Early detection and treatment saves unnecessary discomfort, time, and money. For the children their parents are the major decision makers about their dental visits and this will be beneficial if parents are well informed about the need for oral health care for their children. Regular attendance at the dental clinic and early diagnosis of oral disease will therefore help to protect vulnerable groups from the onset of these diseases and those who develop the condition can quickly be monitored and evaluated for effective treatment. 2.18 Role of diet and nutrition in the etiology and prevention of periodontal diseases Periodontal conditions progress more rapidly in under nutrition partly due to the impact of good nutritional status on immune response (Enwonwu, 1995). The low immunity in the undernourished hence lack of protection may allow periodontal conditions to get worse in people with different levels of malnutrition. Periodontal conditions are also associated with an increase in the presence of free radical oxidant species which if not neutralized may cause further damage to cells and tissue (Moynihan, 2005,). There is evidence that antioxidant nutrients such as vitamin C, beta-carotene and vitamin E are important in checking the oxidative damage to cells and tissues especially of the periodontium (Moynihan, 2005). These antioxidants are very common in fruits, vegetables, seeds, grains and nuts (Puertollano, 2011). Severe vitamin C deficiency in particular results in scurvy- related periodontitis (Touyz, 1984; Touyz, 1997; Staudte et al., 2005; Amalia et al., 2007) and inadequate intake of these raw fruits exposes the individual to risk of oxidative damage of the periodontium (Lianrui et al., 2002; Amalia et al., 2007). 27 University of Ghana http://ugspace.ug.edu.gh 2.19 The role of diet and nutrition in caries Poor nutrition in childhood may affect the proper structure of the tooth enamel exposing it to caries in later life. In addition chronic malnutrition may affect both the anatomy and function of salivary glands (Johnson, 1993; Mazengo et al., 1994). It may reduce the rate of saliva flow and the buffering capacity of the saliva; adversely affect the volume, antibacterial and physiochemical properties of saliva (Johansson, 1992). Thus diet and nutrition may interfere with the balance of tooth demineralization and re-mineralization process. The diet provides sugars and other fermentable carbohydrates which are metabolized to acids by plaque bacteria. The resultant low pH favors the growth of acid producing bacteria such as streptococcus mutans. In contrast, a diet lower in added sugars and fermentable carbohydrates and high in calcium-rich cheese may favor remineralization (Position paper; Academy of Nutrition and Dietetics 2013). Sucrose in addition to providing fermentable carbohydrates also facilitates the colonization of teeth by streptococcus mutans and their outgrowth (Van Houte et al., 1976; Minahet et al., 1981). 2.20 The role of diet and nutrition in disease of the oral mucosa The first signs of deficiency of some micronutrients e.g., B-vitamins, are seen in the mouth and include glossitis, chelitis, and angular stomatitis, (Moynihan, 2005). Undernutrition has been shown to worsen the severity of oral infections and it contributes to life threatening disease such as noma, a dehumanizing oro-facial gangrene (Enwonwu et al., 2002). Oral cancer is the eighth most common cancer in the world (Pertersen, 2003). Diet is known to be a preventable risk factor for it. Nutrients such as iron, selenium, vitamin A 28 University of Ghana http://ugspace.ug.edu.gh and E, and beta-carotene have shown positive associations with reducing risk of oral cancer and case control studies have suggested protective role of vitamin C. (Moynihan, 2005; Bravi et al., 2013). An association between the consumption of char-grilled foods with oral cancer has also been reported (Knize et al., 2005; Rohmann et al., 2007). Although whole grain foods may be protective the evidence shows that fruits and vegetables protect against oral cancer. Thus the risk of oral cancer decreases with increasing fruit and vegetable intake. And this often has been attributed to the antioxidant component of the fruits and vegetable (Morse, 2004). In a large cohort study in the USA, the risk of cancer was decreased by 40-80% in people with high intake of fruits and vegetables as compared with those with low intake (Al- Zahrani et al., 2003). 2.21 The possible mediating role of diet in oral health conditions in obese people Al- Zahrani et al, (2003) assessed the dietary practices of 11-to-18 year old children in the general US population and found significant low intake of raw fruit and vegetables which are good sources of vitamin C. They also observed a decrease in the intake of calcium-rich foods needed for strong teeth. They showed that the children were drinking more sodas and non-citrus drinks. Decreased intake of fresh fruits, high in vitamin C needed for the integrity of the oral mucosa, leads to increased risk of oral infections (Al- Zahrani et al., 2003). The consumption of grapefruit, rich in vitamin C was also shown to improve vitamin C status and healing of periodontitis patients. (Touyz, 1997; Staudte et al., 2005; Amalia et al., 2007) 2.22 Oral health practices in school children The risk of oral conditions such as caries and gum disease is greatly reduced if children are taught and do practice good oral hygiene such as twice daily brushing and the use of 29 University of Ghana http://ugspace.ug.edu.gh fluoride containing dentifrices (e.g. toothpaste). Effective tooth brushing therefore helps to remove food debris and checks plaque accumulation on the teeth hence reduces the risk of caries substantially. With very good oral hygiene practices diet becomes a less risk factor for caries especially in children (Alm, 2008). Some children may be genetically or physiological predisposed to caries as a result of poor enamel formation in childhood (Descroix et al., 2010; Wändell, 2013). This condition sometime occurs when pregnant mothers suffer vitamin D deficiency or calcium deficiency (Godel, 2007). Such children may be helped if they attend dental clinics for early detection and treatment of the condition. Fermentation products such as lactic acid alters the pH in the saliva as well as the plaque. The acidity of the plaque leading to the drop in the plaque pH below 5.5 then initiates the demineralization process resulting in the tooth decay (Keyes et al., 1963, Miller, 1973,). When the diet content is such that the plaque pH rises beyond this critical value the process of mineral lost from the tooth surface is reversed by re-mineralization process restoring the lost minerals onto the tooth surface. The balance of these two processes actually determines the severity of the caries event. When demineralization outstrips the re- mineralization process then caries event occurs. A sustained fermentation process resulting from continuous supply of sugar substrate tends to drop the plaque pH hence favoring demineralization increasing the risk of caries. Therefore a diet with high sugar content will influence the balance between the demineralization and re-mineralization process in favor of the former. On the other hand diet low in sugars but high in calcium and phosphorus will favor re-mineralization thus protecting the tooth from decay (Reynolds, 2008). Apart from acid production from sugars, fermentable carbohydrates also facilitate the colonization of the tooth surface by plaque bacteria such as streptococcus mutans. The 30 University of Ghana http://ugspace.ug.edu.gh sugars enhance the bacteria overgrowth thus increasing the acid production process in the plaque (Krasse et al., 1967; Van Houte et al, 1976; Minahet et al., 1981). 2.23 Modifiable factors in reducing caries and gum disease risk Since dietary practices as well as the content of the diet has impact on the risk of oral diseases, it is important to identify those modifiable dietary factors to ensure lower risk of the conditions. Plaque formation and resultant caries and gum disease can be avoided with good oral hygiene practices. Twice daily brushing has been recommended at early morning and just before bed. The regular removal of plaque and cleaning of the mouth will be the best preventive measure of risk reduction of caries and gum diseases. The use of fluoride containing pastes or gels has helped to reduce the risk of caries by strengthening the enamel (Clarkson et al., 1993; Stookey et al., 1995). 2.24 Oral bacteria associated with dental caries and periodontal diseases The oral cavity is colonized by several bacteria some of which are involved in oral diseases. The acid producing ones such as streptococcus mutans and lactobacillus species are the commonest bacterial associated with caries (Bradshaw and Marsh, 1994). For a long time it was thought that the presence of these bacteria are the major causes of caries but later studies have demonstrated that there were cases where caries really occurred even in the absence of these bacteria (Bradshaw et al., 2001). Several other acid producing bacteria are involved in the caries process as the product of fermentation increase the acidity of the plaque and hence promote enamel erosion. Some of these other bacteria include streptococcus sanguinis, streptococcus oralis, Neisseria sublava but when streptococcus mutans and lactobacillus species dominate the plaque that caries occurs faster (Bradshaw and Marsh, 1994; Bradshaw et al., 2001, 2002). Colonization of some of the oral bacterial starts even before the eruption of teeth in the mouth of the children 31 University of Ghana http://ugspace.ug.edu.gh (Bockmann et al., 2011). These bacteria are thought to be transmitted from mother to child (Li and Caufield, 1995; Caufield, 1997, Caufield, 2005; Berkowitz, 2006). Possible differences in the infection in the obese and the non-obese may give an indication of significant differences in the oral hygiene practices and status of the two groups. Even though the presence of the bacteria is important for the caries and gum disease to develop, the interplay of substrate availability and oral cleanliness will determine how severe their action will be on the tooth and the gum (Berkowitz, 2006). Apart from acid producing bacteria other bacteria are more associated with gingivitis and periodontitis (gum diseases). These include anctinobacillus, Porphyromonas, Prevotella, Fusobacterium and Treponema species often isolated from periodontal pockets. The commonest often observed are the actinobacillus actinomycetemcomitans and porphyromonas gingivalis (Genco et al., 1988; Moore and Moore, 1994; Socransky et al., 1998). 2.25 The gap in information to be addressed in this study Recent systematic review and meta-analysis by Chaffee and Weston, 2010, revealed an inconsistent association between obesity and periodontal diseases. Almost all of these studies were carried out among adult obese and non-obese populations. In addition all of the studies were carried out outside the African population. The African population is becoming equally susceptible to obesity therefore there is a need to investigate this association among the African populations. It is not certain if there has been any changes in the oral hygiene status of Ghanaian children and if any change had occurred the degree of change that might have occurred, 32 University of Ghana http://ugspace.ug.edu.gh thus, whether it has improved or worsened is not known either. It is also not clear if there is any difference in the caries and gum disease prevalence in the Ghanaian obese and non- obese children. Whether or not there is any association between obese Ghanaian children and oral diseases it is yet to be shown. If any such association exits between child obesity and oral diseases the possible risk factors are not yet known. This child obesity and oral health status study was designed to seek answers to these questions. 33 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 METHODOLOGY The study examined the association between dietary practices and oral health status among obese and non-obese children. It sought to identify factors associated with risk of oral disease in the obese children. The study was carried out first in private schools and later with modification in the design a case-control was used to examine the research question (association between oral health and obesity) among pupils in public schools. 3.1 Phase 1. A survey to examine association between oral health status and obesity status of children in private schools. A cross-sectional design was employed to assess the association between dietary habits and oral health status in obese and non-obese children. Obese children were age-sex marched with normal weight controls to study the association between child obesity and risk of oral health conditions. 3.2 Target Population: Target population was private school children (9 to 15 years) in primary and Junior High School (JHS) schools in the Accra Metropolitan Authority (AMA) Private schools were chosen because of the likelihood of seeing more obese children (Charker and Salameh, 2006). The middle to higher socioeconomic class is more likely to send their children to private schools where the cost of education is relatively higher than the public schools. Since childhood obesity has socioeconomic link it was thought to initially target the private schools. These schools were randomly selected from a list of schools obtained from Ghana Education Service regional office in Accra. 34 University of Ghana http://ugspace.ug.edu.gh 3.3 Sampling of schools Multistage sampling method was used to select schools and respondents. Firstly the schools were sampled by systematic random sampling from a list obtained from Accra Education Office. Eight schools were required from a list of 180 schools. Sample interval of 22 was computed. The number 12 was randomly selected by ballot as the starting point and every 22nd school on the list was selected to make up the number of 8 schools. All the schools selected had more than one stream of classes. In each school two of the streams were selected by balloting. All children in the classes from class 4 -6 and JHS 1 to 3 in the selected streams were screened for their weight status. 3.4 Sample size determination To detect caries prevalence of 15% among children 12-15 years with error margin of 5% and 85% statistical power assuming 95% confidence level, sample estimate required was 418 school children. Assuming 15% no response, a sample size of 480 was determined. A total sample size of 547 participated in the cross-section survey (Fleiss, 1981; Kelsey et al, 1996) (Appendix 8). In all 8 private schools within the Accra Metropolitan Authority (AMA) were randomly selected. 3.4 Cluster sampling design effect The sample size was based on multistage random sampling and was not intended to be a cluster sample. The original sample size based on the random sampling was 418. To account for possible cluster of the children according to classes this figure when multiple by a design effect (DEFF) of 1.3 yields a values of 543 which is completely accounted for with the actual sample size of 547. 35 University of Ghana http://ugspace.ug.edu.gh Statistical power computed even after the findings of caries prevalence still gave a value of 0.79 which is equivalent to acceptable value of 0.8. Hence the study and the sample size used had sufficient power to detect any difference if there was one. 3.6 Recruitment of participants within schools Within each school, children (9-15 years) in the primary classes 4-6 and JHS 1-3 were targeted. All the schools selected had more than one stream of classes. Two of the streams were randomly selected by balloting. All the children in classes 4 to JHS 3 who were present were screened for their weight categories. Their weights, heights and ages were taken and used to compute their BMI-for-Age using WHO AnthroPlus software, 2006. Child obesity was defined as BMI-for-age percentile greater than or equal to 95th percentile (WHO, 2002). Those identified as obese were then included in the study. Their age and sex were matched with the non-obese children in the same class. 36 University of Ghana http://ugspace.ug.edu.gh 3.7 Sampling flow chart Total sample interviewed n=547 Obese Non-obese n=219 n=291 Plaque sample Plaque sample collected for oral collected for oral microbial culture microbial culture n=75 n=75 Figure 2.1. Recruitment statistics 3.8 Parental consent A letter explaining the objective of the study was sent by the selected child to the parents. The letter had a section where parents gave consent for the child to participate in the study. Children who had parental consent, expressed willingness to participate and both parents and the child gave written consent were included in the study. Children who did not bring back signed consent forms from their parents were excluded from the study. They were then replaced by other children of the same age and sex in the same school. 37 University of Ghana http://ugspace.ug.edu.gh 3.9 Research instrument: Structured questionnaire was used to collect information on demographic data, oral hygiene habits, and oral health practices among the Ghanaian school children. Food frequency questionnaire was used to collect dietary intake information. Physical activity data was assessed using structured questionnaires. All questionnaires were administered to the subjects individually. Information on household demographic and socioeconomic data were obtained from the children. All measurements on the children were taken at the school. 3.10 Background data collection A structured questionnaire was used to collect background information on household socioeconomic and demographic variables (e.g. educational level of parents, tenancy status, occupation, relevant household possessions). Other sections of the questionnaire that covered child eating habits and physical activity were filled at the school with the assistance of research assistants. Dietary intake was assessed using food frequency questionnaire that referred to intakes in the past 24 hours and past one week. 3.11 Anthropometric measurements All measurements were taken with the subjects wearing their usual school clothing. Body weight was measured using Seca 782 (Humberg, Germany,) weighing scale. Subjects were asked to remove heavy clothing and objects (shoes belts, jewelry etc). Their wrists watches were removed and they were made to empty their pockets prior to the measurement. The height of the subjects was measured using Seca stadiometer 213 (Humberg, Germany). The waist and hip circumferences was measured using a Seca special tape that also estimates the waist hip ratio. Mid-upper arm circumference (MUAC) was also measured with a Seca MUAC tape. 38 University of Ghana http://ugspace.ug.edu.gh 3.12 Assessment and classification of Obesity BMI-for-age and sex percentile was used to determine weight categories for the children. BMI-for-age-sex between 85th and 95th percentile was classified overweight and 95th percentile and above were classified obese (WHO, 2002). 3.13 Age-sex matched control group All children who were within the ages of 9-15 in each selected class in the school were screened for obesity. This was done by taking their weight and height to compute their BMI. In each class the children were further stratified into obese and non-obese based on BMI-age-sex percentile. Those with BMI-for-age-sex 95th percentile or more were classified as obese. All the obese children whose parents gave consent were included in the study. The obese children were then age-sex matched with the non-obese children. For each obese child the age-sex matched control was randomly selected by ballot from the same class. The number of non-obese children of the same age and sex as the obese child was listed. They were either two, three or four. Since a match for each obese child is required number of ballot papers were presented to the non-obese children. The ballot papers contained one marked with YES and the others marked with NO. Any non-obese child who picked the YES marked ballot paper was chosen to match with the obese for that particular age and sex. 3.14 Oral examination to ascertain caries and gum disease status Oral examination was carried out on all respondents who returned their consent form. A total of 510 agreed to undergo the oral examination. Oral health conditions such as decay, missing and filled teeth (DMFT), gingivitis (inflammation of gum), periodontitis, (loss of attachment of gum from teeth). Gum sores, Plaque and calculus score, Community 39 University of Ghana http://ugspace.ug.edu.gh Periodontal Index of Treatment Needs (CPITN) score were determined on index teeth as recommended by WHO oral health guidelines (Clerehugh et al, 2001). Silness and Lӧe plaque index was used to determine overall oral hygiene status. The values range form 0 to 3; 0 means excellent oral hygiene and 3 means very poor oral hygiene. Higher mean values of Silness and Loe index indicate poorer oral hygiene status. Examination was done in day light using mouth mirrors. The examination was done by Dental surgeons. Prior to doing the dental examination, the dental surgeons were standardized to ensure consistency in their diagnosis. 3.15 Standardization of examiners Ten school children chosen from a non-participating school were examined by the two dental surgeons. The children were examined for caries and gum disease. The agreement measure Kappa between the two dental surgeons was 0.95 for caries diagnosis and 0.89 for gum disease diagnosis. To ensure consistent diagnosis, as the study progressed, at each school the first two children who were selected each morning were examined by the two surgeons and results compared before the examination continued. The screening for periodontal disease involved assessing index teeth; Upper right 6 (UR6), Upper right 1 (UR1), Upper left 6 (UL6), Lower left 6 (LL6), Lower left 1 ( LL1) and Lower right 6 (LR6), (Appendix 1) using a WHO 621 probe with a 0.5 mm ball end and black band at 3.5 to 5.5 mm using BPE codes 0-2 in 9- to 11-year-olds and the full range of codes 0, 1, 2, 3, 4 in 12- to 15-year-olds. (Ramfjord, 1967; Clerehugh et al., 2001). Each sextant was designated as either; healthy (Score 0), bleeding but no dental calculus detected (Score 1), calculus detected but no pockets (Score 2), a probing depth of more 40 University of Ghana http://ugspace.ug.edu.gh than 4 mm (Score 3) or a probing depth of more than 6 mm (Score 4). The highest score for the sextants was recorded as the CPITN score for the participant. CPITN score, average depth and gingival bleeding (rate of bleeding of gums) was used to determine severity of periodontal disease (Koichi et al., 2006). Some other oral symptoms assessed included, bad breath, red or swollen gums, tender or bleeding gums, painful chewing, loose teeth and sensitive teeth. 3.16 Assessment of oral hygiene To assess oral hygiene status, Silness and Loe Plaque Index was used which employs probing of index teeth on four surfaces, buccal, mesial, lingual and distal surfaces. Each surface is given a value ranging from 0 to 3. The mean value of the four surfaces for each tooth and the overall means for all the teeth probed becomes the plaque score for the child. The higher the Score the poorer the oral hygiene status in the child. The gum was assessed for gingivitis and the individual score was expressed as the mean score of the examined teeth (Löe, 1967; WHO, 1997). 3.17 Collection of oral plaque for specific bacteria examination A sub-sample of 150 school children (75 Obese and 75 non-obese) with visible plaque were randomly selected for oral microbial examination. Plaque sample could only be collected from those who had plaque at the time of the collection. Most of the school children at the time of collection had only barely visible plaque hence could not be included in the sample collection. A sterile curette was used to take plaque samples and placed in sterile broth for microbial culturing for the presence of specific bacteria associated with caries and periodontal disease. The specimen was collected using 41 University of Ghana http://ugspace.ug.edu.gh anaerobic jar to preserve the anaerobic species. Microbial culture was done at the microbiological laboratory of the Ghana Medical School. The plaque samples were cultured for streptococcus mutans, lactobacillus species, actinobacillus actinomycetemcomatans and porphyromonas gingivalis. 3.18 Specific culture media for the various micro-organisms To determine the prevalence of the infections of the various bacteria of interest, specific culture media were used for each. Mitis-Salivarius-Bacitracin (MSB) and mitis-salivarius agar; (MSA) non-mutans streptococci (non-MS) and Trypticase yeast extract-salts agar were used (Tanzer et al., 1984; Schaeken et al., 1986 ; Gutiérrez et al., 1997; ). Polymerase chain reaction (PCR) method could also be used but that would be appropriate if the interest was in specific DNA subspecies of the bacteria. 3.19 Sample collection and preparation for culturing Plaque sample was collected from 75 obese and 75 non-obese children directly into sterile broth. The specimens were pre-enriched in thioglycolate broth for 48 hours at 37oC. Streptococcus mutans and Lactobacillus species were recovered after subculturing the broths onto selective agar, Mitis Salivanus Bacitracin (MSB) and Man Rogosa Sharpe (MRS) plates respectively, under anaerobic conditions at 37oC (Gutiérrez et al., 1997). The isolates were identified using Gram morphology and catalase activity (Wyder et al., 2011; Raemy, 2013). 42 University of Ghana http://ugspace.ug.edu.gh 3.20 Data Analysis Data were captured using MS Access database 2010. Cleaned data were analyzed using SPSS version 20. Continuous numeric variables were summarized as means and standard deviations while categorical data were summarized by frequency and percentages. T-test and ANOVA were used to compare differences in the means of the two groups and significance level set at alpha (α) = 0.05. Pearson’s Chi-square test was used to compare proportions and test for association between categorical variables and between obese and control groups of all relevant variables. Mantel-Haenszel chi-square test was also done to compare the proportions among various factors. Logistic regression was used to establish possible associations between various factors and the disease outcome. Odds ratios and their 95% confidence intervals were computed to identify significant factors involved in the oral diseases. Variables that are known to be associated with oral disease and nutritional status were included in a logistic model to assess their overall significance. The odds ratio values give indication of effect measures for each factor in the model. 3.21 Ethical consideration The proposal was submitted to the Institutional Review Board of Noguchi Memorial Institute for Medical Research (NMIR) for approval before the start of the study. Ethical clearance was given on 24th July 2010. A written consent form explaining the study to the child and the parent or guardian was signed by parents and children before study was carried out. Permission was sought from Ghana Education service and then from the selected district education offices, school heads and School Health Education Programme (SHEP) office. 43 University of Ghana http://ugspace.ug.edu.gh 3.22 Phase 2. Association between oral health status and obesity in public schools The result from the study on the private school children did not establish significant association between obesity and oral diseases. Possible reasons for this finding was the low prevalence of oral diseases in the population studied and the good oral hygiene status of the children. Significant proportion of the obese parents were concerned about the intake of soft drinks in the children. This may imply high level of parent’s attention on the child’s snacking and oral hygiene habits. In addition the higher socioeconomic status of these parents may have offered the children better access to oral and dental care. To evaluate the possible effect of socioeconomic status of the children on the association between obesity and oral conditions, a phase 2 study was carried out among public school children. Most public schools are attended by children from low socioeconomic status. The phase 2 study involved 5 randomly selected public schools in Accra. Out of a list of 320, five schools were selected after a systematic sampling procedure based on sample interval of 65. The number 25 was randomly selected as the starting point, and then every 65th school on the list was chosen. In this second phase case control design was used since obesity prevalence among the public schools was expected to be very low. The school children were first screened for caries (infection of the hard tissue) and gum disease (infection of the soft tissues of the mouth). In each selected school all children from class 4 – JHS 3 present at the time of the study were screened for either caries or any gum disease. A total of 493 school children were examined of which 210 children with either caries or gum disease were identified and 283 children without oral diseases were selected from the same classes. 44 University of Ghana http://ugspace.ug.edu.gh A case was defined as a child with caries or gum disease (i.e., DMFT score greater than 0 and Gingival index (GI) greater than 0) and the control was defined as a child in the same class but without any gum disease or caries thus, DMFT=0 and/or GI=0. The weights, heights, ages and sexes of all respondents were recorded. These were used to classify them into normal weight, overweight and obese categories by computing their BMI for age and sex. BMI for age percentile of below 85% was classified normal weight, 85% - <95% was classified as overweight and 95% and above was classified obese. Weight categories were then compared between cases and controls. Dietary and oral hygiene practices among the two groups and within obese and non-obese were also compared. For the second phase ethical review was sought for the modification of the study design to permit the study to be done among public school children using a case control (child with caries or/and gum disease) and control (child without oral disease) design. The request was approved by NMIMR. Parental and child’s written consents were sought. Dietary and oral hygiene assessment were done as in the first phase using the same questionnaire. Oral examination was then carried out by two calibrated dental surgeon as before. DMFT score, Plaque and Calculus Index as well as Gingival index were used to estimate caries and gum infection among the children. Silness and Lӧe score was estimated for overall oral hygiene status assessment. 45 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 RESULTS The results as shown below present the comparison of the factors that are likely to influence the association between obesity and oral disease outcomes in the obese and the non-obese groups. These included the dietary factors, oral hygiene factors (habit and status) and oral bacterial infections. These factors were compared between the obese and the non-obese groups. The significance of the association between obesity and the oral disease in the children was then tested. 4.1 Demographic Characteristics of private school children studied. The demographic characteristics of the private school children studied are shown in Table 4.1. The categories of children (obese and non-obese) had similar background characteristics. There were no significant differences in sex distribution. Both groups had parents with similar educational level and socioeconomic backgrounds. However obese children were significantly more likely to come from homes with air conditions and homes owned by their families than the non-obese children. Obese and non-obese families had similar mean number of children. Similar proportions of obese and non-obese children were living with both parents just as those living with only single parents. Parental educational levels was high for both the obese and non-obese children with more than half of the obese mothers having tertiary education as against 45% of the non-obese school children. The mean age of respondents was 11.49 ±1.67 years. 46 University of Ghana http://ugspace.ug.edu.gh Table 4.1, Background characteristics of the school children Characteristics Obese* Non-obese Overall p-value n (%) n (%) n (%) Sex Male 94 (40.3) 141 (44.9) 235 (43.0) 0.287 Female 139 (59.7) 173 (55.1) 312 (57.0) Total 233 (43.6) 314 (57.4) 547 (100) Age groups (yrs) 9-11 136 (58.4) 159 (50.6) 295 (53.9) 0.121 12** 40 (17.2) 54 (17.2) 94 (17.2) 13-15 57 (24.5) 101 (32.2) 158 (28.9) Class 233 233 Primary 150 (64.7) 168 (58.2) 318 (58.2) 0.009 JHS 82 (35.2) 146 (46.5) 229 (41.8) Living situation Living with both parents 172 (77.8) 219 (70.6) 391(66.9) 0.301 Living with single parent 36 (15.6) 55 (17.7) 91 (16.6) Living with guardians 22 (9.6) 36 (11.6) 58 (10.7) High Socioeconomic status indicators of parents Air condition at home 96 (41.21) 94 (30.0) 190 (34.8) <0.001 Owned home 117 (50.4) 120 (38.2) 237(43.4) <0.001 Mean no. of children at home 3.65 ±2.02 3.69 ±1.72 3.67 ±1.850 0.784 Mean age of respondents 11.30 ±1.53 11.64 ±1.74 11.49 ±1.67 0.109 *BMI-age-sex >= 95th percentile. **12 yr olds are used for caries prevalence among school children according to WHO recommendation (WHO, 2002) 47 University of Ghana http://ugspace.ug.edu.gh 4.2 ASSOCIATION BETWEEN DIETARY HABITS AND ORAL HEALTH PRACTICES OF OBESE AND NON-OBESE CHILDREN Comparison of dietary habits between obese and non-obese children is presented in Table 4.2. The dietary habits of the two groups were similar except the forms of vitamin and minerals used and amount of pocket money given to children for food. While higher proportions of the non-obese were more likely to use vitamins and mineral supplements the obese children were more likely to be given more pocket money for food at school. Over 90% of the children ate at least three times a day and this was expected for the school children. Only about a third of the school children reported eating breakfast before start of school. In addition about half of the children reported getting food from roadside venders. Less than 10% of the children ate at school canteen. Examining the favourite meal time of the students supper meals were the most preferred by the school children followed by lunch time meal and then breakfast. This may explain the low breakfast intake among the school children. These favorite meal times were equally expressed by the obese and the non-obese. 48 University of Ghana http://ugspace.ug.edu.gh Table 4.2, Dietary habit among obese and non-obese children Dietary habits Obese=233 Non-obese=314 Overall P-value n(%) n(%) n(%) Daily frequency of eating Twice 12 (5.2) 24 (7.6) 36 (6.6) Thrice 130 (55.8) 159 (50.6) 289 (52.8) 0.583 More than three times 91 (40.1) 131 (41.7) 183 (40.6) Places meals were taken Home 231 (99.1) 297 (94.6) 528 (96.5) School canteen 19 (8.2) 36 (11.5) 55 (10.1) Restaurant 56 (24.0) 85 (27.1) 141 (25.8) 0.544 Road-side vendor 133 (57.1) 143 (45.5) 276 (50.5) Chop bar or local restaurant 184 (79.0) 246 (78.3) 430 (78.6) Breakfast intake before school 71 (30.5) 95 (30.3) 166 (30.3) 0.953 Frequency of breakfast intake Always 54 (23.2) 82(26.2) 136 (24.9) Very often 18 (7.7) 16 (5.1) 34 (6.2) Sometimes 113 (48.5) 164 (52.4) 277 (50.6) 0.076 Rarely 16 (6.9) 28 (8.9) 44 (8.0) Never 32 (13.7) 23 (7.3) 56 (10.3) Money for school food No money given 5 (2.2) 12 (3.8) 17 (3.1) Less 1 GHS 15 (6.9) 57 (18.2) 73 (10.0) 1-2 GHS 129 (55.6) 147 (46.8) 276 (50.5) 0.001 >2 GHS 82 (35.2) 98 (31.2) 180 (33.0) Use of vitamins and minerals 197 (84.5) 266 (85.0) 460 (84.1) 0.471 Forms of vitamin and mineral used Multivitamin tablets 52 (46.4) 60 (53.6) 112 (20.5) 0.0028 Mineral (Fe, Ca) tablets 22 (33.8) 43 (66.2) 65 (11.9) Vitamin and minerals syrups 135 (48.0) 146 (52.0) 281 (51.4) Blood tonic 59 (32.2) 124 (67.8) 183 (33.5) Other 0 (0.0) 5 (100) 5 (0.9) Favorite meal time Breakfast 32 (13.7) 51 (16.2) 15.2 Lunch 76 (32.6) 78 (24.8) 28.2 Supper 101 (43.3) 135 (43.0) 43.1 0.127 Snacks 15 (6.4) 36 (11.5) 9.3 Other 9 (3.9) 14 (4.5) 4.2 49 University of Ghana http://ugspace.ug.edu.gh 4.3 Meal time skipped by school children Skipping of meals may be typical of children and the meal time skipped by the children is shown in Figure 4.1. Breakfast was the commonest meal time skipped by the children. This is likely to influence eating habit later in the day. Lunch and supper were skipped to the same extent and less than 20% of the children did so. The level of skipping of meals was comparable between the obese and the non-obese children. Figure 4.1 Meal times skipped by respondents 39.1 40 36 37.3 Obese 35 Non-obese 30 25 Over all 18.8 18.9 20 18.2 18.1 16.3 15.7 15 12.9 13.1 13.4 11.5 9.4 10 10 5 1.7 1.2 0.6 0 Meals skipped 4.4 Reasons for skipping meal time Reasons for skipping meals are reported in Table 4.2.1. The major reasons given were lack of time, not feeling hungry and the dislike of the food. Only few of the children disliked 50 Percent of respondents University of Ghana http://ugspace.ug.edu.gh the breakfast foods. Similar reasons were given for the skipping of meals by both the obese and the non-obese children. p=0.543. Table 4.2.1, Reasons for skipping meals RESPONDENTS CATEGORY OBESE NON OBESE REASONS n=217 n= 303 TOTAL n(%) n(%) n(%) Lack of time 87 (40.1) 114 (37.0) 201 (38.7) Not hungry 76 (35.0) 109 (36.0) 185 (35.6) Dislike food 10 (4.6) 23 (7.6) 33 (6.3) Inadequate food 5 (2.3) 6(2.0) 11 (2.1) Other reasons 9 (4.1) 5 (1.6) 15 (2.9) Total 217 (100) 303 (100) 520 (100) p>0.05 4.5 Snacking habits among the school children Snacking habits included the place where the children took their snacks, types of snacks consumed and the frequency of snacking are shown in Table 4.3. A snacking score was calculated by summing up the different snack foods consumed in a week (Kant et al., 1993, Fernandez et al., 1996). The mean snacking score between obese and non-obese children was not significantly different. Both obese and non-obese children showed similar snacking habits. The obese were significantly more likely to take more raw fruits than the non-obese (p=0.042). While parents of the obese children expressed some concerns about their children taking soft drinks, the parents of the non-obese children might consider it to be okay for their children to drink soft drinks. Significantly more parents of obese children (20.2%) than non-obese (9.3%) children, expressed concern about their children’s intake of soft drinks, p=0.0001. Snacking was mostly done at school than at home. Nuts were the least consumed snacks among the two groups of children. Availability of soft drinks at home, ease of access to soft drink as well as how they felt when they drank soft drink were all similar between the obese and the non-obese groups (Table 4.3) 51 University of Ghana http://ugspace.ug.edu.gh Table 4.3, Snacking habits among obese and non-obese children Obese Non-obese Overall P-value N=233 n-313 Snacking n(%) n(%) n(%) Home snacking 102 (43.8) 155 (49.5) 257 (47.1) 0.184 School Snacking 139 (59.9) 209 (66.8) 348 (63.9) 0.099 Types of snacks Raw fruits 77 (33.3) 79 (25.3) 156 (28.7) 0.041 Fruit drinks 132 (57.1) 161 (51.6) 293 (54.0) 0.200 Sweets 57 (24.7) 99 (31.7) 156 (28.7) 0.072 Biscuit and cakes 111 (48.1) 157 (50.3) 268 (49.4) 0.601 Soft drink 115 (49.8) 144 (46.2) 259 (47.7) 0.402 Nuts 17 (7.4) 13 (4.2) 30 (5.6) 0.109 *Types of snacks mean score (total number of various snacks consumed in a week) 2.2 (1.5) 2.1 (1.4) 2.1 (1.4) 0.399 Frequency of snacking Days per week of snacking 3.6 (2.0) 3.8 (2.1) 3.7 (2.1) 0.358 Average daily snacking 1.10 (0.41) 1.17 (0.43) 1.14 (0.42) 0.478 Frequency of buying snacks 1.81 (1.64) 1.91 (1.74) 1.89 (1.70) 0.684 Weekly intake of soft drink 3.03 (2.31) 3.12 (2.37) 3.08 (2.34) 0.627 Average unit of soft drink per day 2.04 (1.99) 1.92 (1.97) 1.97 (1.98) 0.480 Availability and motivation for snacking on soft drinks Usually get soft drink at home 142 (60.9) 189 (60.4) 332 (60.6) 0.501 Ease of accessing soft drink With ease 165 (70.8) 235 (75.1) 400 (73.3) With some difficulty 68 (29.2) 78 (24.9) 146 (26.7) 0.265 Feeling after drinking a soft drink Feel Good 197 (87.2) 268 (85.9) 465 (86.5) Feel Normal 25 (11.1) 38 (12.2) 63 (11.7) 0.969 Feel bad 4 (1.8) 6 (1.9) 10 (1.8) Parent response when child drinks soft drink Good (Showed approval) 112 (48.1) 202 (64.8) 314 (57.6) Normal (felt normal) 74 (31.8) 81 (26.0) 155 (28.4) <0.001 Bad (expressed concern) 47 (20.2) 29 (9.3) 76 (14.0) *Number of different types of snacks consumed in a week 4.6 Snacking during Television watching Snacking during television watching is common among children and this is thought to influence the snacking and oral habits of children. Frequency and types of snacks 52 University of Ghana http://ugspace.ug.edu.gh consumed by the children during the period of watching TV is reported in Table 4.4. The result showed that four out of every five children indicated that they snacked during TV watching. Though about halve of the children do snack, it was not a frequent practice as less than 10% said they often do so. This may have very little impact on risk of oral conditions. Soft drinks, Pastries and raw fruits were the most commonly consumed snacks during TV watching. While more of the obese tend to choose pastries and natural fruit juices, more of the non-obese seem to choose raw fruits and fruit drinks. However these differences were not significant. Table 4.4, Frequency and type of snacks during TV watching among obese and non- obese children Obese Non-obese Overall P-value Level and frequency n (%) n (%) n (%) Snacking during TV watching 175 (75.1) 242 (77.8) 417 (76.7) 0.460 Frequency of snacking while watching TV (single response) Always 15 (6.5) 24 (7.7) 39 (7.2) Often 13 (5.6) 14 (4.5) 27 (5.0) Sometimes 118 (51.1) 180 (58.1) 298 (55.1) 0.230 Rarely 34 (14.7) 30 (9.7) 64 (11.8) Never 51 (22.1) 62 (20.0) 113 (20.9) Types of snacks consumed (multiple response) Pastries (cakes, biscuit) 72 (22.6) 85 (17.9) 157 (19.8) soft drinks 88 (27.6) 130 (27.4) 218 (27.5) Raw fruits 54 (16.9) 88 (18.6) 142 (17.9) 0.238 Fruit drinks 46 (14.4) 90 (19.0) 136 (17.2) Natural fruit juice 50 (15.7) 61 (12.9) 111 (14.0) Other (nuts) 9 (2.8) 20 (4.2) 29 (3.7) 4.7 Weekly frequency of consumption and 24 hour foods consumed by Obese and non-obese The types of foods consumed in the previous 24 hours were recorded and compared between the obese and the non-obese groups (Table 4.5). 53 University of Ghana http://ugspace.ug.edu.gh For the mean weekly frequency of consumption, fruit juices, evaporated milk, milk drinks, pizzas were all significantly higher among the obese than the non-obese, but corned beef and watermelon were higher in the non-obese than the obese children, For the foods consumed in the past 24hrs, only fruit juices and evaporated milk showed significantly higher proportions among the obese than the non-obese. Table 4.5 Mean consumption of selected food items by school children in private schools Mean weekly frequency Food item Obese Non-obese p- value mean SD mean SD Fruit juice 0.9 1.4 0.6 1.1 0.001 Evaporated milk 1.7 2.4 1.3 2.0 0.035 Milk drink 0.9 1.6 0.6 1.2 0.035 Pizzas 0.7 1.5 0.4 1.0 0.007 Corned beef 0.6 1.2 0.9 1.4 0.009 Watermelon 0.5 1.1 0.8 1.5 0.010 * Significant Food Obese Non-obese Over all consumed in the past 24 n(%) n(%) n(%) p-value Fruit juices 64(27.5) 61(19.5) 125 (22.9) 0.028 Evaporated milk 99(42.5) 104(33.3) 203(37.2) 0.023 There were 59 food items that were studies and only those with significant means frequencies differences are reported in this table. *Most of the foods consumed in the past 24hrs when compared between the obese and the non-obese did not show significance except these two food items. The results of the other foods are presented in appendix 9 4.8 Consumption of food groups (categories) among the obese and non-obese There were no significant differences among the two categories of children regarding the consumption of foods from the various food groups (Table 4.6). The results therefore described the general consumption patterns among all the children combined. Weekly frequency was comparable between the two groups. 54 University of Ghana http://ugspace.ug.edu.gh Table 4.6 Mean weekly frequency of consumption of various food groups between obese and non-obese children Mean weekly frequency of consumption Obese, Non-obese, Food groups n=233 n=314 P-value mean±SD mean±SD Cereals 14.9 ±12.6 13.6 ±9.6 0.157 Protein 12.3±11.1 11.4 ±8.5 0.295 Fruits 8.2±9.7 7.4±8.7 0.304 Pastries 8.4± 7.0 9.1±6.7 0.298 Milk Products 7.7±7.2 6.9±6.5 0.171 Soft drinks 4.1±4.3 4.1±3.8 0.104 4.9 Physical activities of school children Table 4.7 presents the results on activities the children engaged in before setting out for school. Significant proportions of the non-obese children walked to school more often than the obese. The commonest house chores before school among the children were sweeping of compound or rooms and washing of plates. Obese children were significantly more likely to be driven to school than non-obese children. None of the other activities (wake up time, household chores, TV watching) were significantly different among the two groups. 55 University of Ghana http://ugspace.ug.edu.gh Table 4.7, Physical activities among obese and non-obese children in private schools Obese Non-obese Overall P-value (n=233) (n=314) (n=547) Physical activities(single response) n(%) n (%) n (%) Walking to school 57 (24.5) 127 (40.6) 184 (33.7) Driven to school by parents 105 (45.1) 86 (27.5) 191 (35.0) Public transport 38 (16.3) 67 (21.4) 105 (19.2) 0.001 Other means of transport (cycling, motor) 33 (14.2) 33 (10.5) 66 ( 10.1) Wake up time Before 5.00 am 108 (46.4) 144 (45.9) 252 (46.1) 0.897 Between 5-6.00 am 106 (45.5) 146 (46.5) 252 (46.1) Between 6- 7.00 am 19 (8.1) 24 (7.6) 43 (7.8) Types of house chores before school Sweep compound/ rooms 105 (45.1) 152 (48.4) 257 (47.0) Washing plates 37 (15.9) 54 (17.2) 91 (16.6) prepare breakfast 24 (10.3) 27 (8.6) 51 (9.3) 0.223 Feed pet 14 (6.0) 14 (4.5) 28 (5.1) Wash baby nappies 0 (0.0) 3 (1.0) 3 (0.5) None 86 (36.9) 103 (32.8) 189 (34.6) TV watching before school 49(21) 53(17) 102(18.6) 0.257 Daily TV watching 164(70.7) 211 (67.4) 375(68.8) 0.414 1-2 hrs. TV daily 83(37.2) 117(38.9) 200(45.2) 0.457 Computer/Video games 111(47.6) 138(44.4) 249 (45.8) 0.449 Play video game daily 18(8.4) 24(8.2) 42(8.3) 0.287 1-2 hrs. of video games per day 78(37.7) 92(31.5) 170(34.0) 0.546 4.10 Oral hygiene habits and oral health status among the obese and non-obese children from private schools Oral hygiene habits among obese and non-obese children are reported in Table 4.8. This included the time and frequency of mouth cleaning as well as the cleaning materials used. Both obese and the non-obese children had similar oral hygiene habits. Morning brushing with toothpaste was the usual oral hygiene habit of both groups of children. Floss knowledge and use were very low among the children. 56 University of Ghana http://ugspace.ug.edu.gh Nearly all the children brush their teeth in the morning and less than half of them brush at night before bed. These proportions were similar for both the obese and the non-obese groups. About 50% of the children brushed once a day while lower proportion brush twice a day. Concerning the materials for mouth cleaning, over 90% used tooth brush and tooth paste and 6% used other materials such as chewing sponge and chewing stick. The knowledge and use of floss was low (20%). About 60% of the children use toothpick. These oral hygiene habits were similar in both obese and non-obese children. Table 4.8, Oral hygiene habits among obese and non-obese children Obese Non-obese Overall P-value Oral hygiene habits n(%) n(%) n (%) Morning brushing 226 (97.0) 300 (95.5) 526 (96.2) 0.381 Night brushing 105 (45.1) 126 (42.2) 231 (42.2) 0.248 Frequency of brushing Brush once a day 116 (50.4) 163 (52.6) 279 (51.7) 0.622 Brush more than once a day 114 (49.6) 147 (47.4) 261 (48.3) Tooth cleaning materials Toothpaste and brush 219 (94.0) 296 (94.3) 515 (94.1) Other materials (Chewing 0.899 stick/sponge. etc) 14 (6.0) 18 (5.7) 32 (5.9) Knowledge of floss 36 (15.5) 36 (13.0) 76 (13.9) 0.414 Floss use 15 (17.2) 16 (19.8) 31 (3.7) 0.676 Use of tooth pick 145 (62.2) 185 (59.1) 331 (60.4) 0.847 4.11 Dental visit and reported history of oral conditions Visit to the dental clinic and conditions reported to the clinic as well as history of oral conditions are shown in Table 4.9. About 30%of the children have ever visited a dental clinic. Of all those who went to see the dentist, 98% had some oral infections. This was similar for the obese and the non-obese children. The result also showed that apart from halitosis (bad breath) both the obese and the non- obese children reported similar history of oral conditions. However, a significantly higher 57 University of Ghana http://ugspace.ug.edu.gh proportion of the obese children (42.5%) reported having had bad breath than the non- obese children (34%). Table 4.9, Dental visit and reported history of oral conditions Oral condition ever Obese No-obese Total p-value experienced n (%) n (%) n (%) Dental visit 74 (31.9) 90 (28.9) 164 (30.2) 0.458 Reported with oral 73 (98.6) 86 (98.9) 159 (98.8) 0.908 condition History of Oral conditions Bad breath 99 (42.5) 105 (33.7) 207 (37.4) 0.028 (halitosis) Gum bleeding 94 (40.3) 154 (49.5) 287 (45.6) 0.102 Painful chewing 142 (60.9) 189 (60.6) 331 (60.7) 0.774 Sensitive tooth 151 (64.8) 205 (65.9) 356 (65.4) 0.444 Loss of teeth 142 (60.9) 181 (57.8) 332 (59.2) 0.417 4.12 Oral hygiene status of the children Plaque and calculus index which define the oral hygiene status and Gingival index (GI) which estimates gum health were compared between the obese and the non-obese (Table 4.10). Proportions of children who had barely visible plaque and those with abundant plaque at the gingival margins were similar in both groups of children. Just about 5% of children had no plaque in the mouth. Supra gingival calculus was the common type of calculus. Sub-gingival calculus was seen in only 0.5% of the obese and 2.4% in the non-obese children. None of the oral hygiene indices showed any significant difference between the two groups. The Mean Silness and LÖe PI value of 1.38 for the obese as against 1.43 for 58 University of Ghana http://ugspace.ug.edu.gh the non-obese suggests a slightly improved oral hygiene status in the obese than the non- obese though this did not prove significant. For the gum health, over 80% had healthy gum as denoted by GI value of 0. GI of 1 implies shiny, slightly red and swollen gum, a sign of mild gum infection. This was observed in only 10% of all the children examined. It was 8.2% in the obese and 11.3% in the non- obese. Moderate to severe gum conditions were observed as marked reddening, obviously enlarged, swollen with exudates, (GI of 2), was found in only 2% of all the children observed. Those with severe gum condition will often show clinical attachment lost which was measured by CPITN score. The gum conditions showed no significant difference between the obese and the non-obese children. 59 University of Ghana http://ugspace.ug.edu.gh Table 4.10, Oral hygiene Status among obese and non-obese school children Oral hygiene indicators Obese Non-obese Total p-value n(%) n(%) n(%) Plaque score 0 = No plaque, 5 (2.3) 16 (5.5) 21 (4.1) 1 = Barely visible plaque 113 (51.6) 141 (48.5) 254(49.8) 0.184 2 = Abundant at gingival margin 101 (46.1) 134 (46.0) 235 (46.1) Calculus score 0= No calculus 61 (27.9) 81 (27.8) 142 (27.8) 1= Supra gingival 157 (71.7) 203 (69.8) 360 (70.6) 0.334 2= Subgingival heavy unilateral 1 (0.5) 7 (2.4) 8 (4.0) Gingival score 0 = Pink, firm, stippled and no exudates (normal) 197 (90.0) 252 (86.6) 449 (88.0) 1 = Shiny, slightly red and 0.494 swollen (moderate infection) 18 (8.2) 33 (11.3) 51 (10.0) 2 = Marked reddening, obviously enlarged, swollen with exudates 4 (1.8) 6 (2.1) 10 (2.0) *Mean Silness and LÖe PI 1.38 ±.34 1.43 ±0.36 1.43 ±0.36 0.066 *Mean Silness and Loe Plaque index is the measure of overall oral hygiene status of the mouth. It scores the level of plaque and calculus and gives it oral hygiene score with values ranging from 0 to 3. The mean score on four tooth surfaces (buccal, lingual, mesial and distal) are computed for all six index teeth as the mean Silness and Loe plaque index for the respondent. 4.13 Prevalence of caries and gum (periodontal) diseases by child nutritional status Oral disease results are reported in Table 4.11. Similar prevalence of caries was observed in obese as the non-obese. But among the twelve year olds, caries prevalence in the obese was about twice the prevalence among the non-obese but did not show statistical significance. Prevalence of caries and gum disease in the whole sample was 19.2%. 60 University of Ghana http://ugspace.ug.edu.gh Mean DMFT score was 0.296 in the non-obese and 0.214 in the obese children. This difference was not significant. The overall mean DMFT score was 0.261. Gum disease was 5.5% in the non-obese and 3.7% in the obese group and this also did not show significance and the overall prevalence was 4.7%. The overall oral disease prevalence was determined by prevalence of both caries and gum diseases since they are oral infections. Caries is an infection of the hard tissue while gum disease is an infection of the soft tissue. The oral condition was not significantly different between the obese and the non-obese groups. Table 4.11, Oral health status (Prevalence of caries, gum disease and mean DMFT, N= 510) Oral condition Obese Non-obese Total p-value N (%) N (%) N (%) Overall Caries 33 (14.9) 44 (15.1) 77 (15.1) 0.991 prevalence Caries in the 12yr 6(15.4) 4(8.2) 10 (11.4) 0.289 olds** Mean DMFT* score 0.215 ±0 .602 0.296 ±0.836 0.261 ± 0.745 0.225 Gum Disease 8 (3.7) 16 (5.5) 24 (4.7) 0.330 Overall Oral health# 40 (18.3) 58 (19.9) 98 (19.2) 0.636 status *DMFT – Decayed, Missing and Filled Teeth; ** Caries in 12 olds is used as prevalence of caries for the young population (WHO, 2002) # Number of people who had either caries or gum disease or both 4.14 Oral cleaning habits and caries experience in obese and non-obese groups The influence of oral cleaning habits on caries prevalence was assessed and the result shown in Table 4.12. Morning and night brushing did not prove any significant association with caries prevalence in the two respondent categories. Also twice daily brushing against once daily brushing showed no significant reduction in caries prevalence. 61 University of Ghana http://ugspace.ug.edu.gh Table 4.12, Oral cleaning habits and prevalence of caries in the two groups Caries prevalence Obese Non-obese Overall P-value OR*(CI) Oral hygiene habits N (%) N (%) N (%) Morning brushing 32 (15.0) 44 (15.8) 74(15.4) 0.820 1.75 (0.81-3.83) (reference cell) Night brushing 11(11.2) 18 (15.5) 29(13.4) 0.327 Frequency of brushing Brush once a day 0.152 (reference cell) 22(18.2) 26(14.8) 48 (16.5) 0.934(0.49 -1.79) Brush more than once a day 11(11.2) 18(15.7) 29(13.5) 0.858 *The reference cells for the odd ratios are the Morning brushing and once brushing which were the most common practices 4.14 Other oral hygiene practices and their influence on caries experience The result of other forms of oral hygiene practices and their association with caries prevalence among the obese and non-obese groups are reported in Table 4.13. Among the obese children caries prevalence among those who clean their mouth with tooth brush and toothpaste had half caries prevalence of those who brush with other materials. The caries prevalence among the non-obese children who clean their mouth with brush and toothpaste had lower prevalence than those who use other cleaning materials, however this difference was not significant. Toothpick use did not show any significant association with caries prevalence among the obese and the non-obese groups. Neither floss knowledge nor its use showed any association with caries prevalence among the obese and the non-obese. However, dental visit showed some significant association with caries prevalence especially among the non-obese school children (Table 4.13). 62 University of Ghana http://ugspace.ug.edu.gh Table 4.13, Other oral hygiene habits and prevalence of caries among obese and non-obese Respondent Oral hygiene CARIES EXPERIENCE MH* category habits Common p- OR value Estimate Tooth brushing CARIOUS CARIES FREE Total (95% CI) material n(%) n(%) n(%) Brush and OBESE CHILD toothpaste only 29 (14.1) 176 (85.9) 205 (100) 0.144 other materials 4 (28.6) 10 (71.4) 14 (100) Total 33 (15.1) 186 (84.9) 219 (100) 0.484 NON OBESE Brush and CHILD toothpaste only 40 (14.6) 234 (85.4) 274(100) 0.319 (0.600- other materials 4 (23.5) 13 (76.5) 17 (100) 1.608) Total 44 (15.1) 247 (84.9) 291 (100) Use of tooth pick OBESE CHILD Use toothpick 18 (13.1) 119(86.9) 137 (100) 0.302 No toothpick 15 (18.3) 67(81.7) 82 (100) 0.982 Total 33 (15.1) 186 (84.9) 219 (100) (0.208- NON OBESE CHILD Use toothpick 28 (16.6) 141 (83.4) 169 (100) 0.434 1.125) No toothpick 16 13.2) 105 (86.8) 121 (100) Total 44 (15.2) 246 (84.8) 290 (100) Floss use OBESE CHILD Use floss 1 (7.1) 13 (92.9) 14 (100) 0.896 No floss use 5 (8.2) 56 (91.8) 61 (100) 0.639 Total 6 (8.0) 69 (92.0) 75 (100) (0.135- NON OBESE CHILD Use floss 1 (6.7) 14 (93.3) 15 (100) 0.526 3.023) No floss use 7 (12.5) 49 (87.5) 56 (100) Total 8 (11.3) 63 (88.7) 71 (100) Dental visit OBESE CHILD Dental visit 15 (21.4) 55 (78.6) 70 (100) 0.071 No dental visit 18 (12) 131 (87.9) 149 (100) 2.088 Total 33 (15.1) 186 (84.9) 219 (100) (1.270- NON OBESE CHILD Dental visit 19 (22.9) 64 (77.1) 83 (100) 0.018 3.433) No dental visit 25 (12.0) 183 (88.0) 208 (100) Total 44 (15.1) 247 (84.9) 291 (100) *Mentel-Haeszel Chi-square overall estimates of the odds ratios 63 University of Ghana http://ugspace.ug.edu.gh 4.15 Distribution of caries experience in the school children Caries prevalence by age for all the children combined is presented in Figure 4.2. Caries prevalence is generally high among the younger ages (9-10 years) thereafter the prevalence decreased steadily from 20% to 5.2%, the lowest prevalence being in children aged 15 years. Figure 4.2, Caries prevalence among the age group of respondents 4.16 Possible effect of maternal educational level, nutrient intake and toothpick use on the oral conditions. 4.17 The effect of maternal tertiary level of education, nutrient intake and toothpick use is shown in Table 4.14. Maternal education is one of the major influences on the overall health as well as the oral health status of children. Also nutrient deficiency such as vitamin C compromises the integrity of the gums hence increasing the risk of gum infection. Improper use of toothpick can lead to injury to the gum as well. The results show that only 64 University of Ghana http://ugspace.ug.edu.gh maternal tertiary level education had significant association on the prevalence of overall oral infection. There children with tertiary educated mothers had significant lower overall oral health, (p=0.043). Table 4. 14: Association of maternal educational level, nutrient supplement intake and toothpick use with oral conditions. overall oral Caries Gum disease infection Factor n(%) n(%) n(%) Tertiary educated mother OBESE CHILD Yes 19 (17.4) 6 (5.0) 23 (19.3) No 14 (12.7) 16 (14.0) 30 (26.3) NON OBESE CHILD Yes 13 (11.8) 12(9.8) 24 (19.5) No 31 (17.1) 29 (15.2) 52 (27.2) p-value 0.331 0.019 0.043 MH common OR 0.937(0.56- 2.06(1.16- 1.54 3.67) 0.66(0.44-0.99) Nutrient supplement intake OBESE CHILD Yes 28 (15.2) 18(9.1) 44 (22.3) No 5 (14.3) 4(11.1) 9 (25.0) NON OBESE CHILD Yes 35 (14.2) 32 (12.1) 63 (23.8) No 8 (18.6) 9 (19.1) 12 (25.5) p-value 0.378 0.710 0.476 MH common OR 0.86 (0.44- 1.54(0.79- 1.65) 2.98) 0.89 (0.52-1.53) Tooth pick use OBESE CHILD Yes 18 (13.1) 11 (7.6) 28(19.3) No 15 (18.3) 11 (12.5) 25 (28.4) NON OBESE CHILD Yes 28 (16.6) 23 (12.4) 44 (23.8) No 16 (13.3) 18(14.1) 32 (25.0) p-value 0.519 0.264 0.257 MH common OR 0.98 (0.6- 1.34(0.79- 1.61 2.26) 0.78(0.52-1.16) Mentel-Haeszel overall estimates of the odds ratios were mostly not significant; p<0.05 except for those children whose mothers had tertiary education who had significant lower overall oral disease as compared to children with non-tertiary educated mothers, p=0.043. 65 University of Ghana http://ugspace.ug.edu.gh 4.17 Puberty and oral infections Hormonal changes associated with puberty in adolescents expose them to increased oral infections. Thus pubertal hormones modify gingival response to dental plaque, hence increased risk for caries and gum disease (De Pommereau et al., 1992; Nakagawa et al., 1994). The pubertal age was 11-15 years and pre-pubertal age was 9-10 years (WHO, 2004). The result of the prevalence of caries, gum disease and overall oral infections among the pubertal and pre-pubertal age for obese and non-obese groups is presented in Table 4.15. In both the obese and non-obese groups caries prevalence seemed higher in the pre-pubertal group than the pubertal group. However it was only significantly higher in the pre-pubertal children among the obese and not in the non-obese children. Significant higher gum infection was observed in the pubertal obese children but not in the non-obese group. Table 4.15, Association between puberty and oral diseases among respondent groups Respondent category Oral health conditions Pubertal age Caries Gum disease Overall Oral disease OBESE CHILD Pre-puberty 18 (22.8) 8 (5.9) 31 (22.8) Puberty 15 (10.7) 14 (14.4) 22(22.7 Total 33 (15.1) 22 (9.4.3) 53 (22.7) P-value 0.02 0.03 0.98 NON OBESE CHILD Pre-puberty 16 (18.2) 23(14.8) 41 (23.8) Puberty 28 (13.8) 41 (13.1) 35(22.6) Total 44 (15.1) 37 (14.7) 76 (24.2) P-value 0.22 0.36 0.50 MH common OR 1.62(0.98-2.70 1.73(1.02-2.94) 1.11(0.75-1.66) The MH common OR show significant association of puberty with gum disease. 66 University of Ghana http://ugspace.ug.edu.gh 4.18 Assessment of periodontal health and Community Periodontal Index of Treatment Needs (CPITN) score CPITN score estimates the severity of periodontal disease, the worse form of gum infection often leads to loss of attachment of gum to the tooth. It measures the periodontal pocket depth to ascertain the level of clinical attachment loss of the gum to the tooth. The score ranges from 0 to 4. The results are shown in Figure 4.3. Majority of the children had a score of 2. This implies there was abundant calculus at the gingival margin of the gum. CPITN score of 3 and above indicate measurable periodontal pocket depth (PPD). Children with PPD greater than 3mm were considered as having periodontal condition. The score of 2 implies there was only mild to moderate gum problems in the children. Score of 3 and above indicate real loss of attachment of gum to the tooth. This condition was slightly higher in the non-obese than in the obese children but was not significant. Figure 4.3. CPITN scores among obese and non-obese school children 100.0 OBESE CHILD90.0 90.0 87.7 NON OBESE CHILD 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.5 6.9 0.0 3.110.0 0.5 0.9 0.5 0.0 0.0 0 1 2 3 4 CPITN score 4.19, Prevalence of Periodontal disease and possible risk associated with obesity and puberty 67 Percent University of Ghana http://ugspace.ug.edu.gh Prevalence of periodontal condition in the school children is reported in Table 4.16. The result shows that periodontal condition was slightly higher among the non-obese than the obese categories but was not statistical significant, p=0.330. Neither obese nor pubertal status showed increased risk of gum disease in the school children. CPITN score of 3 implies periodontal pocket depth (PPD) >3mm. Table 4.16, Periodontal risk levels among obese and non-obese and pubertal age groups Respondent Periodontal conditions OR p-value categories (95% CI) PPD>3mm PPD<=3mm Perio Non-Perio Obese 8(3.7) 211 (96.3) 0.652 0.330 Non-obese 16 (5.5) 275 (94.5) (0.274 – 1.550) Pre-pubertal 12 (4.3) 269 (95.7) 0.807 Puberty 12 (5.2) 217 (94.8) 0.353 – 1.831 0.607 Total 24 (4.7) 498 (97.6) 4.20 Healthy sextants among the school children Another way of assessing the periodontal health of the children is to examine the level of healthy sextants in the mouth. This is done by dividing the mouth into six parts often called sextants and examining number of sextants with CPITN = 0. The overall distribution of healthy sextants is shown in Figure 4.4. Only 6.7% of the sample had good oral health in all the sextants while 75% of the children had a problem in one or more sextants. This implies that though there were mild periodontal conditions it was more generalized in the mouth, thus affected more than one area of the mouth. A comparison of healthy sextants between obese and non-obese was not significantly different (results not shown). 68 University of Ghana http://ugspace.ug.edu.gh Figure 4.4, overall distribution of healthy sextants in the school children. OBJECTIVE 2: PREVALENCE OF CARIES AND GUM DISEASES AND ASSOCIATED DIETARY FACTORS 4.22 Association between dietary factors and oral health status Table 4.17 shows the associations between specific dietary habits (such as frequency of snacking and soft drink consumption) on the prevalence of caries and gum disease. The results showed that days per week of snacking, number of bottles of soft drink consumed in a day, excitement attached to soft drink intake and parental response to child’s soft drink intake did not show any significant association with caries or gum disease in the children examined. The estimated odds ratios of the factors were mostly greater than 1 but did not show any significant risk. 69 University of Ghana http://ugspace.ug.edu.gh Table 4.17, Association between dietary factors and oral health status Factor Caries prevalence Gum disease Overall Oral disease prevalence prevalence N (%) N (%) N (%) Days per week of snacking ≤ 2 days 40(16.1) 16 (6.5) 54 (31.8) >2 days 37(14.1) 8 (3.1) 44 (16.8) Odds Ratio ( 95% CI) 1.17 (0.72-1.90) 2.19 (0.92 -5.42) 1.379 (0.886 – 2.147) Bottle of soft drink per day ≤2 bottles 63 (15.4) 18(4.4) 78 (19) >2 bottles 7(12.7) 2 (3.6) 9 (16.4) Odds Ratio ( 95% CI) 1.245 (0.539-2.876) 1.217 (0.275 -5393) 1.2 (0.564 – 2.557) Feelings attached to drinking of soft drink Positive feeling (excited) 64 (14.7) 20 (4.6) 82 (18.9) Negative or no feeling 13 (19.4) 4 (6.0) 16 (23.9) Odds Ratio ( 95% CI) 0.719 (0.371-1.392) 0.761 (0.252-2.299) 0.743 (0.403-1.368) Feelings expressed by parent when child drinks soft drink Positive feeling (encourage) 40 (13.4) 16 (5.4) 55 (18.4) Negative or no feeling 36 (17.2) 8 (3.8) 42 (20.1) (concerned) Odds Ratio ( 95% CI) 0.742 (0.458-1.211) 1.42 (0.596-3.383) 0.896 (0.573-1.403) Accessibility to soft drink Easy access 58 (15.6) 19 (5.1) 75 (20.1) Difficult access 19 (13.9) 5 (3.6) 23 (16.8) Odds Ratio ( 95% CI) 1.147 (0.656-2.005) 1.421 (0.520-3.883) 1.252 (0.748-2.094) Availability of soft drink at home Readily available 44 (14.5) 14 (4.6) 56 (18.5) Rarely available 33 (16.0) 10 (4.9) 42 (20.4) Odds Ratio (95% CI) 0.891 (0.545-1.453) 0.952 (0.413-2.181) 0.885 (0.567-1.383) Frequency of buying soft drink in a day ≤2 times 62(14.8) 19 (4.5) 79 (18.9) >2 times 14 (15.7) 5 (5.6) 18 (20.2) Odds Ratio (95% CI) 0.930 (0.495-1.749) 0.798 (0.290-1.624) 0.917 (0.517-1.624) 4.23 Binary logistics analysis for possible risk factors for caries and gum disease Table 4.18 shows the result of the binary logistic analysis of the data. This examined the association between child obesity, snacking habits and other factors on caries prevalence. Most of the factors did not show any significant risk relationship with the caries condition. 70 University of Ghana http://ugspace.ug.edu.gh Surprisingly, the results showed that children who snacked during TV watching had lower prevalence of caries which was contrary to expectation. Table 4.18, Results of the binary logistics analysis of possible factors associated with caries Factor Odds Ratio Confidence interval P-value Obesity (yes)* 2.04 0.53 – 7.831 0.289 Puberty (yes) 0.618 0.273 – 1.023 0.060 Twice brushing (yes) 0.818 0.496 – 1.340 0.428 Average daily snacking (Once) 0.871 0.447 - 1.697 0.215 Mothers support for drinking (yes) 0.790 0.200 – 3.113 0.736 Twice brushing (yes) 0.810 0.305 – 2.151 0.672 Average daily snacking 0.896 0.296 – 2.715 0.846 Parents support for drinking soft drink (yes) 1.743 0.168 – 18.095 0.641 Break time eating (yes) 2.452 0.284 – 21-189 0.415 Snacking during TV watching (yes) 0.334 0.121 – 0.920 0.034 *Reference category in bracket Objective 3; Oral bacterial infection in the school children and relation with caries and gum disease 4.24 Prevalence of oral bacterial infection in the school children The major oral bacteria associated with the various oral infections were examined in 75 obese and 75 non-obese school children (Table 4.19). Streptococcus mutans and Actinobacillus actinomycetemcometans were the commonest positive oral bacteria cultures observed. Streptococcus mutans infection was the predominant oral infection among the children. This was significantly higher in the obese children than for non-obese 71 University of Ghana http://ugspace.ug.edu.gh children (p=0.030). The infection of Lactobacillus was very low in both groups of children. The infection of actinobacillus actinomycetencometans tended to be higher in the non- obese than the obese but the difference was marginally significant (p=0.068). No positive porphyromonas gigngivalis was isolated in either the obese or the non-obese because these bacteria are often found in patients with acute and aggressive periodontitis conditions and none of the children had this form of oral condition. Table 4.19, Prevalence of oral microbial infections among obese and non-obese children Microbes Obese Non-obese Total P-value n(%) n(%) n(%) Streptococcus mutans 31 (41.3) 20 (26.0) 51 (33.6) 0.033 Lactobacillus species 1 (1.3) 1 (1.3) 2 (1.3) 0.985 Actinobacillus actinomycetemcometans (aa) 5 (6.7) 12 (15.6) 17 (11.2) 0.068 Porphyromonas gingivalis - 0 0 0 4.25 The oral bacterial infection status in children with caries and those without caries Table 4.20 shows the infection status of children with caries among obese and non-obese groups. The result shows that even though some of the children had caries no positive cultures of Streptococcus mutans were found in their mouth; similarly some of those who did not have caries rather had the bacteria isolated. For the non-obese group no streptococcus mutans was isolated in the oral plaque of those who had caries but rather 27% of those without caries had the bacteria isolated from their oral plaque. Thus, there were no significant associations observed in the streptococcus mutans infection in carious and caries free children among the obese and the non- obese groups. 72 University of Ghana http://ugspace.ug.edu.gh Table 4.20, Association between streptococcus mutans and caries experience among the obese and non-obese children Obesity Streptococcus mutans Caries Positive Negative Total Obese Caries free 27 (41.5) 38 (58.5) 65 (100) Carious 4 (40.0) 6 (60.0) 10 (100) Total 31 (41.3) 44 (58.7) 75 (100) P-value 0.653 Non-obese Caries-free 20 (27.4) 51 (72.6) 71 (100) carious 0.0 4 (100) 4 (100) Total 20 (26.0) 57 (74.0) 75 (100) P-value 0.151 Study Phase 2 Association between obesity and oral health status in public schools using Case control study design The objective of the second phase of the study was to examine the association between obesity and oral health by comparing the prevalence of obesity and overweight among those who had oral disease, cases (e.g., caries and gum disease) and those who did not have as controls. To achieve this objective case-control design was used. Cases were defined as those who had DMFT score greater than 0 and/or having Gingival Index greater than 0. DMFT score of 0 implies caries-free while score greater than 1 implies caries at least in one tooth. Gingival index greater than 0 implies mild to moderate gingivitis. The controls consisted of school children in the same class between the ages of 9-15 years who had DMFT score of 0 and Gingival index of 0. 73 University of Ghana http://ugspace.ug.edu.gh In the five public schools selected, children from classes 4 – JHS 3 within the ages of 9 to 15 years were examined. Anthropometric data, dietary and oral hygiene data as well as oral health status data were all collected through interviews and oral examination. In each school, children were first examined after they had submitted signed consent form from parents in addition to consent from the children themselves. Those with oral conditions were matched with those who did not have any oral condition in each class by sex and age. RESULTS AND ANALYSIS OF PUBLIC SCHOOL DATA Oral health and obesity study was carried out in five public basic schools randomly selected from School list in Accra. 4.26 Demographic characteristics of the public school children studied. Table 4.21 presents the general demographics of the children in the public school who were studied. A total 494 children were recruited for the study. Slightly more children were recruited in the primary schools than the JHS classes. Total number of cases was 213 which is 42.6% and controls was 281 (57.4%). Children with normal weight were 432 (87.6%), overweight/obese was 61 (12.4) and only obese children was 18 (3.7%). The females and males were almost similar. 74 University of Ghana http://ugspace.ug.edu.gh Table 4.21, Demographic characteristics of the public school children studied Characteristics N % Educational level Primary school 282 57.2 JHS 211 42.8 Sex Male 230 46.3 Female 263 57.7 Case and control Cases (had Caries and Gum disease) 213 42.6 Controls (no caries nor gum disease) 281 57.4 Weight Categories Obese 18 3.7 Overweight 43 8.7 Overweight /obese 61 12.4 Normal 432 87.6 Total 493 100 4.26a Socio-economic background of parents of public school children The socio-economic background of the school children is reported in Table 4.21a. Only 4.9% of fathers had tertiary education with about a tenth did not have any formal education. Just 2.4% of the mother had tertiary education and over 60% had no formal education. The five top occupation of fathers are driver, farmer, trader, carpenter and teacher. For the mothers the major occupation was trading. Only 21.3% owned their homes and the others were either rented or company residence or house caretakers. 75 University of Ghana http://ugspace.ug.edu.gh Table 4.21a Socio-economic characteristics of parents of public school children Socio-economic background of parents N % Fathers education Tertiary 24 4.9 Non tertiary 359 72.9 No education 55 11.2 Not known 55 11.2 Mother’s education Tertiary 12 2.4 Non tertiary 314 63.7 No education 91 18.5 Not known 76 15.4 Major occupation of fathers Driver 97 19.7 Farmer 49 9.9 Trader 32 6.5 Carpenter 23 4.7 Teacher 22 4.5 Major occupation of mothers Trader 334 67.7 Hairdresser 16 3.2 Teacher 14 2.8 Farmer 13 2.6 Living with both parents 295 59.8 Tenancy status Own house 105 21.3 Family house 143 29.0 Rented house 216 43.8 Company/mission house 3 0.6 Government house 5 1.0 Caretakers 3 0.6 Number of children at home 1-5 262 53.1 6-10 185 37.5 >10 29 5.9 76 University of Ghana http://ugspace.ug.edu.gh 4.27 Weight status among the sexes Overweight/ obesity prevalence by child sex is shown in Table 4.22. Significant higher prevalence of overweight /obese was observed in the females than the males, p<0.001. 4.22 Weight status among the sexes Weight categories Gender Overweight/Obese Normal weight Total p-value Male 16(7.0) 214(93.0) 230 (100) Female 45 (17.3) 218 (82.) 263 (100) <0.001 Total 61 (12.3) 441(87.7) 493 (100) 4.28. Prevalence of caries by obesity status of public school children Caries prevalence among the obese and normal weight children is shown in Table 4.23. Caries prevalence was highest among the obese children compared to the overweight and the normal weight school children. The prevalence among the overweight/obese group was also higher than the normal weight groups but was not significant. Similarly the caries prevalence was higher in the obese group than the non-obese group, this also did not prove significant. The odds ratio of caries among obese children as compared to the non-obese was 2.082 (0.7612 - 5.692) and the odds ratio for the overweight/obese to the normal weight children was 1.669 (0.9075, 3.071), none of them was significant. Table 4.23, Comparison of Caries prevalence among the weight categories Weight category Caries Caries-free Total P-value, N (%) N (%) N (%) OR (95 CI) Overweight/obese 17 (27.9) 44 (72.1) 61 (100) 0.097 Normal weight 81 (18.8) 351 (81.2) 432 (100) 1.669 (0.9075, 3.071) Obese 6 (33.3) 12 (66.7) 18 (100) 0.145 Non-obese 92 (19.4) 383 (80.6) 475 (100) 2.082 (0.7612 - 5.692) 77 University of Ghana http://ugspace.ug.edu.gh 4.27 Level of caries among the subject groups Decay, Missing and Filled Teeth (DMFT) score estimates the degree of caries among the school children (Table 4.24). The mean DMFT score was highest among the obese group. The overweight/obese group also had DMFT score slightly higher than the normal weight children but was not significant. The females had higher but non-significant mean DMFT score than the males. Table 4.24, DMFT score for obese and non-obese children by sex Std. P-value Obesity status N Mean Deviation Min Max Obese 18 0.61 1.24 0 5.0 Non-obese 475 0.40 0.04 0 8.0 0.371 Overweight /obese 61 0.54 1.08 0 5.0 Normal weight 432 0.37 0.98 0 8.0 0.255 Sex Male 230 0.3609 0.92 0 5.0 0.368 Female 263 0.4449 1.05 0 8.0 4.28 Comparison of gum infection among the various weight categories Table 4.25 shows the prevalence of gum infection by child weight status (obese, non- obese, and the normal weight children). The prevalence of gum infection was similar in all the weight categories without any significant difference. 78 University of Ghana http://ugspace.ug.edu.gh Table 4.25, Prevalence of gum infections by the weight categories Weight category Infected Gum Normal gum Total P-value n(%) n(%) n(%) OR (95 CI) Obese 7(38.9) 11 (61.0) 18 (100) Overweight 15 (34.9) 28 (65.1) 43 (100) 0.860 Normal weight 143 (33.1) 289 (66.9) 432 (100) Obese 7(38.9) 11 (61.0) 18 (100) 0.620 Non-obese 158 (33.3) 317 (66.7) 457 (100) 1.277 (0.4856- 3.357) Overweight/obese 22 (36.1) 39 (63.9) 61 (100) 0.655 Normal weight 143 (33.3) 288 (66.8) 431 (100) 1.136 (0.6491-1.988) 4.29, Comparison of caries, gum disease and the overall oral condition among the primary and JHS school children. Level of education of the children showed significant association with gum infection and the overall oral disease but not caries prevalence. The prevalence of gum infection was 37.2% and 28.2% respectively for primary and junior high school children, p=0.036. The overall oral disease (caries and gum infection) was 47.3% for the primary school children and 36.4% for the JHS students. Table 4.26, Prevalence of Oral conditions among the Primary and JHS school children Educational level Oral conditions Total Gum Oral Caries infection diseases Primary 54 (19.1) 103 (37.2) 134 (47.3) 282 (100) junior High 44 (20.9) 59 (28.2) 76 (36.4) 211 (100) Total 98 (19.9) 164 (33.4) 210 (42.8) 493 (100) P-value 0.639 0.036 0.014 79 University of Ghana http://ugspace.ug.edu.gh Prevalence of oral infection (tooth and gum) was not significantly associated with any of the weight categories, p>0.05. Thus similar prevalence was observed in the normal weight children as well as overweight/obese children while it was slightly higher in the non-obese than the obese. None of these were significantly different. Table 4.27, Prevalence of oral disease among the weight categories and possible risk associations Weight category Oral disease Normal oral Total P-value N(%) health N(%) OR (95 CI) N(%) Obese 9(50.0) 9(50.0) 18 (100) Overweight 17(39.5) 26(60.5) 43(100) 0.753 Normal weight 184 (42.6) 248 (57.4) 432 (100) Obese 9(50.0) 9(50.0) 18(100) 0.518 Non-obese 274 (57.7) 201 (42.3) 475(100) 0.734 (0.286- 1.881) Overweight/obese 35 (57.4) 26 (42.6) 61(100) 0.992 Normal weight 247 (57.3) 184 (42.7) 431(100) 1.003 (0.583- 1.724) 4.30, Oral hygiene status indicators for all the public school children Figures 4.5, 4.6 and 4.7 respectively show the distribution of plaque, calculus and Silness and Loe plaque scores among the children. Barely visible plaque was seen in 23.7% while abundant plaque at gingival margin was only 5.3%. Supra gingival calculus was observed in 58.0% while subgingival calculus was observed in only 8.9% of the sampled children. The mean Silness and Lӧe plaque index of 0.94±0.36 implies adequate overall oral hygiene status for the children. The values range between 0 and 2 with 2 implying worse oral hygiene status. Values less than 1 are considered good oral hygiene status. 80 University of Ghana http://ugspace.ug.edu.gh Figure 4.5, Plaque score for the children Figure 4.6, Calculus score 81 University of Ghana http://ugspace.ug.edu.gh Figure 4.7, Overall distribution of Silness and Loe plaque score 4.31 Comparison of oral hygiene status among the weight categories The comparison of oral hygiene status among the weight categories is shown in Table 4.28 and 29. The mean silness and Loe plaque score was highest among the obese followed by the normal weight and least in the overweight students. But the value for overweight/obese category was higher than the normal weight school children but this difference was not significant. The plaque and calculus index were not significantly different among the various weight categories. 82 University of Ghana http://ugspace.ug.edu.gh Table 4.28, Comparisons of mean Silness and Loe plaque score by weight category Std. p-value Obesity Status Mean N Deviation Minimum Maximum Obese .9898 16 .10499 .67 1.12 Overweight .8317 30 .37611 .04 1.50 0.254 Normal weight .9371 303 .36996 .00 2.04 Obese .9898 16 .10499 .67 1.12 Non-obese .9276 333 .37118 .00 2.04 0.504 Overweight/Obese .8867 46 .31723 .04 1.50 Normal Weight .9366 302 .37047 .00 2.04 0.387 Total .9300 348 .36386 .00 2.04 Table 4.29, Association between oral hygiene status and weight categories Obesity Status Plague index Barely Abundant at No plaque visible gingival Total p-value plaque margin Obese 0 16 (88.9) 2(11.10) 18(100.0) 0.357 Overweight 3(7.00) 2(62.80) 13 (30.20) 43(100.0) Non-obese 26 (5.5) 334(70.3) 115 (24.2) 475 (100) Normal weight 23 (5.30) 307 (71.1) 102 (23.60) 432 (100.0) Total 26 (5.30) 350 (71.0) 117(23.70) 493 (100.0) Calculus index Sub- Obesity Status No calculus Supra gingival gingival heavy Total unilateral Obese 6 (33.30%) 12 (66.70) 0.0 18 (100.0) Overweight 16 (37.20) 23 (53.50) 4 (9.30) 43 (100.0) Non-obese 157 (33.1) 274(57.7) 44(9.3) 475(100.0) Normal weight 141(32.60) 251 (58.10) 40 (9.30) 432 (100.0) 0.681 Total 163 (33.10) 286 (58.00) 44 (8.90) 493 (100.0) 83 University of Ghana http://ugspace.ug.edu.gh 4.32 Gum disease status by child weight categories Gum health was estimated by Gingival index which ranged from 0 (healthy gum) to 2 (severely inflamed gum) and is presented in (Table 4.30). The prevalence of mild to moderate gum infection was observed in 137(27.8%) of the sampled children. Only 5(27.8%) of the obese and 126 (26.5%) of the non-obese had mild gum infection. The prevalence in the overweight/obese group was (23.0%) as against the (27.1%) in the normal weight group. Only one person of overweight/obese group had moderate as against 5(1.2%) among the normal weight children had moderate gum infection. Obesity status was not significantly associated with any of the gingival indices. Table 4.30: Gingival index by child weight categories Gingival index Pink, firm, Shiny, slightly Marked reddening, stippled and no red or swollen obviously enlarged Weight category exudates swollen exudates P-value (0=healthy) (1=mild) n(%) (2=moderate) n(%) n(%) Obese 13(72.2) 5 (27.8) 0 (0.0) Overweight 33(76.7) 9(20.9) 1(2.3) 0.852 Normal weight 310(71.8) 117(27.1) 5(1.2) Obese 13(72.2) 5 (27.8) 0 (0.0) 0.888 Non-obese 343(72.2) 126(26.5) 6(1.3) Overweight/obese 46(75.4) 14(23.0) 1(1.6) Normal weight 309(71.7) 117(27.1) 5(1.2) 0.673 Total 356(72.20) 131 (26.60) 6 (1.20) 4.33 Dietary habits among the public school children The dietary habits of the public school children by obesity status did not show any significant differences. Just about a third of the children ate breakfast at home and for those who did it was not a regular practice since 65.4% said it was only done sometimes. Amount of money given for school were often between one and two Ghana cedis although 50% of the obese indicated they received more than GHC 2.0 cedis. Dietary habits did not 84 University of Ghana http://ugspace.ug.edu.gh differ significantly between children with oral infections (cases) and those without oral infections (control). Table 4.31, Dietary practices between obese and non-obese public school children Dietary habits Obese Non-obese Overall P-value n(%) n(%) n(%) Daily frequency of eating Once 0 5 (1.1) 5(1.0) Twice 1 (5.6) 85 (18.0) 86 (17.5) Thrice 14 (77.8) 321 (67.9) 335 (68.2) 0.539 Four-or more 3 (16.7) 62 (13.1) 65 (13.2) Total 18 (100) 473 (100) 491 (100) Places meals were taken Home 17 (85.0) 411 (71.2) 428 (71.7) School canteen 2 (10.0) 102 (17.7) 104 (17.4) 0.646 Restaurant 0 18 (3.1) 18 (3.0) Road side vendor 0 20(3.5) 20(3.4) Chop bar 1 (5.0) 26 (4.5) 27 (4.5) Breakfast at home 5(29.4) 161 (35.9) 166 (35.7) 0.581 Frequency of breakfast intake Always 4 (22.2) 59 (12.6) 63 (13.0) Very often 1 (5.6) 11 (2.4) 12 (2.5) Sometimes 10 (55.6) 308 (65.8) 318 (65.4) 0.648 Rarely 0 6 (1.3) 6 (1.2) Never 3 (16.7) 84 (17.9) 87 (17.9) Use of vitamins and minerals 14 (77.8) 375 (79.1) 389(79.1) 0.995 Forms of vitamin and mineral used Multivitamin tablets 5 (29.4) 31 (7.6) 36 (8.5) Mineral (Fe, Ca) tablets 3 (17.6) 70 (17.2) 73 (17.2) Vitamin and minerals syrups 0.173 8 (47.1) 178 (43.6) 186 (43.8) Blood tonic 2 (11.1) 114 (27.9) 115 (27.1) Combination of the above 0 14 (3.4) 14 (3.3) Money for school 10-50p 3 (17.6) 125 (26.3) 128 (26.0) 60-100GP 2 (11.8) 52 (10.9) 54 (11.0) 0.235 1-2GHC 4 (23.5) 176 (37.0) 180 (36.5) Greater than 2GHC 9 (50.0) 111 (23.3) 119 (24.1) None 0 12 (2.5) 12 (2.4) 85 University of Ghana http://ugspace.ug.edu.gh Table 4.32, Dietary habits by child oral infection status Cases Control Total p-value Number of times eaten n=213 n=281 n=494 in a day n(%) n(%) n(%) Once 1 (0.5) 4 (1.4) 5 (1.0) Twice 43 (20.6) 43 (15.2) 86 (17.5) Thrice 146 (69.9) 189 (67.0) 335 (68.2) 0.096 Four- or more 19 (9.1) 46 (16.3) 65 (13.2) Total 209 (100.0) 282 (100.0) 491 (100.0) Place of eating Home 180 (68.2) 248 (74.9) 428 (71.6) Chop-bar 10 (3.8) 15(4.5) 25(4.2) Roadside vender 9 (3.4) 8(2.4) 17 (2.9) 0.1961 Restaurant 7 (2.7) 11 (3.3) 18 (3.0) School canteen 58 (22.0) 49 (14.8) 107 (18.4) *Total 264 (100.0) 331 (100.0) 595 (100.0) Breakfast intake before school 110 (41.5) 56 (28.0) 166(35.7 0.003 Frequency of breakfast intake Always 44 (15.9) 19(9.5) 63 (13.2) Very often 7 (2.5) 4(2.0) 11 (2.3) Sometimes 174 (63.0) 136 (68.0) 310 (65.1) 0.217 Rarely 4 (1.4) 1 (0.5) 5 (1.1) Never 47 (17.0) 40 (20.0) 87 (18.3) Money for school food No money given 6 (2.1) 5 (2.5) 11 (2.3) Less 1 GHS 90 (32.1) 65 (43.6) 187 (36.9) 1-2 GHS 109 (38.8) 68 (33.7) 177 (36.6) 0.075 >2 GHS 76 (27.0) 41 (20.3) 117 (24.2) Total 281 (100) 202 (100) 483 (100) Case=213, Control = 281 4.34 Commonest foods consumed by public school children school Rice (plain or as Jollof rice) was commonest food eaten as breakfast meal by 58% of the school children (Figure 4.8). Just about 15% ate Waakye (rice and beans meal) and 12.7% ate banku or kenkey food at breakfast. These meals are eaten with either stew or soup. 86 University of Ghana http://ugspace.ug.edu.gh Figure 4.8, Eight commonest foods eaten at breakfast in school 70.0 57.6 60.0 50.0 40.0 30.0 20.0 14.6 12.7 10.0 5.1 4.3 3.1 1.6 1.0 0.0 Foods eaten at breakfast 4.35 Breakfast intake and association with oral health among the obese and the non- obese groups Breakfast intake before school was significantly associated with oral infection among the obesity and non-obese groups (Table 4.33). Thus those children who took breakfast had lower prevalence of oral infections. The result shows that oral conditions were far higher among those who did not take breakfast than those who took breakfast. Breakfast intake therefore seems to have protective effect on oral disease in those children who took breakfast before going to school. This may be attributable to the saliva flow during food intake and its oral cleansing effect as well as possible less demand for snacks. 87 Percent University of Ghana http://ugspace.ug.edu.gh Table 4.33, Association between oral infection and breakfast intake among obese and non-obese Obesity Eat breakfast before Oral condition coming to school Total Healthy Oral mouth infection n(%) p-value n(%) n(%) Obese Yes 3 (37.5) 2(22.2) 5 (29.4) No 5 (62.5) 7 (77.8) 12 (70.6) 0.041 Total 8 (100.0) 9 (100.0) 17 (100.0) Non-obese Yes 107 (41.6) 54 (28.3) 161 (35.9) No 150 (58.4) 137 (71.7) 287(64.1) 0.004 Total 257 (100.0) 191(100.0) 448 (100.0) 4.35 Snacking habits among the categories of school children. Comparisons of snacking habits in weight categories and case control are shown in Table 4.34. Home snacking was slightly higher among the obese than the non-obese while snacking at school was higher among the non-obese than the obese children. These differences however were not significant. Similarly, snacking habits were not significantly different among children with oral infections and those without oral infections. 88 University of Ghana http://ugspace.ug.edu.gh Table 4.34 Snacking behavior among obese and the non-obese groups as well as case and control by oral infection status Obese Non-obese Total p-value n(%) n(%) n(%) Snacks at home 10 (55.6) 218 (45.9) 228 (46.2) 0.420 Snacks at school 11 (61.1) 283 (60.6) 293 (60.5) 0.885 Types of snacks Raw fruits 7 (41.17) 108 (24.26) 115 (24.9) Fruit drink or juices 3 (17.64) 116 (26.06) 119 (25.8) Sweets 1 (5.88) 45 (10.11) 46 (10.0) 0.991 Biscuits, cakes 3 (17.64) 95 (21.34) 98 (21.2) Soft drinks/ minerals 1 (5.88) 29 (6.51) 30 (6.5) Nuts and something else 2 (11.7) 11 (2.27) 13 (2.8) Combination of the above 0 41 (9.2) 41 (8.9) Case Control Total Snacks at home 90 (43.9) 133 (47.7) 223 (46.1) 0.675 Snacks at school 114 (57.3) 172 (62.5) 286 (60.3) 0.248 Types of snacks Raw fruits 52 (26.9) 62 (23.8) 114 (25.1) Fruit drink or juices 43 (22.3) 75 (28.70) 118 (26.0) Sweets 19 (9.8) 23 (8.8) 42 (9.3) Biscuits, cakes 40 (20.7) 56 (21.5) 96 (21.1) 0.455 Soft drinks/ minerals 10 (5.2) 20 (7.7) 30 (6.6) Nuts and something else 6 (3.1) 7 (2.7) 13 (2.9) Combination of the above 23 (11.9) 18 (6.9) 41 (9.0) Case=213, Control = 281 4.36, Oral conditions among public school children Children were asked if they have had the following conditions: bad breath (halitosis), red and swollen gum, bleeding gum, painful chewing, loose teeth and sensitive tooth. The commonest oral health condition reported were sensitive teeth, bleeding gum and painful chewing, (Figure 4.9). Loose teeth and bad breath were the least conditions experienced by the school children. 89 University of Ghana http://ugspace.ug.edu.gh Figure 4.9, Oral health conditions experienced among public school children 55.5 60 46.1 50 38.6 40 30 30 20.5 20.5 20 10 0 Bad Red and Beelding Painful Loose Sensitive breath swollen gum chewing tooth tooth gum oral health conditions (N=494) 90 Prevalence % University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0 DISCUSSION, CONCLUSION AND RECOMMENDATION 5.1 Discussion Oral disease is a major public health problem in high income countries and it is increasingly becoming a burden in many developing countries (Petersen, 2003). Studies in the US and Japan and recent systemic review (Hayden et al., 2012) on the subject of obesity and oral diseases, have all indicated that obesity and periodontal (gum) conditions are significantly related especially in older people as well as young adults (Oliveira et al., 2008; Sharma et al., 2009; Narksawat et al., 2009; Vazquez-Nava et al., 2010). The condition in children has not been investigated fully (Katz and Bimstein, 2011). This study set out to investigate the relationship between childhood obesity and oral health. The main aim was to determine the differences in caries and gum diseases prevalence in obese and non-obese school children and to examine if differences in dietary practices and oral hygiene habits are contributing factors. The questions this study sought to address included whether there is any significant difference in the oral infections (caries and gum disease) among the obese and non-obese school children. If differences exist, do these explain any association between obesity and oral health in children? Are there differences in oral infectious bacteria associated with caries and gum diseases among the obese and the non-obese school children? This study showed that at least among the Ghanaian school children obesity did not show any significant association with oral health even though other studies showed contrary results among similar age groups. The demonstration of the link between obesity and oral infection in young adults and the elderly is not confirmed by this study among the Ghanaian obese children. This was believed could be due to several factors including 91 University of Ghana http://ugspace.ug.edu.gh similar dietary and oral hygiene practices even though some specific dietary factors significantly differed among the obese and the non-obese groups. The study compared caries and gum disease prevalence among the obese and the non- obese. It also examined the differences in oral hygiene practices and dietary habits of the two groups. The result showed that prevalence of caries and gum disease in both groups was about 15%. This prevalence among the Ghanaian children seems relatively low as compared to reports from other countries. For example, in Mexican children the prevalence was 17.9% (Vázquez-Nava et al., 2010), and 28.9% in Indian children (Sakeenabi et al., 2012). Among the Brazillian children 6-9 years old it was 50.9% (Moreira et al., 2006). Among German children the prevalence was as 66.3% (Willershausen et al., 2004). Another Brazilian study in 12 year olds gave the caries prevalence as 71.8% (Jamelli, 2010). The low caries recorded in this study may be influenced by several factors including the socioeconomic factors. The children in this study came from relatively high socioeconomic homes as indicated by the higher tertiary level of education of their mothers. The socioeconomic levels can influence the availability of cariogenic snacks as well as provision of good oral cleaning materials for keeping the mouth clean, thus reduce the risk of caries and other oral conditions. The DMFT score which reflects the degree of caries in the children also showed relatively low values in this study. The value in the obese and non-obese were similar and the overall score was way below 3.0 which is the recommended level by WHO for intervention in the populations (WHO, 2005) Gum disease prevalence in the two groups showed slightly higher but non-significant prevalence in the non-obese than the obese school children. In this study very few of the children had periodontitis as identified by CPITN scores greater than 3mm. The overall 92 University of Ghana http://ugspace.ug.edu.gh severe gum disease prevalence was 4.7%. But mild to moderate gum diseases are generally low in children and occur mostly as gingivitis which are reversible gum changes. Gingivitis observed as gum changes was only 12% of the children. The children had adequate oral hygiene practices which it is believed helped to maintain good gum health. The result also showed that dietary habits and oral hygiene practices were adequate and similar in both the obese and the non-obese groups. All the indicators of oral hygiene status, which included Plaque Index, Calculus Index and Sinless and Loe Plaque score, examined in the two groups did not show any significantly differences between the obese and the non-obese groups. The major significant factor observed to be different between the two groups was the prevalence of streptococcus mutans infection which was significantly higher among the obese than the non-obese. When this was compared among carious and caries-free children it did not show any significant association with the caries condition. 5.2 The socio-demographic background of the school children The school children aged between 9-15 years were recruited from primary class 4 to JHS forms 1 to 3. Obesity in the girls was more common than in the boys. This finding was not different from other studies reported from South Africa (IOTF, 2004) and the UK (Summerbell et al., 2004). The socioeconomic indicators of the parents of these children showed that two thirds of their fathers and half of the mothers had tertiary education. This, it is believed, did have marked impact on the oral health status and general health of the children especially the influence of maternal educational level on overall health behavior. Various researchers have reported that mother’s educational level is a better predictor of overall health status and health behavior of children than that of the father (Currie and Moretti, 2003; Yuyu and 93 University of Ghana http://ugspace.ug.edu.gh Hongbin, 2006; Meherun and Kazi, 2007). With this high level of maternal education it is expected that better dietary and oral hygiene practices will be observed by the children. This is because a better educated mother would be more knowledgeable in good nutrition and health care. Such mothers are more likely to teach the child healthier behaviors, and provide safer and more sanitary homes and living environments for their children (Behrman and Deolalikar, 1988; Behrman and Deolalikar, 1990; Thomas, Strauss and Henriques, 1991; Glewwe, 1999; Currie and Moretti, 2003). In addition, psychosocial and home environment are significant factors in explaining eating behaviours in children and especially in adolescents (Haerens et al., 2008). In another study on Palestinian children consumption of fruits and milk products as well as meat, chicken and soft drinks were all positively associated mother’s education (Al Sabbah et al., 2007). 5.3 Dietary practices among the school children Diet is one of the major factors that can affect the oral health of individuals. The major dietary factors investigated in this study included type and variety of foods, frequency of consumption, the cariogenicity of the diet and the amount of cariogenic foods consumed. This study found that majority of the children ate at least three times a day. This is typical of most homes. Almost all the children regularly ate at home and majority also regularly ate away from home. About half of all the children regularly bought food from road side vendors. Only one out of ten children said they regularly ate from school canteen. This was observed to be due to lack of this facility at the schools because formal canteen was seen in only three of the schools recruited. Some of the children expressed dislike for certain foods. The commonest foods disliked by the children included Kokonte, Tuo zaafi, Fufu, Banku, and beans. Kokonte is a paste made from dried, fermented cassava dough, Tuo Zaafi is made from maize flour, fufu is 94 University of Ghana http://ugspace.ug.edu.gh made from boiled cassava and pounded into a paste and Banku is a paste made from fermented maize dough. The three major reasons given for the dislike for those foods included taste, appearance, and health or allergy. Incidentally these are the major staples in Ghana but the proportion who proscribe them are low hence may have no effect on the oral health of the children. The Kokonte and Tuo Zaafi are common among the northern people while fufu is liked most among the middle and forest belt and banku more eaten by people along the coast. None of the foods disliked has any cariogenic effect because they are often eaten with soup which may have some oil and proteins which are anti-cariogenic foods. 5.4 Intake of nutrient supplement (vitamins and minerals) Majority of all the children indicated taking nutrients supplements in one form or another at different times. The level of intake was similar for both the obese and the non-obese children. The two major reasons given for the intake of nutrient supplement were on medical grounds and food. The top three nutrient supplements taken were in the form of vitamin and mineral tablets, Blood tonic and multivitamin syrups. The intake of supplements in addition to their usual meals was likely to improve their nutrient intake hence help check oral disease as in the case of vitamin C deficiency which tends to affect the integrity of the oral mucosa. (Staudte et al., 2005; Amalia et al., 2007; du Plessis and Magdalena, 2010). 5.5 Favorite meal time and Breakfast intake The timing of meals affects the availability of substrate to the oral microbes to continue to ferment sugars into acids to increase the risk of caries. Acid production continues well over one hour after the meal (Linke et al., 1997; Linke et al., 1999). Supper was the favorite 95 University of Ghana http://ugspace.ug.edu.gh meal time indicated by the children followed by lunch. The major reasons given for the choice of favorite meal time included the taste and appeal of the meal, the quantity served, and the fact that it is prepared and served by mother at home. If supper is eaten without night brushing this might increase the risk of caries because salivary flow during sleep is reduced significantly and this also reduces the cleansing effect of saliva in the mouth (Schneyer et al, 1956; Dawes, 2008). In addition the type of supper meal served may either promote or reduce the caries risk especially if the meal contains adequate proteins and oil and less fermentable sugars. Breakfast was also the most skipped meal time. Skipping breakfast may lead to imbalanced eating later in the day and consumption of snack foods with high caloric value such as sugar-sweetened beverages (Newbrun, 1982; Timlin et al, 2008). In this study about two- thirds of all the children skipped breakfast. Reasons given for skipping breakfast were lack of time and not feeling hungry. These reasons were similar for the obese and the non-obese children. While it is advocated for children to take breakfast in the morning it seems the early start of classes does not give the children ample time to eat in the morning before school. In addition the late supper meals which the children indicated as their favorite meal time may also not make the children feel hungry in the morning so they might feel okay to forego breakfast. It has been reported that adolescents who skip breakfast have a higher body mass index (Cho et al., 2003). Only a third of the children said they often took breakfast before start of classes. This was similar for the obese and non-obese groups. A Tunisia study in 2011 also found no significant difference in breakfast intake between the obese and normal weight school children (Samir et al., 2011). In the Tunisian study majority of the children who took breakfast before school said they always do so, while 10.9% said they sometimes do. In 96 University of Ghana http://ugspace.ug.edu.gh this current study only 24.9% of those who took breakfast do so regularly but 50.5% only do so sometimes. Nearly all the school children said they ate at break time in the school. This was expected since most of them said they do not eat breakfast before class starts. Most schools have two break times in a day, the morning and afternoon breaks. This means only break time meals will provide food for the day before they go home for their supper. This could explain the reasons for the choice of supper as their best meal time. 5.6 Snacking behavior among the school children One of the major dietary habits that promote caries and other oral conditions in children is snacking on sugary fizzy drinks and toffees. Snacking on anti-cariogenic food such as fresh fruits and nuts are encouraged to contribute to the nutrient needs of school children and also to reduce their risk of caries. Snacking at school was more common among the children than at home. Over 60% of the children snacked at school. This difference was however not significant between the obese and the non-obese children. Concerning the types of snack consumed by the children, high proportions of the obese and non-obese children chose fruit drinks, soft drinks, and raw fruits as well as sweets, biscuits and cakes. Only the intake of raw fruits showed significant difference between the two groups, p=0.041, with the obese children eating more fresh fruits than the non-obese. The snacks chosen by majority was fruit drinks, and the least was nuts (e.g., groundnut). A similar study conducted among obese children in South Africa in relation to snacking habits, reported the snack foods most commonly consumed daily included coffee (48.3%), tea (46.1%), crispy chips (39.1%), fruit juice (38.0%), chicken (35.1%), fried potato chips (33.6%), carbonated drinks (26.9%), biscuits (26.2%), toffees (26.2%) and yoghurt (25.8%), (du Plessis and Magdalena, 2010). 97 University of Ghana http://ugspace.ug.edu.gh Carbonated drinks are real risk factors for caries and other oral conditions (Edwards et al., 1999; Wongkhantee et al., 2006; Tahmassebi et al., 2006; Ran et al., 2009). The possible harmful effect of soft drinks is related to the high content of sugar, caffeine and acid and their subsequent effects on teeth and bones. This in effect promotes caries and other gum disease. Majority of soft drinks contain large amounts of refined sugar of up to 15 teaspoons in a 325 ml can and 250 calories, and 91 mg of caffeine, and a pH of 3 or lower (http://www.sugarstacks.com/beverages.htm, accessed on 26-Sep-13). A can a day may give more sugar than is necessary for the body. The snacks consumed by the children in this study do not seem to have much effect on caries prevalence since the prevalence were low as compared to other populations. 5.7 Frequency of food intake The most important factor influencing the cariogenicity of a diet is the frequency at which it is eaten (König et al., 1968, Bowen et al., 1980, Lims et al., 2008), as acid production continuous after one hour of food consumption (Linke et al., 1997; Linke et al., 1999). In this study the mean number of days in a week that soft drink was consumed by obese and non-obese groups were similar. Similarly the obese and the non-obese on average consumed about two bottles per day of soft drinks. As to what were the motivating factors for snacking, just few of the children said they feel bad when they drink soft drinks but the rest reported feeling great when they drink soft drinks. As to their parents’ response when the child is seen drinking soft drinks, majority of the children felt parents will either feel good or normal. But significantly higher proportion of the obese children as against of the non-obese said parents express some misgivings when they are seen drinking soft drinks, p<0.001. 98 University of Ghana http://ugspace.ug.edu.gh The implication of these results is that soft drinks intake for most parents might be a normal practice for the children. Verbal praise given to children by mothers was a significant factor for child's consumption of vegetable and regular consumption of soft drinks and sweets (Elfhag et al., 2008). On the other hand significantly higher proportions of obese mothers as against non-obese children do express concern when children are seen drinking soft drinks, p=0.001. This might be an indication that these mothers may be more concerned about the weight issues of the obese children than their risk of caries from the soft drinks the children consumed but in the end might reduce caries prevalence as well. There was ready availability and easy access to snack foods at home and school for the children. In addition majority snacked 1-2 times in a day. This was similar for the obese and the non-obese groups. The mean weakly intake of snacks was also similar for the two groups. The ease of access and high intake of soft drinks are associated with the risk of oral lesions in this age group (Edwards et al., 1999; Tahmassebi et al., 2006, Wongkhantee et al., 2006; Lims et al., 2008). In addition obese children were significantly given more money for school than their non-obese counterparts, p=0.001. The more money they have to spend the more likely they are to choose cariogenic snacks. In Mauritanian school children, pocket money was one of the major factors that influenced the snacking habits in addition to availability of the snack, its taste and cost (Oogarah-Pratap and Heerah-Booluck, 2005). 5.8 Consumption of specific foods within the last 24 hours The foods consumed in the last 24 hours were classified into various food groups which included sweetened drinks and fruits juices, milk and milk products, bread and cereal 99 University of Ghana http://ugspace.ug.edu.gh products, fried foods, protein foods, spread and toppings, fruits and high fat foods. Among the sweetened drinks and fruit juices groups, significantly more obese children consumed fruit juices than the non-obese, p=0.028. Among the milk product food group, significantly more obese children consume evaporated milk than the non-obese, p=0.023. Similar proportions of obese and non-obese children consumed cereal products and fried foods. Significantly greater proportions of obese children consumed corned beef/bacon than the non-obese children. Only corned beef and watermelon was more frequently consumed among the non-obese than the obese. The implications of this result are that even though more obese children consumed high energy foods, the impact on their oral condition was minimal because they consumed both the cariogenic as well as anti-cariogenic food types. For example, the fruit juices are cariogenic but the evaporated milk and bacons are anti-cariogenic. This might have accounted for the similar caries and periodontal prevalence observed in both the obese and non-obese children. 5.9 Weekly intakes of different foods in various food groups The weekly frequency of intake was assessed by asking the number of times a particular food was eaten in a week. The mean number of intakes was compared between the obese and the non-obese children. The foods that showed significant mean differences included, fruit juice, evaporated milk, milk drink (eg. cowbell), pizza, corned beef and water melon. The obese group significantly consumed more frequently the fruit juices, p=0.001, milk products, p=0.035 and pizzas, p=0.007. The non-obese group more frequently consumed corned beef, p=0.009 and watermelon, p=0.010 in a week. For the rest of the foods both groups had similar weekly frequency of intake. 100 University of Ghana http://ugspace.ug.edu.gh The high frequency of intake of the above foods was expected to have very little differential effect on the oral health status of the obese and the non-obese group since most of the foods did not show any significant differences in their weekly consumption. This again may account for low prevalence and lack of significant differences in the oral conditions found in both the obese and non-obese groups. Cariogenicity of a food is just one of the major factors in caries development and it has more influential role when host and environmental conditions favour the disease. Diet is therefore less of a factor in caries risk when adequate oral hygiene and daily fluoride use are observed (Bowden et al., 1976; Axelsson and Lindhe, 1978; Marsh, 1989). Nine out of every ten dental expert believe that the principal dietary message for caries prevention should be reduction in the frequency of cariogenic foods. (van Loveren et al., 2004). Advice from dental professionals to promote good oral health includes healthy eating habits, eating breakfast and increased intake of fruits and vegetables, and in addition to reduce the intake of sugary beverages. The emphasis for caries prevention and healthy living should be based on good diet and dietary practices. (Duggal et al., 2001). If children are taught to observe these recommendations both at home and school oral disease risk will be very low as observed in this study. 5.10 Physical Activities and effect on oral conditions Studies have linked exercise with the risk of periodontal condition at least in adults. People who have maintained their normal weight and practiced healthy diet accompanied by regular exercise, reduced their periodontitis risk up to 40% (Al-Zahrani et al., 2005). This was not observed in people who maintained normal weight, good diet but did not practice regular exercise. This gives an indication that lack of adequate physical activity may increase the risk of oral condition especially periodontal diseases (Dauglass, 2005). 101 University of Ghana http://ugspace.ug.edu.gh This study showed that less than half of both the obese and non-obese children wake up before 5:00 am and about the same proportion wake up between 5:00 and 6:00 am. This was expected because the students had to get up early enough to prepare for school. Most schools start morning classes by 8:00 am. After waking up most children do some house chores before school. The commonest house chores that they do include sweeping, washing dishes and other activities (e.g., washing clothes, bathing siblings). These may not be considered adequate physical activity. About a third of the children said they do not do any house chores at all in the morning before school. This means very little or no physical activity in the morning before school apart from actions involving taking their own bath before school. Significantly more non-obese children walk to school while more of the obese than the non-obese children are driven to school by their parents, p=0.001. For those who walk to school, more of the non-obese do so daily than the obese children. The walk to school will increase their level of physical activity. 5.11 Sedentary activity of the children Television watching and computer games are considered sedentary activities especially among young children. Very low proportions (17-20%) of the children said they watch Television before going to school in the morning. For those who reported watching TV, most of them watch it at the weekend and they spend 2 hours or more watching. Less than half of all the children play video games. For those who do, it is not a daily occurrence and they spend between 1-2 hours on average playing the games. These sedentary activities in the children in themselves may only contribute to their weight gain and to a less extent influence their risk of periodontal disease. Since obesity seems not to have any association with oral conditions from this study, no significant effect is expected by the video games 102 University of Ghana http://ugspace.ug.edu.gh on oral conditions. Only when the video game is accompanied by snacking on sugary foods in the absence of good oral hygiene would their oral health be affected. A study on the effect of obesity and lifestyle on oral health in pre-adolescent children in Chennai, India, reported that when TV watching and video games are accompanied by high energy snacks oral health is affected. Significant association was observed between poor oral hygiene and long period of video games and TV watching. They also reported that the longer they play the computer games the more snacks they consumed (Nithya et al., 2014). 5.12 Snacking during TV watching The proportions of children who indicated snacking during television watching was high, over 70%, but the practice was not frequent and the distribution was similar between the obese and the non-obese. This means that though the practice was common the impact of snacking during TV watching may have little effect on oral health especially if it less frequently done coupled with good oral hygiene. A study of TV watching on snacking reported that the effect extends far beyond the time of television watching to affect subsequent consumption. This they called snack attacks (Higgs and Woodward, 2008). If the effect extends beyond the period of watching TV then it may imply that snacked foods that started during the TV watching will be continued long after the TV shows and this might contribute to increased risk of caries in the absence of good oral hygiene. In the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study in Europe, it was reported that boys significantly chose beers and soft drinks while girls chose fruit juices, water and sweets during TV watching, (Rey-López et al., 2011). They also showed that watching TV for more than two hours in a day was significantly associated with the intake of energy-dense foods and drinks (Van den Bulck 103 University of Ghana http://ugspace.ug.edu.gh and Van Mierlo, 2004; Rey-López et al., 2011). The result from this study did not show this effect. Possible reason being that the children in this study had good oral hygiene practice as indicated by low plaque index. 5.13 ORAL HYGIENE PRACTICES Oral hygiene practices involve those actions and behaviors that ensure oral cleanliness and promote good oral health. These include oral cleaning at least twice a day, brushing the teeth with the appropriate material (especially fluoride containing dentifrices) and regular visit to a dental clinic. In this study only about a third of all the children have ever visited a dental clinic. Almost all those who said they visited the dental clinic were also observed to have some oral health condition as most likely these conditions would have caused them to attend the dental clinic in the first place. Regular dental visit is good for early detection and treatment of oral diseases. 5.14 Tooth brushing habits Brushing the tooth with fluoride containing paste has been the most effective preventive public health measure to check caries (Marinho et al., 2003, Petersson et al., 2007, Petersson, 2013). Nearly all the studied children brush their teeth every morning, while less than halve do so at night. Studies have demonstrated that with effective regular brushing with fluoride paste, the contribution of diet to the risk of caries becomes less significant (Axelsson and Lindhe, 1978). With this high proportion of the children practicing good oral health habits, the relatively low level of caries reported was expected in both groups. 104 University of Ghana http://ugspace.ug.edu.gh 5.15 Tooth pick use and flossing Tooth pick use was common among the children. People are encouraged to use toothpick to remove food debris between teeth to reduce caries but the use may result in injury to the gum when it is not carefully done. Tooth pick injury can result in serious infectious complications (Chang et al., 2003). Incidence of toothpick injury in children in 1982 was 3.6/100,000/year. This incidence occurred mostly in children aged 5 to 14 years (Budnick, 1984; Lawrence and Budnick, 1984). Flossing is another preventive measure to reduce the risk of caries in the mouth by removing food particles between the teeth. Floss knowledge was very low and similar in both obese and non-obese children. Very low proportion of those who said they knew about floss had ever used it. Flossing habit can mostly be acquired if children are introduced to it early in life and are motivated to do it (Judah et al., 2013). Low levels of flossing as seen in this study is mainly due to their lack of knowledge about it. Even among university students tooth flossing is reported to be low (Schüz et al., 2006) 5.16 Oral hygiene status among the study groups Oral hygiene status (oral cleanliness) is defined by the degree of plaque and calculus accumulation as estimated by Plaque and calculus Indices. Abundant plaque at the gingival margin was observed in less than half of the children. Supragingival calculus was common in the two groups, while subgingival calculus was observed in only few of the children. There was no significant difference in the level of plaque and calculus between the obese and the non-obese groups. A Tanzanian study among 14-17 year old students reported similar plaque and calculus score among the sample. In the Tanzanian study most of students had supragingival plaque (74%) and calculus (56.9%) and it was more common in males than females (Carneiro and Kabulwa, 2012). A Uganda report in 2007 also showed 105 University of Ghana http://ugspace.ug.edu.gh lower plaque and calculus scores of 25.9% (Batwala et al., 2007). Plaque is responsible for the inflammation in the gum leading to plaque induced gingivitis. 5.17 Silness and Lӧe score for overall oral hygiene status This score combines the plaque and calculus accumulation around six index teeth after probing to assess the overall oral hygiene status of the child. The overall oral hygiene status was good and was not significantly different for the two groups, (p=0.066). 5.18 Healthy sextants among the school children To examine which part of the mouth is mostly affected the mouth was divided into six parts called sextants. Index teeth in each sextant were probed. CPITN score of zero implied a healthy sextant. The distribution of healthy sextants showed that over 75% of the children had at least one or more sextants affected but mildly. Less than 10% of the sample had complete healthy sextants. This implies that though there were no serious oral conditions except mild forms in the children, those who had it seem to have the condition generalized in the mouth. This then calls for continuous monitoring of the oral hygiene status of the school children before the conditions spread any further. 5.19 Age impact on caries prevalence The caries prevalence was lower in the older than the younger children and was similar among the obese and the non-obese groups. At age 12 most of the children would have lost their primary teeth, acquired oral hygiene habits and would have been old enough to choose their own snacks. For these reasons this age group is recommended by WHO to be used to determine the population prevalence of caries (WHO, 2001) among children. The caries prevalence in the 12 year old obese was nearly twice that of the non-obese children but was not significant. Compared to a study carried out in the US for children aged 2-11 106 University of Ghana http://ugspace.ug.edu.gh years, 41% had dental caries in their primary teeth and 42% of the children and adolescents aged 6-19 years had it in their permanent teeth. Prevalence was higher in females (44.5%) than males (39.5%). About 32% had received dental sealants (Eugenio et al., 2005). In a Nigerian study on 12 year olds, caries prevalence was 13.9 % with mean DMFT of 0.14. More than 85% of the children were caries free (Adekoya-Sofowora et al., 2006). Caries trends among adolescents 11 – 16 year olds in Lagos, Nigeria showed that 23.4% were carious with mean DMFT score of 0.72±1.67. Females had higher caries than males but was not influenced by their socioeconomic conditions (Umesi-Koleoso et al., 2007). The caries prevalence reported in a private school in India was 27.6% (Swati et al., 2010). A Swedish longitudinal study on obese and non-obese children reported that obese adolescent children significantly had higher caries than their non-obese counterparts (Alm et al., 2011). In this study though the 12 year old obese adolescents had nearly twice caries prevalence than their non-obese counterparts this was not significant. The prevalence was slightly higher than the Nigerian reported prevalence for the same 12 years olds. The general caries prevalence was relatively low 15.1% as compared to the US and Indian studies. The good oral hygiene status of the children in this study may be responsible for the low caries. 5.20 DMFT scores among the obese and the non-obese Mean DMFT score was used to estimate the degree of caries among the children and was similar in the two groups. The results showed that more of the non-obese had the worse form of caries than the obese group. A Ugandan study among 5-12 year old school children reported mean DMFT of 1.6±0.9 in permanent teeth and 3.0±1.9 milk teeth (Batwala et al, 2007) which was far higher than what was found in this study. The Ugandan study showed 107 University of Ghana http://ugspace.ug.edu.gh that Children in private schools were more likely to have caries in permanent teeth than in public schools. In this study only the decay component of the DMFT was higher than in the Nigerian study but the filling component as well as the missing components were lower than the report in the Nigerian study. In the Nigerian study on 12 year olds, the decayed component was 77.2%, filling was 15.8% and missing teeth was 7% (Adekoya-Sofowora et al., 2006). Low level of filling in the Ghanaian children might be due to low interest in filling of carious teeth for the children probably thinking those teeth might be replaced anyway in later life. Only a third of the children said they have ever visited the dental clinic where fillings are normally done. 5.21 Prevalence of gum disease (gingivitis) The health of the gum is defined by the gingival index. The study showed most of the children had high levels of healthy gums. Only about 10% of the children had mild gingival condition (manifested as slightly red and swollen gums). Severe gingivitis, observed as enlarged swollen gum with exudates, was seen in only just few of the children and the overall prevalence of mild to moderate gum disease among the obese in the non-obese groups was about 12%. This compares favorably with the prevalence of gum disease in Ugandan study (Batwala et al., 2007), but was far lower than prevalence from the Indian study that gave gum disease prevalence among 10-12 year olds as 81% (Deepak et al, 2010). 5.22 Association between dietary factors, caries and gum disease The likelihood of developing oral conditions was similar in the obese as in the non-obese (OR= 0.478, (95% CI, 0.150 - 1.522). This demonstrates no significant difference of oral condition among obese and non-obese children. Examining the association between caries prevalence and various oral hygiene practices among the obese and the non-obese groups, 108 University of Ghana http://ugspace.ug.edu.gh only dental visit was significantly associated with caries among the non-obese and not in the obese group, P=0.018. Tooth brushing, toothpick and floss use were not significantly associated with caries prevalence. Pubertal age was significantly associated with caries among obese, p=0.032, but not in the non-obese. There was no significant association between any of the dietary factors with caries, gum disease or the two conditions combined. Frequency of daily snacking, number of units of soft drink per day, availability and accessibility to soft drinks, were not significantly associated with the prevalence of oral conditions in the children studied. A binary logistic regression analysis to reveal possible significant odd ratios for factors associated with caries and gum disease, the results showed that only people who did not snack during TV watching significantly had lower odds of developing oral conditions, OR = 0.334 (0.121-0.920), p=0.034. 5.23 Oral bacterial infection in the obese and non-obese school children Both caries and gum conditions are infectious diseases caused by specific putative microbes. For caries to develop, factors such as sugar substrate, susceptive tooth surface and the presence of microbes in the plaque must be present. Dietary as well as oral hygiene practices may favor these conditions for the development of caries and gum infections. This study investigated in the obese and non-obese children, major bacteria associated with caries and gum disease. Only prevalence of Streptococcus mutans infection was significantly higher in the obese (41.3%) than the non-obese (26%), p=0.033. Actinobacillus actinomycetemcometans infection in the non-obese (15.6%) was about twice that in the obese (6.7%) but was not significant. Lactobacillus species was positive 109 University of Ghana http://ugspace.ug.edu.gh for only 2 children. No positive culture was observed for P. gingivalis in the children. Thus, similar infection rates were observed in the children irrespective of their obese status. These findings indicate that the presence of the microbes alone was not enough to cause the disease condition in the children. If oral hygiene status of the children is adequate there is less likelihood of developing oral conditions in the children even in the presence of the bacteria (Bowden et al., 1976; Marsh, 1989). 5.24 Risk factors associated with oral disease In the literature the dietary factors known to be associated with caries and other oral health conditions include the following; High sugar intake especially added sugar, fruit drinks with high sugar content, some nutrient supplementation, soft drinks with high acidic content, eg., coke and fanta and frequency of snacking. Also snacking during TV watching and lack of raw fruits in diet are associated with the oral conditions. This study did not observe any significant association of any of these factors with the prevalence of either caries or gum disease among the school children studied. The likely reasons for these observations are; (i) This study observed adequate oral hygiene status among the school children irrespective of their obesity status. Their frequent morning brushing and sometimes night brushing was adequate to keep caries and gum disease low. Though their snacking habits can be said to be very high, their normal brushing practices could have helped to minimize the possible effect of the snacking on the oral health of the children. (ii) The obese as well as the non-obese children had similar dietary and oral hygiene habits so it was expected that they will have similar oral health outcomes or status. 110 University of Ghana http://ugspace.ug.edu.gh (iii) This low prevalence of oral conditions in this population could also be due to the fact that many of the children came from families which can be classified as middle to higher socioeconomic status. These families are more likely to have the means to readily provide mouth cleaning materials, provide the motivation for the children and also more likely to ensure that the children comply with oral hygiene instructions given by the parents. 5.25 Examining possible association between obesity and oral diseases in the public school using case control design Following the result obtained in the children from private schools, the phase two of the study used a case control study design to examine if the prevalence of oral disease was associated with obesity status in the public school or similar to what was observed in the private school. The cases were children with oral disease (caries or gum infection) and the controls were children without any oral disease. Obesity status was then compared between the cases and the controls. Caries prevalence, DMFT scores and gum diseases were not significantly associated with the weight status among the public school children, (the obese, overweight and normal weight children). The odds ratio for developing caries and gum disease was not significantly different among the obese and the non-obese children. The overall prevalence of oral infection (tooth and gum) was not significantly associated with body weight (obese, overweight and normal weight). Thus similar prevalence was 111 University of Ghana http://ugspace.ug.edu.gh observed in the normal, as well as the overweight/obese as well as in the obese and the non-obese. 5.26 Oral hygiene indicators in the public school children The oral hygiene practice of this population was adequate. This was confirmed by the fact that majority of the children had barely visible plaque and just about 24% had abundant plaque at the gingival margin. The bacteria in the subgingival plaque are often the major source of irritation of the gum that often leads to gum inflammation. Supra-gingival calculus was observed in more than half of them and just few had sub-gingival calculus. Both plaque and calculus indices were not significantly associated with any of the weight categories observed. The overall oral hygiene status as estimated by mean Silness and Lӧe plaque index was less than 1.0 and this implies adequate overall oral hygiene status for the children irrespective of their weight status. Gingival index which estimates the health of the gum showed that less than a third of the public school children had mild to moderate gum conditions shown as shiny, slightly red or swollen or marked reddening (mild), obviously enlarged with swollen exudates (moderate). This result again confirms no significant association between oral health and weight categories in Ghanaian children. 5.27 Dietary practices between the case and controls in relation to their weight status The dietary habits of the cases and controls were similar across the weight categories. Frequency of food consumption is one of the critical factors that influence caries risk and since this was similar in both the case and control groups and across weight categories of the children no significant increased risk was observed. 112 University of Ghana http://ugspace.ug.edu.gh Just about a third (35.7%) of all the public school children indicated taking breakfast at home. In addition, among those who take breakfast only 15.9% indicated doing it always while the rest of them do so often. Significantly lower proportion of those who had some form of oral conditions took breakfast than those who did not. This shows a significant association between oral infection and breakfast intake. Also significantly lower prevalence of oral disease was observed among obese and non-obese children who took breakfast than those who did not take breakfast. Possible explanation is that food intake is associated with continuous flow of saliva which has both buffering and cleansing effect in the mouth. Dry mouth or low saliva flow is associated with high caries risk (Dawes, 2004; Peng et al, 2004; Stookey, 2008). Thus among the public school children breakfast intake was helpful in lowering oral infection especially if that foods consumed had relatively low sugar contents. The breakfast meal also provided energy for the morning activity which is likely to reduce the need for snacks therefore reduce snack intake. Therefore among the public school breakfast intake was significantly associated with lower prevalence of oral infections. No significant differences were observed in the levels of snacking among the cases and controls and across the weight status. All the children consumed similar types of snacks with fruit juices and raw fruits being the commonest snacks and nuts the least snack consumed. Snacking at school was more common than at home. This could be due to the fact that only about a third ate breakfast before school started just as in the private school children. Breakfast food contributes a high proportion to the intakes of energy and nutrients to the child (Nicklas et al., 1993; Nicklas et al., 2000; Deshmukh-Taskar et al.; 2010). The low intake of breakfast will mean that by the morning break when the children 113 University of Ghana http://ugspace.ug.edu.gh become hungry they are more likely to choose snacks rather than buy whole foods to satisfy their hunger hence the high level of snacking. If snacking is accompanied by good oral hygiene the risk of oral diseases is lowered. The adequate oral hygiene status of the school children ensured low overall caries and gum disease. The general observation from this study is that Ghanaian school children have good oral hygiene habits and this might have accounted for the low oral health diseases prevalence irrespective of their weight category. In addition though their snacking behaviors could be said to be high this did not show any significant association with their oral infections. Breakfast intake before start of school was low in both private and public schools. Just about a third took breakfast and this did not affect the prevalence of oral diseases among the private school children but seem to be associated with low prevalence of oral disease among the public school children. The results of this study agrees with other reports that obesity in children may not be significantly associated with oral infectious diseases. Thus irrespective of snacking behavior once oral hygiene practices were adequate, caries and gingivitis can be kept to the barest minimum. 114 University of Ghana http://ugspace.ug.edu.gh CONCLUSION AND RECOMENDATIONS Conclusion The prevalence of oral conditions in obese and non-obese Ghanaian children was relatively low and similar in the two groups. This implies that obesity in children though may increase the risk of other disease conditions, in Ghanaian children between the ages of 9- 15 years, obesity was not significantly associated with developing dental caries and gum disease possibly because of relatively better oral hygiene practices. Therefore the hypothesis that obese children have higher oral disease was not proven by the study. It was also hypothesized that obese children would have poor dietary and oral hygiene status but the school children irrespective of obesity status had similar dietary practices and oral hygiene habits which were adequate to keep the prevalence of oral diseases low. Oral health status of the school children did not give any indication of worsening oral health condition even though snacking was very common among the children. The hypothesis that higher oral bacterial infection will be observed in the obese children was only proven for streptococcus mutans. The major oral bacteria known to cause caries and gum disease did not show significant difference among the obese and non-obese except for Streptococcus mutans which was significantly higher among the obese than the non-obese. Streptococcus mutans infection though higher in the obese did not reflect any significant association with caries prevalence in the obese group. Similar findings were observed in the private and public school children. There was no significant difference in the oral health status between the obese and non-obese children in private or public schools. Dietary habits and oral hygiene practices in the public school children were similar to that observed among the private school children. Level of 115 University of Ghana http://ugspace.ug.edu.gh breakfast intake was similar in children from both private and public schools. Among the public school children breakfast intake was significantly associated with lower caries in both the obese and the non-obese groups. This was not observed in the private school children. None of the known risk factors associated with oral disease in both adults and children was shown to have any significant association with the prevalence of oral disease in the Ghanaian children studied. Among private school children, dental caries and gum diseases were not significantly higher in the obese. In the public school, dental caries and gum disease (cases) and those without oral disease (controls) were not significantly associated with weight status. Thus oral health was not significantly associated with obesity status among Ghanaian children. Of all the hypothesis tested only the significant higher infection of streptococcus mutans in the obese was confirmed by the study. RECOMMENDATIONS Though this study did not establish any significant association between child obesity and oral conditions in the Ghanaian school children it will be necessary to continue to monitor this association in order to early detect changes when they occur. This study is the first of its kind, to best of our knowledge, in examining dietary habits, oral hygiene practices and oral health status in obese Ghanaian school children and it therefore can serve as baseline for further monitoring of dietary and oral health conditions among school children. 116 University of Ghana http://ugspace.ug.edu.gh For now, there is no association between obesity and oral conditions but there is a need to intensify the oral health education as well as advocate weight control measures among school children because childhood obesity has tracks to adulthood with many health risks including oral diseases. Obesity in Ghanaian children must continually be monitored to reduce or eliminate the early onset of related health complications. This must include parents and teachers encouraging the children to have breakfast before living for school. 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Comparison of the microbiota of supra- and subgingival plaque in health and periodontitis. J Clin Periodontol Sep;27(9):648-57. Ximénez-Fyvie LA, Haffajee AD, Socransky SS. (2000). Microbial composition of supra- and subgingival plaque in subjects with adult periodontitis. J Clin Periodontol. Oct;27(10):722-32. Yi HK, Hwang PH, Yang DH, Kang CW, Lee DY. (2001). Expression of the insulin-like growth factors (IGFs) and the IGF-binding proteins (IGFBPs) in human gastric cancer cells. Eur J Cancer. Nov;37(17):2257-63. Yin N, Wang D, Zhang H, Yi X, Sun X, Shi B, Wu H, Wu G, Wang X, Shang Y. (2004). Molecular mechanisms involved in the growth stimulation of breast cancer cells by leptin. Cancer Res. Aug 15;64(16):5870-5 Yu H, Rohan T. (2000). Role of the insulin-like growth factor family in cancer development and progression. J Natl Cancer Inst. Sep 20;92(18):1472-89. 144 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix 1 INDEX TEETH PROBED FOR CARIES AND GUM DISEASE Index teeth UR6, UR1, UL6, LL6, LL1, LR6 and grid for recording simplified (Basic Periodontal Examination (BPE) in the under-18s (Clerehugh, et al, 2001) Probing technique with WHO 621 on LL6 index tooth 145 University of Ghana http://ugspace.ug.edu.gh Appendix 2 CHILD OBESITY AND ORAL HEALTH STUDY QUESTIONNAIRE QUESTIONNAIRE TO ASSESS THE EFFECT OF OBESITY ON ORAL HEALTH RISK AMONG PUPILS IN SELECTED BASIC SCHOOLS IN ACCRA A. BACKGROUND INFORMATION 1. Date of interview (dd/mm/yy) _________________ 2. Subject ID ________________ 3. Name of school __________________________________ 4. Name of respondent ______________________________ 5. Sex of respondent 1=Male 2-Female 6. Age of respondent (completed years) __________________ 7. Date of birth of respondent (dd/mm/yy) ___________________ 8. At which stage/level are you in the school?: 1. Primary 2. Junior High 9. In which class/form are you? ______________________________ B. SOCIODEMOGRAPHIC DATA 1. Are you living with both parents: 1=Yes, 2=no 2. If no who are you living with [1]Relative [2] Family friend, [3] Grandparents) [4] Other __________ 3. Father’s Educational level [0] None, [1] Primary/Elementary [2] Secondary [3] Post-secondary [4] Tertiary [5] Other (specify) ……………………………………………. 4. Mother’s Educational level [0] None, [1] Primary/Elementary [2] Secondary [3] Post-secondary [4] Tertiary [6] Other (specify) ………… 146 University of Ghana http://ugspace.ug.edu.gh 5. Occupation of father: …………………………………… 6. Occupation of mother: …………………………………… 7. Tenancy status: [1] Own house [2] Family house [3] Rented house [4] Company/mission house [5] Government house [6] Caretakers 8. How many children are you in your family? ___________________ 9. Does your family own any of the following? Saloon car or any other vehicle 1=Yes 2=No Refrigerator/Deep freezer 1=Yes 2=No Gas/electric cooker 1=Yes 2=No Television 1=Yes 2=No Video deck/VCD player 1=Yes 2=No Air conditioner 1=Yes 2=No C. FOOD / EATING HABITS 1. How many times in a day do you usually eat? [1] Once [2] Twice [3] Thrice [4] Four-five times [5] >5 times [6] Other (specify) ………………………………………… 2. Where do you usually get your food? [1] Home [2] Chop bar [3] Roadside vendors/sellers [4] Restaurants/Shops [5] School canteen [6] Other (specify) ______________________________ 3. What foods don’t you like/do you avoid? ___________________________________ 4. Why do you dislike such foods? [1] Not applicable [2] Taste [3] Appearance [4] Health (allergy) [5] Culture [6] Other (specify) ___________________ 5. Do you take nutrient supplements? 1=Yes 2=No 5a. If yes, what type of supplements do you take? [1] Multivitamins [2] Minerals, [3] Vitamins and minerals [4] Blood tonic [5] Other (specify) ___________________________ 147 University of Ghana http://ugspace.ug.edu.gh 5b. why do you take this supplements? [1] Medical reason, [2]For appetite [3] Reduce weight, [4] other _______ 6. What is your favorite meal time? [1] Breakfast [2] Lunch [3] Supper [4] Snacks [5] Other _____________ 7. Why is the above meal time your favorite? ______________________________ 8. Which of the following meals do you usually skip? [1] Breakfast [2] Lunch [3] Supper [4] Snacks [5]. None 6. Other (specify) ___________________________________ 8a. Why do you skip the above meal? 1. Not hungry 2. Lack of time 3. Don’t like foods served (taste) 4. Food is inadequate 5. NA 6. Other (specify) _____________ 9. Do you eat breakfast before coming to school every day: [1] Yes, [2] No 10. How often do you eat at home before coming to school? [1] Always [2] Very often [3] Sometimes, [4] Rarely, [5]Never 11. What food do you often take for breakfast? (Tick as many as applicable) [1] Breakfast cereals (Koko, tom brown etc,) [2] Rice and stew, Jollof rice, etc [3]Red-Red, soya meal, [4] TZ, banku, kenkey [5] Ampesi , fufu, etc [6] Beverages (cocoa products, etc.) [7] Waakye (rice and beans) [8] other (specify) ………………………………. 12. Do you eat at school during break time? [1] Yes, [2] No 13. What types of foods do you often take during break time? (Tick as many as applicable) [1] Breakfast cereals (Koko, tom brown etc, ) [2] Rice and stew [3]Red-Red, soya meal, [4] TZ, banku, kenkey [5] Ampesi , fufu, etc [6] Bevearges (cocoa products, etc.) [7] Waakye (rice and beans) [8] other (specify) ………………………………. 1. Do you take snacks after eating your meals at home? [1] Yes, [2] No 2. Do you take snacks after eating at school? [1] Yes, [2] No 148 University of Ghana http://ugspace.ug.edu.gh 3. What types of snacks do you often choose? [1] Raw Fruits [2]Fruit drink or juices [3] Sweets [4] Biscuits, cakes [5]Soft drinks / minerals [6]Nuts and something else etc [7] Others ………………………………………………………………………… 4. How much money are you given to school per day for food (in GHC/GP)? 1 = 10-50 GP 2 = 60GP-100GP 3 = 1-2GHC 4 = Greater than 2GHC 5 = None 6 = Other (specify) _____________________________________ 5. What food do you buy/take in school for break period? ___________________________________________________________ FREQUNECY OF SOFT DRINKS INTAKE IN THE PAST ONE WEEK 1. During the past week, how many days per week did you drink soft drinks? 0= never drank 1=I day/week 2= 2 days/ week 3=3 days/ week 4=4 days/ week 5=5 days/week 7=6 days/ week 7. Each day 2. On the days you consume soft drinks/minerals, how many bottles /day on average do you take? 1=1 bottle 2=2 bottles 3=3 bottles 4=4 bottles 5=5 bottles 6=6bottles 7=7 or more bottles 8= N/A 3. How do you feel when you drink soft drinks/minerals? 1=Great 2=Good 3=Not good/not bad 4=Bad 5=Very bad 4. How do you feel when you don’t drink soft drinks? 1=Very pleasant 2= Pleasant 3=Normal 4=Unpleasant 5=Very unpleasant 5. How do your parents feel about you taking soft drinks or minerals? 1=Completely good 2=Good 3=Not good/not bad 4= Bad 5=Very bad 6. How easy is it for you to get soft drinks/minerals to buy? 1=Quite easy 2=Easily 3= Not easily/not with difficulty 4=With difficulty 5=Very difficult 9. Usually, are there soft drinks/minerals in the house for you? 1=Yes 2=No 149 University of Ghana http://ugspace.ug.edu.gh 10. How frequently do you buy soft drinks/minerals from sellers at school? 1= Never 3= I day/week 4= 2 days/ week 5= 3 days/ week 6= 4 days /week 6= 5days/ week. SNACKS HABIT IN THE PAST ONE WEEK (These questions refer to the consumption of cakes, pies, doughnuts, biscuits in the past one week) 1. On the average, how many times in a day do you take snacks? _________ 2. How many days per week do you generally take snacks? _________ 3. How many times did you eat such foods yesterday? __________ D. PHYSICAL ACTIVITY 1. When do you usually wake up in the morning for school? 1 = Before 5.00 am 2 = 5.00-6.00 am 3 = 6.00-7.00 am 4 = After 7.00 am 5 = Other (specify) ______________________________________________ 2. What household chores do you do before going to school in the morning? 1=Sweeping (compound, rooms), 2=washing plates, 3= preparing breakfast, 4= feeding the pets 5=washing baby nappies, 6=others _____________________ 3. Do you often watch TV before going to school in the morning?, 1 = Yes 2 = No 4. If yes, how many hours do you watch TV before going to school? 1 = Less than one hour 2 = One hour 3 = Two hours 4 = Three hours 5 = More than three hours 6 = N/A 7 = Other (specify) ________________ 5. What means of transport do you often use to get to school? 1= Walk to school, 2= Cycle to school, 3=Ride motorbike to school, 4=driven to school by parent, 5=use public transport. 6=other _______________ 6. If you walk or cycle, how many times do you walk or cycle to and from school in a week? 1 = Daily 2 = 1-3 times per week 3 = 4-6 times per week 4 = N/A 6 = Other (specify) ____________________________ 7. Do you watch TV after school every day? 1 = Yes 2 = No 150 University of Ghana http://ugspace.ug.edu.gh 8. If yes, how many hours do you watch TV after school? 1= One hour 2 = Two hours 3 = Three hours 4 = Four hours 5 = Five hours 6 = > 5 hrs 7 = Other (specify) ……………… 8 = N/A 9. Do you play video games? 1 = Yes 2 = No 10. If yes, do you play video games every day? 1 = Yes 2 = No 3 = N/A 11. How many hours do you play video games each day? 1= One hour 2 = Two hours 3 = Three hours 4 = Four hours 5 = Five hours 6 = > 5 hrs 7 = Other (specify) ……………… 8 = N/A Snacking while watching TV or playing Computer game 12. While you watch TV or play computer games do you take any snacks? [1] Yes, [2] No 13. How often do you take snack while watching TV or play computer games? [1] Always, [2] Often, [3] Sometimes, [4] rarely, [5] Never 14. What types of snack do you take while watching TV or play computer games? [1] Pastries, [2] Soft drinks, [3] Fruits [4] Fruit drinks, [5] Natural fruit juice, [6] Other ………………. ANTHROPOMETRY FOR CHILD Weight: (kg) _______________ Height: (cm) _______________ BMI: (kg/m2) _______________ Waist Circumference: (cm) ___________________ Hip Circumference: (cm) ___________________ Mid upper arm circumference (MUAC) ___________________ 151 University of Ghana http://ugspace.ug.edu.gh FOOD FREQUENCY QUESTIONNAIRE Please tell me whether you ate any of the following foods during the past 24 hrs and the past week and how often? CODE SWEETENED DRINKS AND FRUIT 24hrs No. of time No. Of times Where do you JUICES 1 = YES, in the past per week get your food 2 = NO week from? 1=HOME 2=SCHOOL 3=STREET Sweetened drinks (Tampico, Kalyppo, Refresh) Fruit juices (Pure Heaven, Ceres, Nourisher) Malt drinks (Malta Guinness, Vitamalt, Amstel) Minerals (eg. Fanta, Sprite, Coca Cola) Other: MILK AND DAIRY PRODUCTS Evaporated milk Powdered milk Whole milk (fresh milk) Condensed milk Milk drinks (Countre Milk, Milko) Yogurt Cheese / Wagashi Cowbell Other: BREADS, BISCUITS AND CEREALS White bread (sugar or tea bread) Biscuits / cookies Cream crackers Cakes Pie (meat and fish) Pizzas Fried rice Other: FRIED FOODS Bofrot / Donuts Akara / Koose Fried plantain / Kelewele Fried sweet potatoes Fried yam / cocoyams Chips / Pastries Fried eggs Fried chicken and poultry Fried meat Other: 152 University of Ghana http://ugspace.ug.edu.gh 24hrs No. of time No. Of times Where do you 1 = YES, in the past per week get your food 2 = NO week from? CODE PROTEIN FOODS Meat (pork, beef, mutton, bush meat) Poultry (chicken, duck, turkey, birds) Kebab Corned beef / luncheon meat Sausage / Bacon Eggs Burgers Other: SPREADS AND TOPPINGS Margarine Butter Jam Groundnut (peanut) paste Chocolate spread Salad cream Mayonnaise Other: FRUITS Citrus (Orange, Tangerine, Grape fruit) Pineapple Water melon Mango Banana Avocado pear Pawpaw Guava Apple Fruit salad Other: OTHER HIGH FAT/CALORIE FOODS Chocolate Toffees/candies/lollipops Nuts (groundnuts/peanuts, cashew, tiger nuts) Sugar Ice cream Popcorn Other: 153 University of Ghana http://ugspace.ug.edu.gh ORAL HEALTH QUESTIONNAIRE Oral habits 1. Do you always brush your teeth in the morning? 1=Yes, 2=No 2. Do you often brush before going to bed at night? 1=Yes, 2=No 3. What do you use in brushing your teeth? 1=Toothpaste and brush 2=Chewing stick/sponge alone 3=Chewing stick/sponge and fluoride containing paste 4=Combination of all the above 5=Other, ________________________________ 4. How many times in a day do you often brush your teeth? ____________________ 5. Do you use tooth pick after meals 1=Yes, 2=No 6. Do you know what is flossing? 1=Yes, 2=No 7. If you know flossing do you use tooth floss 1=Yes, 2=No 8. Have you ever visited a dental clinic or seen a dentist? 1=Yes, 2=No, 3=Not sure 9. If you have visited a dental clinic how long ago? 1=Less than 3 months 2=Six month ago 3=1 year ago 4=2-4 years ago 5=Don’t remember 10. What was your main complaint when you went to the dental clinic? 1=severe toothache 2=Bleeding in the mouth 3=Mobile tooth 4=Lost tooth 5=Went for cleaning or checkup 6=Realignment of teeth in the mouth 7= Other complaint _____________________ Have you ever experienced the following conditions? 11. Bad Breath [1] Yes, [2] No [3] Don’t know 12. Red or swollen gum [1] Yes, [2] No [3] Don’t know 13. Tender or bleeding gum, [1] Yes, [2] No [3] Don’t know 14. Painful chewing, [1] Yes, [2] No [3] Don’t know 15. Loose teeth [1] Yes, [2] No [3] Don’t know 16. Sensitive teeth. [1] Yes, [2] No [3] Don’t know Do you currently experience the above conditions? 17. Bad Breath [1] Yes, [2] No [3] Don’t know 154 University of Ghana http://ugspace.ug.edu.gh 18. Red or swollen gum [1] Yes, [2] No [3] Don’t know 19. Tender or bleeding gum, [1] Yes, [2] No [3] Don’t know 20. Painful chewing, [1] Yes, [2] No [3] Don’t know 21. Loose teeth [1] Yes, [2] No [3] Don’t know 22. Sensitive teeth. [1] Yes, [2] No [3] Don’t know Periodontal Conditions Plaque index (soft debris) [0]= No plaque, [1] = Barely visible plaque, [2]= Abundant at gingival margin Calculus index (hard debris) [0]= No calculus, [1]= Supra gingival, [2] = Subgingival heavy unilateral Gingival index [0]= Pink, firm, stippled and no exudates [1] = Shiny, slightly red and swollen [2]= Marked reddening, obviously enlarged, swollen with exudates Caries Experience Decay teeth: 1=Yes, 0=No Number of decay teeth: ………………. Filled teeth: 1=Yes, 0=No Number of filled teeth: ………………….. Missing teeth: 1=Yes, 0=No Number of missing teeth: ………………. DMFT SCORE: …………………………………. CPITN SCORE UR6 UR1 UL6 LL6 LL1 LR6 155 University of Ghana http://ugspace.ug.edu.gh Other oral anomalies observed: 1. ._________________________ 2. ._________________________ 3. ._________________________ 4. __________________________ Oral plaque sample collected 1.Done, 2- Not done Silness and Loe plaque index chart Teeth surfaces Buccal Lingual Mesial Distal Total Index 16 12 24 36 32 44 Total (Silness and LÖe, 1964) 156 University of Ghana http://ugspace.ug.edu.gh Scores Criteria 0 No plaque 1 A film of plaque adhering to the free gingival margin and adjacent area of the tooth. The plaque may be seen in situ only after application of disclosing solution or by using the probe on the tooth surface. 2 Moderate accumulation of soft deposit s within the gingival pocket, or the tooth and gingival margin which can be seen with the naked eye. 3 Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin. Appendix 3: PARENT’S INFORMED CONSENT A study to assess childhood obesity and the effect on oral health status among school children in Accra Principal Investigators: Thomas A. Ndanu, Nutrition and Food science Department, Legon and Co-investigator: Dr Josephine Sackeyfio University of Ghana Dental School/College of Health Sciences Korlre Bu Introduction Childhood obesity is a problem in many parts of the world. There is concern about overweight and obese children because they are likely to become obese adults. Obese adults have high risk of many chronic diseases such as diabetes, hypertension and heart diseases. In addition other studies have shown that obese people tend to have poorer oral health (periodontal health). In Ghana, childhood obesity is seen mainly in urban cities. The extent of the problem among urban Ghanaian school children is not known. This study set out to find out the oral health conditions in both obese and non-obese children. It is hoped that through this study an appropriate guidelines will be developed to encourage healthy eating habits as well as better oral hygiene practices for school children in general and obese children in particular. 157 University of Ghana http://ugspace.ug.edu.gh Study procedures This study will recruit school children between the ages of 9-15 years (pre-adolescent and adolescent) attending selected private school in Accra. Children will be screened for overweight and obesity status assessment and those who are found obese will be compared to non-obese children of the same sex and age. The study will involve measurements of weight and height, mid-upper arm circumference and waist and hip. We will collect information on your child’s diet/food intake and usual eating patterns. We will also collect information on your child’s physical activity level using a standard questionnaire. On the scheduled date the child’s mouth will be examined by a trained dentist to assess the health of the mouth and the gum and see if there is any oral disease. Duration of study The study will take about 30 minute for each child. The interview will take about 20 minutes while the weight, height , body composition assessment will take about 10 minutes. Benefits The results of the weight and height measurements and child’s nutritional status will be communicated to the child. If any adverse oral health condition is detected the child will be referred to the University of Ghana Dental School clinic or any dentist of your choice for follow up. There will be no other direct benefits to your child for participating in this study. However, the information provided from the study will help us understand the impact of childhood obesity on oral health problems in Ghana and how we can develop appropriate educational guidelines for proper eating habits and good oral care among school-aged children. Risks to the individual There are no foreseeable risks associated with this study. All procedures to be carried out are routine and pose no danger to your child. Costs There is no cost to participants in this study. Participation is totally free. Confidentiality All data collected will be kept in strict confidence and used for purely research purposes. You can be sure that no information by which you or your child can be identified will be released or published in any of our study report. No participant will be identified by name in any report. 158 University of Ghana http://ugspace.ug.edu.gh Voluntary participation and subject rights Your child’s participation in this study is voluntary. If you refuse the participation of your child in this study, it will not affect him in any way. You can choose to withdraw your child from the study at any stage without penalty or loss of benefits to which he or she is entitled. Please feel free to ask questions at any time regarding this study. You will be given a copy of this consent form. Contact Please contact the Principal Investigator at the following address if you have any further questions, need clarifications about your rights or experience any problems in this study: Thomas. A. Ndanu University of Ghana Dental School; College of Health Science, UG Box KB 460 Korle Bu Tel: 0244872410 Email: nutcaresoft@gmail.com If you have any questions about your rights under this study you may contact the following address: Rev. Dr. Ayete-Nyanpong; Tel: 0208152360 Declaration by Parent /Guardian “THE STUDY HAS BEEN EXPLAINED TO ME AND MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I GIVE CONSENT TO MY CHILD’S PARTICIPATION IN THIS PROJECT”. ----------------------------------------------------------------------------------------------------------- Parent’s name ---------------------------------------- -------------------------------------- Parent’s signature Date ----------------------------------------- --------------------------------- Researcher’s signature Date 159 University of Ghana http://ugspace.ug.edu.gh Appendix 4 CHILD’S INFORMED CONSENT A study to assess childhood obesity and the effect on oral health status among school children in Accra Principal Investigators: Thomas A. Ndanu, Nutrition and Food science Department, Legon and Co-investigator: Dr Josephine Sackeyfio University of Ghana Dental School/College of Health Sciences Korle Bu Introduction Overweight or obesity in childhood is a problem in many parts of the world. There is concern about this condition in children because they are likely to become obese adults. Obese adults can easily develop chronic diseases such as diabetes, hypertension and heart diseases. In addition other studies have shown that obese people tend to have poorer oral health. In Ghana, overweight and obesity in childhood is seen mainly in urban cities. The extent of the problem of child obesity among urban Ghanaian school children is not known. In this study we hope to find out the oral health conditions in both obese and non-obese children. We also wish to know how the obese condition affects their social interactions. It is hoped that through this study we can develop appropriate guidelines to encourage healthy eating habits as well as better oral hygiene practices for school children in general and obese children in particular. Study procedures This study will recruits school children between the ages of 9-15 years (pre-adolescent and adolescent) attending private schools in Accra. Children will be screened for overweight and obesity and those who are found obese will be compared to non-obese children of the same sex and age. The study will involve measurements of weight and height, mid-upper arm circumference and waist and hip. We will collect information on your diet/food intake and usual eating patterns. We will also collect information on your physical activity level using a standard questionnaire. 160 University of Ghana http://ugspace.ug.edu.gh On the scheduled date your mouth will be examined by trained dental personnel to assess the health of the mouth and the gum and see if there are any oral diseases. Duration of study The study will take about 30 minute for each child. The interview will take about 20 minutes while the weight, height , body composition assessment will take about 10 minutes. Benefits The results of the anthropometric measurements and your nutritional status will be communicated to you. When any adverse oral health condition is detected you will be referred to the University of Ghana Dental School clinic or any dentist of your choice for follow up. There will be no other direct benefits to you for participating in this study. However, the information provided from the study will help us understand the extent of childhood obesity in Ghana and some of the oral health problems associated with it. This will help us develop appropriate educational guidelines for proper eating habits and good oral care among school-aged children. Risks to the participant There are no foreseeable risks associated with this study. All procedures to be carried out are routine and pose no danger to you. Costs There is no cost to participants in this study. You don’t have to pay for anything it is totally free. Confidentiality All data collected will be kept in strict confidence and used purely for research purposes. You can be sure that no information by which you can be identified will be released or published in any of our study report. No participant will be identified by name in any report. 161 University of Ghana http://ugspace.ug.edu.gh Voluntary participation and subject rights Your participation in this study is voluntary. If you refuse to participate this study, it will not affect you in any way. You can choose to withdraw from the study at any stage without penalty or loss of benefits to which you may be entitled. Please feel free to ask questions at any time regarding this study. You will be given a copy of this consent form. Contact Please contact the Principal Investigator at the following address if you have any further questions, need clarifications about your rights or experience any problems in this study: Thomas A. Ndanu: University of Ghana Dental School; College of Health Science, UG Box KB 460 Korle Bu Tel: 0244872410 Email: nutcaresoft@gmail.com If you have any questions about your rights under this study you may contact the following address: Rev. Dr. Ayete-Nyanpong Tel: 0208152360 Declaration by Child “THE STUDY HAS BEEN EXPLAINED TO ME AND MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I GIVE MY CONSENT TO PARTICIPATE IN THIS STUDY”. ---------------------------------------------------------------------------------------------------------- Child’s name ---------------------------------------- -------------------------------- Child’s signature or thumb print Date ----------------------------------------- ---------------------------------- 162 University of Ghana http://ugspace.ug.edu.gh Researcher’s signature Date Appendix 5 SUMMARY FOR LAY PUBLIC A study to assess the effect of childhood obesity and its risk factors on oral health among school children in selected School in Accra Metropolitan Area. Principal Investigator: Thomas Akuetteh Ndanu University of Ghana Dental School, CHS/ Korle Bu Dept. of Nutrition and Food Science, UG, Legon and Introduction Obesity in childhood has become a major concern in many parts of the world because these overweight and obese children easily become overweight or obese adults. Obesity sets the stage for many chronic diseases such as diabetes, hypertension and heart diseases in adulthood. The extent of the problem among Ghanaian school children is not known and the impact it has on these children has not been investigated. This study is to investigate the extent of the problem and the oral health and psychological impacts it is having on the children in Accra. It is hoped that through this study we can better understand the problem and come up with ways for encouraging healthy eating, physical activity and better oral habits among the school children. The survey will involve primary and junior high school children between the ages of 9-15 years from private schools in Accra. Selection of schools Selected private Primary and Junior High Schools will be invited to participate. A letter explaining the objectives of the study will be sent to Ghana Education Service for permission to be granted for the study to be conducted among schools children. A similar letter will be sent to the heads of the selected schools for the study to be conducted in their 163 University of Ghana http://ugspace.ug.edu.gh schools. About 20 private schools having both primary and Junior High School (JHS) departments will be randomly chosen. Recruitment of participants within schools Within each school, children in primary 4 to 6 and JHS 1 to 3 will be recruited because they are the ones most likely to fall in the age range of 9 – 15 years. The class register of children (aged 9 – 15yrs) will be obtained from the various class teachers. All students within the selected class within the age group will be screened for overweight and obesity. Those who will be identified will receive letters to their parents for consent. A letter explaining the objective of the study will be sent by the children to their parents. The letter will have a section where parents will give consent for the child to participate in the study. Children who have parental consent and they themselves have expressed willingness to participate will be included. Children will be excluded from the study if their parents do not give approval. For those children whose parents give approval, weight and height measurements will be taken and will also be interviewed about their eating habits and physical activity. Oral screening will be done to look for oral disease and caries. Overweight and obese children will be compared with normal weight children of the same age and sex. It is hoped that the results of this study will give us better understanding of childhood obesity in Ghanaian school children and their impact on oral health and how we can reduce both the obesity and oral condition in these children. 164 University of Ghana http://ugspace.ug.edu.gh Appendix 6 PERMISSION LETTER TO GES PERMISSION TO CARRY OUT A STUDY ON CHILD OBESITY AND ORAL HEALTH RISK IN SCHOOLS We wish to seek permission from the Ghana Education Service to carry out a study on the topic; Childhood obesity and oral health risk. This study is being undertaken by the Department of Community and Preventive Dentistry of the Dental School, Korle Bu in collaboration with the Department of Nutrition and Food Science, University of Ghana, Legon. This study is an extension of an earlier study approved by GES on the topic, Prevalence of Child Obesity in Urban Cities in Ghana, last year 2009 which is being carried out by the Nutrition and Food Science Department of University of Ghana, Legon. The study seeks to determine the prevalence of caries and periodontal conditions in obese as against non-obese children within particular age groups and ascertain the factors that may be responsible for possible increased risk among the obese children. The study will involve children between the ages of 9 and 15 years. It is targeting private schools within the Accra Metropolitan Area where we think it is likely to find more obese children. The Study will involve about five hundred school children. This we hope to obtain in 8 randomly selected public school schools. The study will involve measurement of weight, height, waste and hip circumference, and oral screening to assess their oral health status. The children will be interviewed to ascertain their oral habits and dietary practices. During the oral examination there will be no invasive procedure. Consent will be sought from both parents and children after explaining the study to them before any school child will be involved in the study. At the end of the study we hope to establish the link between childhood obesity and oral condition and be able to ascertain those factors that may be associated with the risk of oral health in the children. These we hope will enable us plan the most appropriate intervention for these school children. We will be grateful if this permission is granted. Yours sincerely Dr. Josephine Sackeyfio (Head, Department of Community and Preventive Dentistry) 165 University of Ghana http://ugspace.ug.edu.gh Appendix 7 PERMISSIONS TO HEADS OF SELECTED SCHOOLS PERMISSIONS TO CARRY OUT A STUDY ON CHILDHOOD OBESITY AND ORAL HEALTH RISK IN YOUR SCHOOL The Department of Community and Preventive Dentistry of Dentals School Korle Bu, in collaboration with the Department of Nutritional and Food Science are carrying out a study on Childhood obesity and oral health risk in Accra. Twenty Private schools have been randomly selected from a list from the Ghana Education Service (GES). Your school happened to be one of the selected schools. The study has been approved by the GES and School Health and Education Programme Office. Ethical clearance has also been obtained for the study. The study will involve children between the ages of 9 and 15 years. It will involve about one thousand school children. This we hope to obtain in 8 randomly selected public schools. The child’s weight, height, waste and hip circumference will be taken. Oral screening will be done to assess their oral health status. The children will be interviewed to ascertain their oral habits and dietary practices. Consent will be sought from both parents and children after explaining the study to them before any school child will be involved in the study We wish by this letter to inform you about the study and seek your permission to carry out the study. We will be grateful if this permission is granted Yours sincerely. Dr. Josephine Sackeyfio (Head, Dept. of Community and Preventive Dentistry) 166 University of Ghana http://ugspace.ug.edu.gh Appendix 8 Sample size calculation for the PHD study Sample Size for Cross-Sectional, Cohort, & Randomized Clinical Trial Studies Two-sided significance level(1-alpha): 95 Power(1-beta, % chance of detecting): 80 Ratio of sample size, Unexposed/Exposed: 1 Percent of Unexposed with Outcome: 15 Percent of Exposed with Outcome: 26 Odds Ratio: 2 Risk/Prevalence Ratio: 1.7 Risk/Prevalence difference: 11 Kelsey Fleiss Fleiss with CC Sample Size - Exposed 209 208 225 Sample Size- Nonexposed 209 208 225 Total sample size: 418 416 450 References Kelsey et al., Methods in Observational Epidemiology 2nd Edition, Table 12-15 Fleiss, Statistical Methods for Rates and Proportions, formulas 3.18 &3.19 CC = continuity correction Results are rounded up to the nearest integer. Print from the browser menu or select, copy, and paste to other programs. Results from OpenEpi, Version 2, open source calculator--SSCohort file:///C:/Program%20Files%20(x86)/OpenEpi/SampleSize/SSCohort.htm Source file last modified on 11/09/2007 21:51:00 Print from the browser, or select all or part of the text and then copy and paste to other programs. Many browsers have an optional setting to print background colors. Sample size in total will be 225* 2 = 450 The sample size formula for the method described in Kelsey et. al. is: 167 University of Ghana http://ugspace.ug.edu.gh and where number of exposed number of unexposed standard normal deviate for two-tailed test based on alpha level (relates to the confidence interval level) standard normal deviate for one-tailed test based on beta level (relates to the power level) r = ratio of unexposed to exposed p1 = proportion of exposed with disease and q1 = 1-p1 p2 = proportion of unexposed with disease and q2 = 1-p2 and The sample size formula without the correction factor by Fleiss is: For the Fleiss method with the correction factor, take the sample size from the uncorrected sample size formula and place into the following formula: When the input is provided as an odds ratio (OR) rather than the proportion of exposed with disease, the proportion of exposed with disease is calculated as: 168 University of Ghana http://ugspace.ug.edu.gh When the input is provided as a risk (or prevalence) ratio (RR) rather than the proportion of exposed with disease, the proportion of exposed with disease is calculated as: When the input is provided as a risk (or prevalence) difference (RD) rather than the proportion of exposed with disease, the proportion of exposed with disease is calculated as: Kelsey JL, Whittemore AS, Evans AS, Thompson WD. Methods in Observational Epidemiology. Oxford University Press, 1996. Fleiss JL. Statistical Methods for Rates and Proportions. John Wiley & Sons, 1981. Updated Feb 16 2007: changed the “-“ sign in the numerator of the Fleiss formula without a correction factor to “+” 169 University of Ghana http://ugspace.ug.edu.gh Appendix 9 Descriptive summary of weekly frequency of consumption of various food items Appendix results Obesity status Specific OBESE CHILD NON OBESE CHILD Total food items Std. Std. Std. Mean N Deviat Mean N Devi Mean N Deviatio p- ion ation n value Fruit juice 0.91 232 1.43 0.55 313 1.06 0.70 545 1.24 .001 Malt drinks 0.64 231 1.30 0.50 313 1.00 0.56 544 1.14 .159 Minerals 1.44 232 1.77 1.34 313 1.62 1.38 545 1.69 .458 Evaporated milk 1.71 230 2.43 1.30 312 2.03 1.48 542 2.21 .035 Powdered milk 1.09 231 1.73 1.20 311 1.86 1.15 542 1.80 .472 Whole milk 0.60 230 1.33 0.67 312 1.43 0.64 542 1.39 .607 Condensed milk 0.55 231 1.32 0.40 312 0.94 0.47 543 1.12 .134 Milk drink 0.90 231 1.62 0.65 313 1.24 0.76 544 1.42 .035 Yogurt 1.30 231 2.12 1.05 311 1.66 1.16 542 1.87 .134 cheese 0.54 230 1.18 0.51 312 1.15 0.52 542 1.16 .795 Cowbell 1.09 230 1.85 1.15 312 1.69 1.13 542 1.76 .683 White bread 3.10 231 3.23 2.72 312 2.40 2.88 543 2.79 .115 Biscuit 2.13 232 2.82 2.09 312 1.99 2.11 544 2.37 .831 Cream crackers 0.78 59 1.49 1.13 55 1.63 0.95 114 1.56 .237 Cakes 1.03 230 1.56 0.85 312 1.42 0.93 542 1.48 .168 Pie 1.48 231 1.85 1.43 312 1.79 1.45 543 1.82 .767 Pizzas 0.72 232 1.54 0.42 313 1.04 0.55 545 1.29 .007 Fried rice 1.24 232 1.68 1.04 311 1.44 1.13 543 1.55 .132 Bofrot 0.89 229 1.46 1.02 311 1.64 0.96 540 1.57 .343 Kose 0.46 228 1.09 0.47 312 1.07 0.46 540 1.08 .937 Fried plantain 1.20 230 1.62 1.06 312 1.60 1.12 542 1.61 .347 170