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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 1033-1036  

Can healthy eating index be a predictor for early childhood caries in Indian children

1 Department of Public Health Dentistry, SB Patil Institute for Dental Sciences and Research, Bidar, Karnataka, India
2 Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
3 Department of Health Care Administration, Epidemiology and Maternal Child Health, Saint Louis University, St. Louis, Missouri, USA
4 Department of Health Care Administration, Conestoga College, Kitchener, ON, Canada

Date of Submission10-Mar-2021
Date of Decision03-Aug-2021
Date of Acceptance06-May-2021
Date of Web Publication10-Nov-2021

Correspondence Address:
H V N Sai Krishna
Department of Public Health Dentistry, SB Patil Institute for Dental Sciences and Research, Naubad, Bidar, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpbs.jpbs_151_21

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Objective: To assess whether Healthy Eating Index (HEI) can predict Error correction code (ECC) in children of 3–6 year old. Materials and Methods: Our sample included 350 3–6 year old children attending outpatient department of Pedodontia. Caries score was assessed using decayed, missing, and filled teeth index and HEI was used to evaluate the diet quality. Results: About 65.9% of the children who were breast feeding and bottle feeding at night had higher S-ECC and it was statistically significant (P = 0.001). Conclusion: HEI scores were inversely related to caries severity, i.e. HEI score was significantly higher in simple ECC (57.4) and lesser in S-ECC (53.2).

Keywords: Diet, early childhood caries, healthy eating index, severe early childhood caries

How to cite this article:
Krishna H V, Kumar C H, Krishna AS, Bandarii SR, Garine L, Yellavula SK. Can healthy eating index be a predictor for early childhood caries in Indian children. J Pharm Bioall Sci 2021;13, Suppl S2:1033-6

How to cite this URL:
Krishna H V, Kumar C H, Krishna AS, Bandarii SR, Garine L, Yellavula SK. Can healthy eating index be a predictor for early childhood caries in Indian children. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Aug 13];13, Suppl S2:1033-6. Available from:

   Introduction Top

India stands in the second place in terms of population, in which about 13% are children.[1] A healthy body is inclusive of a mouth which works good and smells good, implicating that oral health and overall health are intertwined. Good oral health includes many other things other than just having healthy teeth. However uncontrolled dental caries solely cause deficit in the quantity of oral and general health.[2] Dental caries affect almost all age groups but the presence of caries in young children is an important concern than older people. Early childhood caries will damage the dentition of small children quickly, affecting their general health, growth patterns, and quality of life. Error correction code (ECC) if not treated may cause pain, abscess and premature loss of deciduous teeth, malocclusion, nutritional insufficiencies, and speech problems.[3]

Of the several risk factors associated with ECC, the most vital is bedtime bottle feeding, breastfeeding quickly, and repeated ingestion of sugary snacks and drinks. The other factors being reduced breakfast intake and eating less of vegetables and fruits. Since diet plays a crucial role in the causing of caries; various dietary assessment methods such as the food frequency questionnaire, food dairy method were commonly used. But all of the diet recall methods were developed for adults. Healthy Eating Index (HEI) was introduced to evaluate dietary quality in children aged 2 years and above and its based on the food pyramid where 24 h dietary recall is used and it comprises 10 component scores, each one in the range from 0 (poor) to 10 (good).[4] There were no data available proving a correlation between HEI and ECC in Indian children. Hence, the present study was undertaken to assess any association between HEI and ECC in Indian children.

   Materials and Methods Top

A hospital-based cross-sectional study was undertaken to appraise the association between HEI and ECC in Indian children. Study subjects were selected from the outpatient department of Pedodontia in Sri Sai College of dental surgery, Vikarabad. The age group of the study subjects ranged from 3 to 6 years old. The study commenced after obtaining informed written consent from the parents in their local language/English and institutional ethical clearance.

Inclusion criteria

  1. 3–6-year-old children who had at least one decayed, missing (due to caries), or filled primary teeth
  2. Parents who were willing to give written informed consent.

Exclusion criteria

  1. Medically compromised children
  2. Children with physical and mental disabilities
  3. Uncooperative children/children without parental consent.

The examiner was trained under the guidance of a dietitian to record the HEI, which was recorded by the examiner on 5 subjects who were not included in the main study. Then the index was recorded by the dietitian on the same individuals and the inter-examiner variability was calculated. The Kappa value of 0.86 was obtained for inter-observer agreement. The sample size was determined by taking the studies done as 37.3%. n = Z2 × p (1 − p)/E2. The size of the sample required was 323 which were rounded off to 350 children. The duration of our study was 6 months from October 2017 to March 2018. Demographics such as age, sex, feeding practices were obtained before clinical oral examination, and diet history.

Clinical examination

On a dental chair, caries were recorded based on World Health Organization (WHO) criteria (1997), decayed, missing, and filled teeth scores were used to calculate caries experience. The definition of ECC was based on the American Academy of Pediatric Dentistry (AAPD), criteria (AAPD 2008), which says the presence of one or more decayed, missing owing to caries or filled tooth surfaces in any primary tooth in children of 6 years age or younger.

Whereas in <3-year aged ones, any sign of smooth-surface caries indicates severe ECC (S-ECC). However, in children from 3 to 5 years, one or more cavitated, missing teeth due to caries or filled smooth surfaces in anterior maxillary teeth, or decayed, missing, or filled score of ≥4 (ages 3–<4), ≥5 (ages 4–<5), or ≥6 (ages 5–<6) surfaces constitutes severe ECC.[5]

Diet recording

United States Department of Agriculture (USDA) center for nutrition policy and promotion developed HEI. It gives scores one to ten, the first five measures the individual diet matching to USDA's food guide pyramid that serves the recommendation for the five major food groups (grains, fruits, milk, vegetables, and meat). Six to ninth components of HEI assesses the degree of adherence to dietary guidelines recommendation in regards to many nutrients (saturated fat, cholesterol, total fat, and sodium). The final score evaluates the varieties of foods in a person's diet. On a whole, the HEI index represents the sum of the components with a likely score of 0–100, as each component has a range between 0 and 10. Zero scores indicate that the child is not eating any of the nutrients and maximum ten score represents that child is consuming particular nutrient at the recommended level. HEI score of more than 80 means a good diet, score between 51 and 80, diet that needs improvement, and <51 implies a poor diet.[6] Scoring is given based on the amount of servings per day; numbers of servings were taken based on recommended dietary allowance (RDA) given by the Indian Council of Medical Research (ICMR). Dietary assessment was done by 24-h recall method where mothers or caregivers were inquired to bear in mind and inform all the foods consumed in the past 24 h by the child.

Statistical analysis

Data were analyzed using SPSS software (17.0, SPSS Inc., Chicago, Ill, USA). Chi-square test was done to test the association between ECC and feeding habits. Mann–Whitney U-test was done to compare the difference of means of the HEI components between two groups of ECC. P < 0.05 was considered statistically significant.

   Results Top

Three hundred and fifty participants with the age range of 3–6 years (mean age = 4.5 ± 0.8) were included in the study [Table 1].
Table 1: Distribution of children according to age-gender

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[Table 2] shows the distribution of children based on the type of feeding habits. There was a statistically significant difference in the children with ECC based on feeding habits (P = 0.001).
Table 2: Distribution of participants based on feeding habits

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[Table 3] shows the distribution of children based on HEI to the ECC. A statistically significant difference was found between the mean intake of grains and meat/dal to the types of ECC (P = 0.001).
Table 3: Distribution of participants based on healthy eating index to early childhood caries

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[Table 4] shows the mean sugar intake of the children to the early childhood caries and a statistically significant association was found between mean intake of added sugar to the S-ECC (P = 0.001).
Table 4: Mean sugar intake of the children to the early childhood caries

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   Discussion Top

WHO suggests that eating pattern is affected hastily between 3 and 6 years of age. Hence, we selected this age group. The WHO recommends that children have to be breastfeed till the age of 24 months (WHO 2003). In the present study, 45.4% were solely breastfed and a similar finding was reported by Mohebbi et al.[7] It was also found that S-ECC was significantly less prevalent in those children who were breastfed. This might be due to the protective action of breast milk causing early transfer of the mother's immunoglobulin's and additional specific antibacterial agents such as lactoferrin, interferon, and lysozymes to the baby. While earlier studies have reported that breastfeeding beyond 12 months is significantly associated with the presence of ECC, this could be attributed to the fact that the protective element in breast milk diminishes progressively with the increasing age of the child.[8]

This index gives us a picture about the various types of foods that people are consuming. It also gives us an idea about the variety of the components in the diet and whether the diet is in falling in line with the guidelines and recommendations. Both HEI and ECC are based on the US dietary guidelines and include both food and nutrient-based indicators. There was little adaptation of these indices in other countries.[9],[10]

India is a vast country and is unique in the entire world with diverse cultures and food habits.[11] Relationship between sugar and dental caries remains complex because “side effects” such as plaque status, saliva, bacteria level and host factor also play a roles in caries formation. There are very few studies to link HEI to the ECC, this kind of index is not seen in India. Hence, an attempt was made to fit this index into the Indian scenario based on the dietary guidelines for Indians given by the ICMR. The majority of Indian diet is custom made, it is not easy to appraise the calorific value and get a precise representation of the dietary influence on caries. In this study number of servings was compared with the RDA for Indians drawn up by the Indian Council of Medical Research published in 1998 (ICMR 1998)[12] where participant's consumption in certain food groups such as grain group, fat, and sodium group met the recommendation while the consumption of milk, fruits and vegetables, was below the RDA.

In the present study, high score for grain, meat/dal was associated with reduced S-ECC. This might be due to the high fiber and less sugar present in grains which would have been the reason for less caries in the grain group. In addition, meat/dal contains adequate protein and have low cariogenic potential which replaces fermentation of refined carbohydrate and relatively are protected from dental caries. In the present study, there is no variety component among the study participants which was dissimilar to the study done by Nunn et al.[3] Variety component gives us the different kinds of food items in a food group consumed in a day by a person, Indian diet is predominantly cereal based (rice, chapatti, etc.) and this different kind of varieties are not seen regularly, and the age group of participants were only 3–6 years, hence no variety component was seen in the study.

The overall HEI score was significantly higher in simple ECC (57.4) and lesser in S-ECC (53.2) and the majority of the participant's diet fall in the needs improvement category (HEI score ranging in between 51 and 80).

Limitations of the study

  1. One cannot establish causal relationship owing to the cross-sectional nature of the data (other unknown factors like hereditary factors not taken in to account)
  2. Radiographs were not taken, only visual method was used for caries detection
  3. Various factors like lack of proper knowledge regarding dietary components, memory makes the information from the parents with regards to the composition of snacks consumed, feeding practices, and weaning not to be entirely reliable.

In future, in-depth dietary information with longer periods of data collection with longitudinal design should be done to assess the relationship between HEI to the early childhood caries.

   Conclusion Top

Children in whom breast and bottle feeding at night was practiced had higher S-ECC and it was statistically significant. HEI scores were inversely related to caries severity, i.e. HEI score was significantly higher in simple ECC (57.4) and lesser in S-ECC (53.2).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Monika M, Santosh A, Veenu N. Nutritional health status of primary school children – A study in Bareilly district. Indian Educ Rev 2011;48:18-29.  Back to cited text no. 1
Mc-Donald RE, Avery DR, Stookey GK.Dental caries in the child and adolescent. In: Mc-Donald RE, Avery DR, Dean JA, editors. Dentistry for the child and adolescent. 8 th ed. New Delhi: Elsevier; 2005. p. 203-35.  Back to cited text no. 2
Nunn ME, Braunstein NS, Krall Kaye EA, Dietrich T, Garcia RI, Henshaw MM. Healthy eating index is a predictor of early childhood caries. J Dent Res 2009;88:361-6.  Back to cited text no. 3
The HEI. A Manual Report 1989-90. Available from: [Last accessed on 2018 Jun 11].  Back to cited text no. 4
Colak H, Dülgergil CT, Dalli M, Hamidi MM. Early childhood caries update: A review of causes, diagnoses, and treatments. J Nat Sci Biol Med 2013;4:29-38.  Back to cited text no. 5
Bowman SA, Lino M, Gerrior SA & Basiotis PP (1998): The Healthy Eating Index: 1994–96. US Department of Agriculture, Center for Nutrition Policy and Promotion. CNPP-5.  Back to cited text no. 6
Mohebbi SZ, Virtanen JI, Vahid-Golpayegani M, Vehkalahti MM. Early childhood caries and dental plaque among 1-3-year-olds in Tehran, Iran. J Indian Soc Pedod Prev Dent 2006;24:177-81.  Back to cited text no. 7
[PUBMED]  [Full text]  
Sankeshwari RM, Ankola AV, Tangade PS, Hebbal MI. Association of socio-economic status and dietary habits with early childhood caries among 3- to 5-year-old children of Belgaum city. Eur Arch Paediatr Dent 2013;14:147-53.  Back to cited text no. 8
Haines PS, Siega-Riz AM, Popkin BM. The diet quality index revised: A measurement instrument for populations. J Am Diet Assoc 1999;99:697-704.  Back to cited text no. 9
Kennedy ET, Ohls J, Carlson S, Fleming K. The healthy eating index: Design and applications. J Am Diet Assoc 1995;95:1103-8.  Back to cited text no. 10
Khan AA, Jain SK, Shrivastav A. Prevalence of dental caries among the population of Gwalior (India) in relation of different associated factors. Eur J Dent 2008;2:81-5.  Back to cited text no. 11
Gopalan C, Ramasastri BV, Balasubramanian SC, Narasinga Rao BS, Deosthala YG, Pant KC. Nutritive value of Indian foods. National Institute of Nutrition ICMR, Hyderabad, India. 2011; 47.  Back to cited text no. 12


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


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