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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2021  |  Volume : 39  |  Issue : 2  |  Page : 171-177

Association of parental food choice motives, attitudes, and sugar exposure in the diet with early childhood caries: Case–control study

1 Pediatric and Preventive Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Karnataka, India
2 Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Karnataka, India

Date of Submission19-Mar-2021
Date of Decision05-Jul-2021
Date of Acceptance06-Jul-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Suprabha Baranya Shrikrishna
Department of Pediatric and Preventive Dentistry, Manipal College of Dental Sciences, Light House Hill Road, Mangalore - 575 001, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisppd.jisppd_104_21

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Background: Parents can affect their children's diet by making some food components more accessible. Food choice motives and attitudes of the parents toward sugary food may influence children's diet. Aims: The aim of the study is to investigate the association of parental food choice motives, attitudes toward sugar consumption, and dietary sugar exposure with early childhood caries (ECC). Settings and Design: This case–control study involved 200 children, aged 3–5 years with an equal number of cases (with ECC) and controls (without ECC), based on the WHO-decay-missing-filled teeth index criteria for dental caries. Materials and Methods: The data for parental food choice motives and attitudes toward sugar consumption were obtained using questionnaire answered by their parents, and the dietary sugar exposure was calculated using a 24 h diet chart. Data were analyzed with multiple logistic regression. Results: Most parents (99.5%) considered “maintaining health and nutrition” as an important criterion, above 85% parents thought “mood of the child,” “child likes and dislikes,” “sensory appeal of the food item,” “natural foods,” “quality of the food,” and “weight control” criteria important while selecting food items, with no significant difference between cases and controls. About 61% of the cases considered buying food based on convenience is important, as compared to 47% controls, and the difference was significant. Cases and controls did not differ in attitudes toward sugar consumption. Sugar exposure was significantly higher among the cases. Conclusion: High dietary sugar exposure is associated with ECC. Parents of children with ECC are likely to buy foods for their children based on convenience and availability.

Keywords: Attitude, choice behavior, dental caries, food, preschool child

How to cite this article:
Samaddar A, Shrikrishna SB, Moza A, Shenoy R. Association of parental food choice motives, attitudes, and sugar exposure in the diet with early childhood caries: Case–control study. J Indian Soc Pedod Prev Dent 2021;39:171-7

How to cite this URL:
Samaddar A, Shrikrishna SB, Moza A, Shenoy R. Association of parental food choice motives, attitudes, and sugar exposure in the diet with early childhood caries: Case–control study. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2022 Aug 11];39:171-7. Available from: http://www.jisppd.com/text.asp?2021/39/2/171/322494

   Introduction Top

Early childhood caries (ECC) is a disease seen in children below 71 months of age that occurs due to interaction of susceptible host, fermentable carbohydrates, and cariogenic bacteria over time.[1],[2] It is further influenced by biological, behavioral, and socioeconomic risk factors.[3] Dietary sugar exposure can influence the microbial composition, increase the levels of cariogenic bacteria leading to dental caries.[4]

Children learn about food choices between 2 and 5 years of age and make food preferences based on the food items that they are exposed to, during this period. They depend on parents for providing food, and hence, food choices of the parents play an important role in their diet.[5] Parents can impact their children's eating habits by making some foods more accessible than others. By their own eating habits and food choices, parents can serve as role models of eating behavior.[6] Parents can regulate the availability of healthy foods such as fruits and vegetables which are noncariogenic and unhealthy foods such as sugar-sweetened beverages which are cariogenic and thus influence their children's dietary choices.[7],[8] Unhealthy dietary preferences can in turn lead to unhealthy eating behaviors among children, which not only affect their general health, but also increases their risk of dental caries.[9] An earlier cross-sectional study indicated an association of food choice motives of parents with the caries experience of primary school children.[10] However, there is an insufficient understanding regarding the influence of food choice motives of parents in the occurrence of ECC among preschool children.

Several factors such as socioeconomic status, parenting practices, and attitudes play an important role in food choices.[6],[11] Oral health behaviors such as consumption of sugar-containing foods are influenced by parental attitudes.[12] Since food choice motives and attitudes of parents toward sugar snacking may vary across cultures,[5],[12] an understanding of these will help understand the barriers for healthy food choices, which in turn will help in education and motivation of parents toward noncariogenic dietary patterns of their child. This is crucial, because a blanket recommendation of “reduce eating sweet snacks and consuming sugary drinks” is not effective in changing dietary patterns.[13]

Hence, this study was conceptualized to study the parents' food choice motives and attitudes toward sugar consumption along with existing dietary sugar exposure of children with ECC in comparison with children without ECC.

   Materials and Methods Top

This study was conducted among preschool children using a case–control study design over a 6-month duration.

Sampling and sample size

The participants were selected from the preschools of Mangalore city located in Karnataka state. A list of preschools of the city was drawn and the schools were selected by a simple random sampling technique using a random number table. All the children attending the selected schools formed the study population, from which the final sample was drawn based on the inclusion and exclusion criteria.

The sample size was calculated as 100 with an equal number of controls, assuming a prevalence of 54% ECC cases in the population[14] at 80% power, 95% confidence interval (P = 0.05), assuming an expected proportion of high sugar exposure in cases to be 60% and the least extreme odds ratio to be detected as 2. The sample size calculation was done using G power 3.1 software.

Ethical issues

A written informed consent was obtained from parents, and the headmaster/headmistress of the preschools gave a written approval before the study. Institutional Ethics Committee provided a clearance before beginning the study.

Informed consent forms were sent to 410 parents of children studying in six kindergarten schools and 270 parents consented to participate in the study.

Inclusion and exclusion criteria

All children enrolled in the selected kindergarten schools between 3 and 5 years of age were included in the study. Children were excluded, if no parental consent was given, history of developmental delay, systemic or mental illness. If there were more than one child belonging to the same family, only one child was included. Children of parents who did not return completely filled questionnaire were also excluded from the study.



Parents were requested to answer a structured questionnaire before the examination. The questionnaire was distributed in the preschools with an instruction to parents to fill them at home and return within 72 h. Incompletely filled questionnaires were sent back to the parents, at least twice, with a request to completely fill them.

The questionnaire consisted of demographic details of the child, such as age, gender, and socioeconomic status (according to Kuppuswamy scale)[15] and a 24-h recall diet chart.[16] The sweet score, which is based on the number of sugar exposures and the consistency of the sugary food in the diet, was determined from the diet chart. Written instructions were given to the parents to fill in the chart with all food items eaten by the child on the previous day. This included food consumed in between and during meals, with the quantity and time at which it was served. Sugary foods were categorized into liquids such as sugared beverage, solid and sticky foods such as cakes, cookies, chocolates, chewing gum, and slowly dissolving foods such as hard candy, cough syrup, breath mint. Each liquid, solid, and sticky foods and slowly dissolving foods consumed were multiplied by 5, 10, and 15, respectively. The total sweet score for each child was calculated by adding all the scores and categorized as excellent (≤5), good (10), and watch out zone (≥15), respectively.[16]

The parents motives for food choice of their child were assessed using a modified Food Choice Questionnaire (FCQ) that consists of 36 items.[5] The questions were under the domains of health, convenience, price, sensory appeal, quality, mood, familiarity, ethical concern, weight control, what the child wants and others preference. The parental attitudes toward child sugar snacking were assessed based on a scale given by Adair et al.[12] on parental attitudes, which consist of two domains: (a) importance and their intention to control child sugar snacking and (b) perception of parental efficacy in controlling child sugar snacking.

Before utilizing in the study, the test-retest reliability of the questionnaire was assessed by requesting 10 parents who were otherwise not included the study to respond to the questionnaire. For the retest, parents were requested to respond again, 1 week later to obtain Crohnbach's α = 0.99. No changes were made to the questionnaire. At the end of the study, out of 270 participants, 70 participants who returned partially filled or did not return the questionnaire or did not fulfill the inclusion-exclusion criteria were excluded from the study.

Oral examination

Cases and controls were selected after an oral examination in their respective preschools. The child was reclined on a table with the examiner standing behind the child's head. All teeth were examined using mouth mirror and WHO probe under the illumination of focusable flash light. The teeth were dried with sterile gauze before the examination and an assistant charted decay-missing-filled teeth index (DMFT) in accordance with the WHO-DMFT criteria.[17]

Definition of cases and control

ECC was defined as the presence of one or more decayed, missing, or filled tooth surface in any primary tooth in a child of 71 months of age or younger.[1] Children with ECC were cases and those without ECC were controls.

Two trained and calibrated examiners (AS and AM) conducted all the examinations. For calibration, ten children not included in the study were examined and rechecked by an expert examiner for reproducibility. Every tenth child was examined again to assess the intra-examiner reliability. Intra and interexaminer reliability assessed using Cohen's Kappa statistics was excellent (interexaminer reliability = 0.91–0.99; intraexaminer reliability at a range of 0.97–1.00).


The parameters for matching of cases and controls were age, gender, and socioeconomic status.

Statistical analysis

Data were analyzed using IBM® Statistical Package for the Social Sciences (SPSS), version 17 software (SPSS Inc., Chicago IL, USA). Descriptive data in terms of frequencies were entered. The cases and controls were compared for the frequencies of the variables using Chi-square test. The data obtained according to the Likert scale were dichotomized for both food choice motive scale (important and not important) and parental attitudes scale on sugar snacking (agree and do not agree). Multiple logistic regression analysis was used to determine the association of independent variables with dependent variable (presence or absence of ECC) and odds ratios were obtained.

   Results Top

The mean age of the sample was 4.11 years with 105 female children and 95 male children. The cases and controls were almost equally distributed in relation to age and gender. Although higher frequency of low socioeconomic status was seen in the control group, the difference was not significant, as shown by the Chi-square test [Table 1].
Table 1: Comparison of demographic characteristics of children between cases and controls

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[Table 2] gives the frequency distribution of the food choice motives of the parents of children with and without ECC. The scale has eleven domains of food choice motives that were entered into the analysis. As shown in the table, maintaining health and nutrition in the children was an important criterion for parents while selecting the food items for both cases and controls, with 99.5% of the parents considering it as important. Above 85% of the parents thought “mood of the child,” “child likes and dislikes,” “sensory appeal of the food item,” “natural foods,” “quality of the food,” and “weight control” are important criteria while selecting food items and the frequencies regarding their importance were similar between cases and controls. Most parents (>70%) also considered “convenience to prepare the food” and “price” to be important, with similar frequencies between cases and controls. About half of the parent population indicated that “convenience to buy” and “others preference” are moderately important while selecting food items. It was seen that that convenience of buying food items was more important for parents of children with ECC, and the difference between the cases and controls was significant (P = 0.047). 61% of parents of children with ECC considered it to be important criteria for food choice compared to 47% of parents of controls.
Table 2: Comparison of parental food choice motives for their children

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The intent and perceived efficacy of the parents in controlling sugar snacking of their children is recorded in [Table 3]. Above 90% of the parents agreed that dental caries can be controlled by reducing the consumption of sugary foods and it is important to control the intake of sugary foods of their children. About half the parents believed that it is difficult to control the sugar intake of their children. However, there was no significant difference between the parents of cases and controls regarding the intention and efficacy to control sugar intake, although more parents of the controls (57%) perceived efficacy to control sugar than cases (51%).
Table 3: Comparison of the intention and efficacy to control sugar snacking among children by the parents between cases and controls

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[Table 4] depicts the sweet score of the study population. About 60% of the population were in the “watch out zone” (≥15) and only about 13% of the children had an “excellent” sweet score (≤5). The number of children in the watch out zone was higher among cases, with higher frequencies observed for good and excellent categories among the controls, but the difference was not statistically significant.
Table 4: Comparison of sweet scores between cases and controls

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All the frequencies on the food choice motives, except health and nutrition that showed equal frequency between cases and controls, were entered into a multiple logistic regression analysis with cases/controls as a dependent variable. Parental attitudes and the sweet score were also entered into the analysis as independent variables. Odds ratio was estimated at 95% confidence interval. The results showed that there was a significant difference between the case and controls regarding sweet scores when controlled for other factors. Thus, cases had significantly higher sugar exposure by 1.8 times compared to the controls, as shown by the odds ratio. In addition, parents of the cases were likely to buy food items based on convenience compared to controls by 2.5 times and the difference was significant [Table 5].
Table 5: Multiple logistic regression for analyzing the association of the parental food choice motives, attitudes of parents toward sugar snacking by children, and sugar exposures in the diet with early childhood caries

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   Discussion Top

Case–control design was chosen to study the role of parent's food choice motives and their attitudes regarding sugar consumption in the occurrence of ECC. The results show that among the food choice motives, convenience of buying foods for the parents and the sugar exposure in the diet of children is associated with ECC. The samples were matched by age, gender, and socioeconomic status to minimize confounding, as these factors are known to influence food choice motives and dietary patterns.[11] FCQ used to quantify the parental food choice motives for their child was given by Steptoe et al.[18] and has been widely used to study food choice motives across various populations.[5],[19] The scale used to measure attitudes toward sugary food consumption in this study, has been validated and reliability analyzed, and found to be good by Adair et al.,[12] in an international collaborative program involving populations of 17 countries including South Asian population. A 24-h recall diet chart was used for diet analysis as it can be analyzed in a shorter period with better parent compliance, than a 7-day diet diary, thus reducing the respondent fatigue. It is an open-ended method for collecting data but limited in its outcome by social desirability.[20]

The results of the study showed that parents of children in the preschool age consider nutritional aspects of food and preferences of the child as important while choosing foods. Similar results were seen in studies conducted in other populations.[5],[21] Although parents appeared to have well-intentioned motives, regarding the choice of environmentally sustainable and healthy foods for their children, it did not translate into health dietary practices in children.[5],[21] Similar results were seen in our study, especially among the cases where their diet had high sugar exposure. Based on the results obtained in our study, it may be inferred that parents of children with ECC had similar food choice motives as that of children without ECC except for “convenience of buying food.” This means that parents of children with ECC would choose foods, which are easily available in a convenience store, which is in the vicinity of the place where they live or work. This could often mean buying cariogenic foods, as they are easily available. Convenience stores in the neighborhood commonly have high energy, low nutrient-dense foods, thus limiting access to healthy foods.[22] In a Norwegian study, “convenience” food choice motive was linked to the consumption of easily accessible processed foods among children and was a barrier for healthy eating pattern.[23] In spite of being aware of healthy food choices, parents often buy cariogenic foods due to their easy availability and allow their children to consume them.[24] In countries such as the USA, Canada, and Australia, lower availability of healthy foods in socioeconomically deprived areas leading to their lesser consumption has been observed.[11] In India, convenience stores, referred to as “kirana stores,” are abundant with ten stores per thousand people and sell cariogenic packaged foods along with other food items.[25] The tendency to buy foods from the neighborhood may be related to issues such as, the availability of convenient transport, time, parental stress, family income, refrigeration, and storage facilities.[22],[24] Hence, there is a need to substitute sweetened beverages, candies, and other sticky sweet sugary foods with nonsweetened healthy foods and increase their access and availability. Community-based efforts and policies are required to enhance the access and availability of healthy foods, which are noncariogenic.

Although most parents in both case and control groups considered it important to control the consumption of sugary foods by their children, only around 50% considered that they were effective in doing so. This perception though marginally higher among controls was not statistically different from cases. However, the sweet score was significantly higher among cases when controlled for other factors. This implies that there is a discrepancy in the parent's attitudes and motives regarding food choices and children's actual food consumption. Possible reasons for this discrepancy could be conflicting child's preferences and demands as well as time pressure.[5] Children tend to be attracted to energy-dense cariogenic foods and low in nutrients and often become aware of them through advertisements in the media.[26],[27] Thus, in spite of the belief that the consumption of sugary foods can result in dental caries, parents end up buying cariogenic foods for their children, as often the choice of food items is child centered.[5] This implies that it is important to study the barriers for the choice of noncariogenic healthy food items in future studies, considering parenting practices, change in food culture, family patterns, and socioeconomic factors.[22] Thus, children of parents with ECC perceived lesser parental efficacy in controlling sugar exposure (though not significant) and had a higher sugar exposure in the diet of their children. The results are in accordance with Adair et al.[12] study that supported the hypothesis that parental attitudes have a significant influence on the oral health practices of their children. In another study conducted in a population of Indian mothers, it was found that mothers would buy cariogenic foods for their children, even though they had good knowledge of cariogenic foods.[23]

Higher sugar exposure in the diet result in ECC, as they promote the accumulation of Streptococcus mutans.[4] Sucrose is a substrate used by these bacteria for the synthesis of glucans that facilitates bacterial adhesion.[28] Higher consumption of sugary foods which are sticky or slowly dissolving has been noted among children with ECC in earlier cross-sectional studies.[4],[29],[30]

It should be noted that, case–control design used in this study establishes causality in terms of odds ratio, which is an advantage over cross-sectional studies, though the temporality of the cause and effect cannot be determined.[31] The study design is prone to recall bias and social desirability bias[32] that may have influenced the responses of parents. Most of the participants in this study belonged to the high socioeconomic status group, which may have affected results related to the food choice motives and attitudes regarding sugar consumption in diet. Hence, further studies considering the role of socioeconomic status in food choices and attitudes toward diet among parents of children with ECC can be conducted. The association of food choice motive and high sugar consumption with ECC implies that there is a need for further studies to explore factors that contribute to high sugar consumption among children with ECC.

   Conclusion Top

The parents of both cases and the control groups consider it important serving healthy and nutritious food to their children. However, the availability of cariogenic foods and the ease of buying these items is a food choice motive associated with parents of children with ECC. Even though parents are aware that sugary food items are cariogenic, the perceived efficacy to control the intake of sugar by their children is low. The association of high sugar exposure in the diet of children with ECC is confirmed.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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