Snack Food Intake of Adolescents and Caries Development

KATHERINE L. CLANCY, BASIL G. BIBBY, HYMAN J. V. GOLDBERG,* LOUIS W. RIPA,

and JAMES BARENIE
Division of Nutritional Sciences, Cornell University, Ithaca, Nezw York 14853, USA,
Eastman Dental Center, Rochester, New York 14603, Department of Dentistry and Dental
Research, University of Rochester School of Medicine and Dentistry, Rochcster, New York
14642, and Department of Children's Dentistry, State University of New York at Stony
Brook, Stony Brook, New York

The relationship between the frequency of eat-
ing various snack foods, socioeconomic varia-
bles, and an increment in caries was studied in
143 adolescents. There were negative correla-
tions between DMFT increments and the fre-
quency of apples, fruit juice, and sugarless gum
intake, and a positive association of DMFT
increments with chocolate candy intake and
spending money.
J Dent Res 45(6):568-573 June 1977.
A considerable body of research evidence in-
dicates that frequent consumption of sweet
carbohydrate or snack foods leads to increased
caries incidence. Although some laboratory and
indirect clinical findings suggest that .sugar-
containing foods may differ in their capacity
to produce caries,23 there is little direct clin-
ical evidence to demonstrate the relative car-
iogenicity of specific carbohydrate snack items
frequently consumed by children.
It has been shown that consumption fre-
quency and caries experience vary with socio-
economic factors. Koch and Martinsson4'5
alyzed specific socioeconomic factors in
sample of 14-year-old Swedish children with
demonstrated high and low caries incidence.
The researchers used dietary histories obtained
from the children's parents in their analysis.
Investigation revealed a strong negative cor-
This investigation was supported, in part, by the
Hatch funds from the Agricultural Experiment Station,
Cornell University, Ithaca, NY.
Presented, in part, at the 53rd annual session of
the AADR, New York City, April 1975.
Received for publication July 31, 1975.
Accepted for publication June 14, 1976.
* Dr. Goldberg is also with the Rochester Health
Network, Anthony L. Jordan Health Center, Roches-
ter, NY.
For reprints please contact Dr. H. V. J. Goldberg,
P.O. Box 611, University of Rochester Medical Center,
Rochester, N.Y. 14642.
568
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relation between parents' educational levels
and social class and the children's caries expe-
rience. There were also relationships (some
positive and some negative) between social
factors and the frequency with which children
used potentially cariogenic between-meal
snacks such as chewing gum and soft drinks.
Evidence further indicated that soft drink con-
sumption by boys in the high caries group was
greater in all social classes; that children of
laboring class parents chewed gum most fre-
quently; and that although girls of all social
groups with high caries activity tended to
chew more gum than those with low caries
activity, the difference was most pronounced
in the professional and managerial class. These
conclusions may be biased, however, because
the parents may not have been fully aware of
what their children had eaten.
Samuelson, Grahner, and Arvidsson6 found
that the caries scores and general health of a
group of children, ages 4, 8, and 13, correlated
with socioeconomic variables; in particular, the
educational level and dietary habits of the par-
an- ents. For example, in 13-year olds of higher
a socioeconomic conditions, there was a positive
correlation of socioeconomic scale with the
frequency of consumption of berries, vegeta-
bles, and fish, and a negative correlation with
the frequency of consumption of sweets, cakes,
and buns. The latter foods had a negative ef-
fect on the caries score. Hankin, Chung, and
Kau,7 who gathered little social class infor-
mation, reported that in children from various
Hawaiian ethnic groups the frequency of
chewing gum and eating candy positively cor-
related with the increased incidence of dental
caries, and the frequency of eating bread and
cereal negatively correlated.
The lack of established correlations be-
tween the frequency of snack food consump-
Vol. 56 No. 6 SNACK FOODS & CARIES IN ADOLESCENTS 569

tion and specific effects on children can be
attributed, in part, to the questionable reli-
ability of the dietary information obtained.
Also, caries found at the time of the exam-
ination may be the result of past, rather than
present, eating habits. Researchers can avoid
some of these problems by obtaining dietary
information from both the children and their
parents and by using the caries increment for
a one-year period as a measure of caries activ-
ity. The present study allowed for these con-
tingencies. In addition, pertinent sociological
information was provided.
Materials and Methods
Initial and one-year incremental caries
scores were obtained from a sample of 172
junior high school students (average age 12.5
years) who were already enrolled in an inde-
pendent study (this was being carried out by
J. B. and L. R.) organized for other purposes
in a small city (population 17,000) in upstate
New York. Mothers of the children were con-
tacted for permission to interview both them
and their children. The children were inter-
viewed in the school setting just before their
annual dental examination. The 143 mothers
who granted permission were interviewed in
their homes when the child in the study was
not present. Data are reported only for those
children (72 male and 71 female) whose
mothers were interviewed.
The interviews were conducted by trained
personnel during a six-week period in April
and May 1974. A pretested, structured ques-
tionnaire was administered to all the students
by the same interviewer. Three interviewers
used a similar pretested, structured question-
naire to obtain information from the mothers.
The children were asked to provide in-
formation about the frequency of intake at or
between meals of 18 types of snack foods, the
amount of personal spending money, and
snack foods purchased with this money. The
mothers supplied demographic information
about their families including income, educa-
tion of father and mother, and number of fam-
ily members. They also reported how fre-
quently they and their children consumed the
same 18 snack foods.
DATA ANALYSIS.- Analyses were per-
formed with the frequency of intake of the in-
dividual snack foods and also with a compo-
site snack food score. The score was developed

3LE 1
FREQUENCY OF INTAKE OF CERTAIN FOODS
BY JUNIOR HIGH SCHOOL STUDENTS

1-2/Wk 3-7/Wk 2-4/Day

Food Hardly Ever (%) (%) (%)
Milk 3.5 2.1 11.2 83.2
Presweetened Cereal 41.3 18.2 38.5 2.1
Milk drinks 23.8 18.9 48.3 9.1
Soda 14.7 33.6 42.7 9.1
Fruit drinks 44.1 23.8 23.1 9.1
Fruit juice 11.9 16.1 58.1 14.0
Cakes 21.7 38.5 35.7 4.2
Cookies 15.4 19.6 58.8 6.1
Salty-snacks 23.8 29.4 42.7 4.2
Oranges 12.6 25.9 51.8 9.8
Apples 14.0 31.5 48.3 6.3
Dried fruit 80.4 15.4 3.5 0.7
Chocolate candy 28.0 44.1 27.3 0.7
Caramels, etc. 45.5 34.3 17.5 2.8
Hard candy 31.5 30.8 33.6 4.2
Sugarless gum 56.6 18.2 16.1 9.1
Regular gum 23.1 15.4 39.2 22.4
Ice cream 9.8 40.6 48.3 1.4

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570 CLANCY ET AL I Dent Res June 1977
TABLE 2
FREQUENCY OF INTAKE OF CERTAIN FOODS
BY MOTHERS OF STUDENTS
1-2/Wk 3-7/Wk 2-4/Day
Food Hardly Ever (%) (%) (%)
Milk 35.0 4.9 29.4 30.8
Presweetened cereal 90.9 3.5 5.6
Milk drinks 86.0 9.1 4.2 0.7
Soda 42.7 17.5 28.0 11.9
Fruit drinks 80.4 4.9 14.0 0.7
Fruit juice 21.0 6.3 63.6 9.1
Cakes 67.8 16.8 15.4 ...

Cookies 35.7 30.1 31.5 2.8

Salty snacks 50.3 35.7 14.0 ...

Oranges 32.9 30.8 34.3 2.1

Apples 37.1 31.5 28.7 2.8
Dried fruit 83.9 14.7 1.4 ...

Chocolate candy 79.0 16.8 2.8 1.4

Caramels, etc. 86.0 9.8 4.2 ...

Hard candy 77.6 12.6 6.3 3.5

Sugarless gum 81.8 2.1 11.9 4.2
Regular gum 70.6 9.1 16.8 3.5
Ice cream 29.4 49.0 21.7

by assigning a numerical value to each fre- Results

quency on a scale of 0 for hardly ever to 5 for The childrcn's frequency of intake of the
four times per day (the categories in Tables 1 18 different foods is given in Table 1. Milk con-
and 2 have been collapsed for ease of report- sumption was high in this group as was the in-
ing). Each child's individual score was com- take of fruit juice, gum, cookies, and oranges.
puted by adding together the intake frequen- Eighty percent of the children reported they
cies reported for 9 of the 18 foods (Table 3), hardly ever ate dried fruit and approximately
these foods having been chosen for inclusion 50% rarely chewed sugarless gum or con-
in the score by a scaling technique that tested sumed fruit drinks.
for the reliability and validity of the items in- The same information for the mother's in-
cluded.8 Information on the times at which take of snack foods is given in Table 2. More
foods were eaten (at meals, between meals,
and before bed) was not included in the score TABLE 3
but was analyzed separately.
Statistical analyses of the data reported CORRELATION OF INDIVIDUAL SNACK FOODS
here include Pearson's r correlations, partial WITH TOTAL SNACK FOOD SCORE
correlations, and t tests. We are aware of the Food r*
problems inherent in the choice of Pearson's r
for the aiiAlysis of data all of which are not of Regular gum 0.62
the bivariate normal type. Most of the r's re- Caramels and chewy candy 0.58
ported are zero-order correlations because no Salty snacks 0.58
controls for the influence of other variables are Cakes 0.55
Cookies 0.51
made. There is also the well-known problem Chocolate candy 0.47
with r in that in large sample studies sample Fruit drinks 0.47
r's may be significant but still explain little of Hard candy 0.46
the existing variation. Holding these points in Soda 0.39
mind, other measures have been computed and
reported where appropriate. * P < 0.001 for all correlations.

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Vol. 56 No. 6
TABLE 4
CORRELATIONS OF FOOD VARIABLES
SF of child versus SF of mother
SF of child versus SF of mother/child
SF of child versus regular gum
SF of mother versus increment in child
Chocolate candy versus increment
Apples versus increment
Fruit juice versus increment
Sugarless gum versus increment
Spending money versus increment
Spending money versus chocolate candy
Regular gum versus mother's education
Regular gum versus gum mother chews
Regular gum versus income
Fruit juice versus income
Note: SF, snack food score.
t P <0.05.
* P < 0.01.
t P < 0.001.
than 50% of these women drank milk and
fruit juice at least once a day. Only dried fruit
and sugarless gum were reported as being
hardly ever eaten by a majority of both moth-
ers and children. The children tended to con-
sume snack foods (for example, fruit drinks,
chocolate candy, gum, and hard candy) much
more frequently than their mothers, 50% of
whom tended not to eat many of these foods.
Overall, the relationship between the
mother's and the child's snack food intake was
significant but somewhat weak. The mother's
report of her child's snack food consumption as
measured by the snack food score was moder-
ately associated with the child's own report
(r= 0.39; P < 0.001). The report for 14 of
the 18 foods furnished significant agreement
between the mothers and children, with moth-
ers knowing least about their children's con-
sumption of hard candy, ice cream, chocolate
candy, and cakes.
In computing the composite snack food
scores for the children, it was seen in the part-
whole correlation of the individual foods to the
score itself that chewing regular gum was most
strongly related to the total score itself (r =
0.62), indicating that regular gum may be a
good indicator of total snack food use in this
population of children (Table 3).
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SNACK FOODS & CARIES IN ADOLESCENTS 57t!
0.18*
0.39t
0.62t
0.154
0.154
0.18 :
-0.32t
-0.154:
0.16:
0.17:
-0.30t
0.23*
-0.21*
0.19t
The average DMFT score for the females
was 6.5 and, for the males, 5.7. There was no
significant difference in the incremental scores
of the two sexes so the data have been reported
together. Of the many correlations computed
of the relationship between the mother or
child's report of the child's snack food intake
and the caries increment during the past year,
only a few reached significant levels. No sig-
nificant correlation was found between either
the child's or the mother's reported total snack
food score and the children's cumulative caries
score, and there was a weak but significant cor-
relation between the mother's own snack food
score and the child's dental caries increment
score (r = 0.15; P = 0.04) (Table 4).
The initial caries score and the amount of
new caries appearing was greater (r = 0.21;
P = 0.007) for children who frequently ate
chocolate candy. Caries scores were negatively
and significantly (P < 0.05) correlated with
the intake of apples, fruit juice, and sugarless
gum (Table 4).
A comparison by t test of the 47 children
who showed no caries increment during a one-
year period with the remaining 96 children in
the study was confounded by the fact that the
zero-increment group had significantly fewer
572 CLANCY ET AL
caries (P < 0.05) at the beginning of the
study. This zero-increment group also had a
higher intake of fruit juice (P < 0.025) and
oranges (P < 0.05) and a less frequent intake
of regular gum (P < 0.025). That the intakes
of fruit juice and regular gum were also sig-
nificantly correlated with family income may
explain some of the results; however, we do
not have specific information on the families'
dental health habits to help explain why there
were less caries especially since there was no
correlation, in this study, between family in-
come and caries incidence. A partial correla-
tion of the DMFT increment and fruit juice,
holding income constant, showed no change in
the relationships so that this relationship re-
mains to be explained by another variable.
There was no correlation either between
spending money and family income in this
study. A weak but significant relation was
found between the amount of spending money
the children had per week and their incre-
mental caries score (Table 4). The data also
revealed that as spending money increased so
did the frequency of snack consumption. This
was strengthened by the finding that there were
strong relationships between the frequency of
intake of chocolate candy (r = 0.21), cara-
mels (r = 0.50), hard candy (r = 0.26), and
gum (r = 0.41) and the children's report of
having purchased these themselves.
Also, in those children who consumed
fruit drinks, cookies, and apples only between
meals or at bedtime there was a greater incre-
mental caries score (r - 0.25; P < 0.05).
Discussion
The average number of DMFT among
youths in this study is somewhat greater than
the average reported for 12-year olds in the
National Health Survey 1966-1970.9 A state-
ment is made in the report of that study that
regional estimates indicate that youths in the
northeastern United States have a higher
DMFT count than those living elsewhere, but
they did not provide information on regional
values for each group so that we could com-
pare our data. We did find, as did the research-
ers in the national study, that the females had
a higher absolute score than the males.
The study was not designed to measure the
effect of specific foods on caries development;
that is, it was not a clinical trial. The fact that
no relationship was established between the
snack food score and the incremental caries
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J Dent Res June 1977
score could be due to many factors, chief
among them, the great amount of both inter-
subject and intrasubject variance for the nine
foods. Of interest are the negative correlations
between incremental caries scores and the in-
take of fruit juice, fruit (apples and oranges),
and sugarless gum. An indirect reason for this
may be that youths consuming these foods,
which are popularly believed to be noncario-
genic, come from families who deliberately at-
tempt to control the disease. This hypothesis is
supported by our finding that there was a tend-
ency for mothers and youths in the same fam-
ily to chew sugarless gum (r= 0.23; P <
0.01). Negative correlations were found be-
tween chewing regular gum, family income,
and both the father's and mother's educational
level. The role of chewing gum in the causa-
tion of dental caries is questionable at this
point since there are quite contradictory find-
ings in the literature.10
Conclusions
If sucrose or a combination of sucrose,
starch, and fat are seen as the major contribu-
tors to plaque formation and subsequent de-
cay, a critical limiting factor in field studies
such as this is the lack of available data on the
sucrose content of foods. Until more foods are
analyzed for their sucrose content and these
data made public, it is impossible to determine
the actual amounts of sucrose consumed during
the day.
Other factors that limit field studies such
as the one reported here might be improved.
Some refinement of the technique used might
be made; for example, additional emphasis
might be placed on whether snack foods are
consumed at or between meals. Likewise a re-
vision or renaming of snack food categories
would lead to finer definitions of the types of
foods being consumed. In the meantime, only
these or similar methods will provide infor-
mation on the interaction of many factors,
dietetic as well as social and economic, on the
development of caries.
The authors acknowledge the services of Suraiya
Roopnarine for the computer analysis and interviewing;
Carolyn Cook and Deborah Meitzer for interviewing;
Norine Jones and Elizabeth Sachter for editing; and
the cooperaLon of Lee E. Thomas, former superintendent
of the Geneva, New York, city schools.
References
1. BIBBY, B.: The Cariogenicity of Snack Foods
and Confections, JADA 90:121-132, 1975.
Vol. 56 No. 6
2. STEPHAN, R.M.: Effects of Different Types
of Human Foods on Dental Health in Ex-
perimental Animals, J Dent Res 45:1551,
1966.
3. PAIGE, D.: Nutritional Considerations of
Plaque Formation, Dent Clin North Am, 18:
609, 1974.
4. KOCH, G., and MARTINSSON, T.: Socio-
Odontologic Investigaton of School Children
with High and Low Caries Frequency: I.
Socioeconomic Background, Odontol Rev,
21:207, 1970.
5. Koci, G., and MARTINSSON, T.: Socio-
Odontologic Investigation of School Chil-
dren with High and Low Caries Frequency:
II. Parents' Opinions of Dietary Habits of
Their Children, Odontol Rev, 22:55, 1971.
6. SAMUELSON, G.; GRAHNER, H.; and ARVIDS-
SON, E.: An Epidemiological Study of Child
Health and Nutrition in a Northern Swedish
Downloaded from jdr.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016 For personal use only. No other uses without permission.
SNACK FOODS & CARIES IN ADOLESCENTS 573
Country: VI. Relationship Between General
and Oral Health, Food Habits and Socio-
Economic Conditions, Am I Clin Nutr 24:
1361, 1971.
7. HANKIN, J., CHUNG, G.; and KAU, M.:
Genetic and Epidemiologic Studies of Oral
Characteristics in Hawaii's School Children:
Dietary Patterns and Caries Prevalence, J
Dent Res 52:1079, 1973.
8. BOHRNSTEDT, G.W.: A Quick Method for
Determining the Reliability and Validity of
Multiple-Item Scales, Am Socio Rev, 34:
542, 1969.
9. NCHS-HRA: Decayed, Missing and Filled
Teeth Among Youths 12-17 Years, US data
from the National Health Survey, series II,
No. 144, 1974.
10. FINN, S.B.: Chewing-Gum Studies, Bull NY
Acad Sci 153:350, 1968.