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RESEARCH REPORT |
1 School of Dental Sciences, University of Newcastle upon Tyne, Framlington Place, Newcastle upon Tyne, NE2 4BW, UK
* corresponding author, p.j.moynihan{at}ncl.ac.uk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: nutrition behavior • stage of change • nutrition • fruits and vegetables • prosthetic rehabilitation • randomized controlled trial
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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75 yrs are edentulous (Kelly et al., 2000). Dental prostheses do not restore function to that of a comparable dentate individual (Wayler and Chauncey, 1983; Krall et al., 1998), and denture-wearers report difficulty in eating numerous foods, in particular, fresh fruits (such as apples and pears) and raw vegetables (Wayler and Chauncey, 1983; Steele et al., 1998). Analysis of dietary intake data supports this, with the edentulous having significantly lower intakes than the dentate of fruits and vegetables (Joshipura et al., 1996; Lee et al., 2004; Hung et al., 2005). A recent World Health Organization report (2003) concluded that there was strong evidence that a diet high in fruits and vegetables ( 400 g/d) is protective against obesity, diabetes, cardiovascular disease, and some cancers. Although improvement in chewing ability with conventional or implant-supported dentures brings improvement in quality of life (Trulsson et al., 2002; Allen, 2005), changes in diet have been disappointingly few (Sebring et al., 1995; Morais et al., 2003; Allen, 2005). Thus, improvement in chewing ability alone does not provide sufficient drive to change what denture-wearers eat, suggesting that dietary intervention is necessary.
Dietary interventions tailored to Stage of Change, from the Transtheoretical Model (TTM) of behavior change (Prochaska et al., 1992), are effective in increasing fruit and vegetable intake (Horwath, 1999). TTM posits that people pass through five discrete, ordered stages of readiness to change behavior, and that by identifying participants’ Stages of Change, it is possible to move them from pre-action to action stages by providing material tailored to their stage.
The combined effect of improving chewing ability and the provision of advice to encourage healthier eating has not been investigated in controlled studies. In view of this, the objective of this study was to evaluate the effectiveness of a tailored nutrition intervention that aimed to increase the fruit and vegetable intake of edentulous patients receiving replacement conventional dentures. The primary outcome measure was change in weight of fruit and vegetables consumed. Secondary outcome measures were change in Stage of Change and nutrient intakes.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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We reviewed records for edentulous patients attending dental-student clinics at Newcastle Dental Hospital for replacement conventional dentures, to identify patients aged 45–80 yrs. Allocation to dietary intervention or control group was randomized and constrained so that the number in each group was equal. Following receipt of written information, patients interested in participating were screened by a nutritionist to determine if they met the other inclusion criteria: edentulous > 1 yr, community-dwelling, not type 1 insulin-diabetic. Non-insulin-dependent diabetics and those on a cholesterol-lowering diet were excluded only if diagnosed < 6 mos. Following baseline (T0) evaluation, participants with fruit and vegetable intakes 500 g/day were excluded (see Fig. 1
). Based on fruit and vegetable intake data from a UK national survey (Steele et al., 1998), it was estimated that a sample size of 49 patients/group would provide 80% power to detect a difference of 1 serving (80 g), 
= 5%.
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). All participants completed a three-day estimated food diary (two consecutive weekdays and one weekend day) and a baseline questionnaire to assess perceived chewing ability, Stage of Change, and socio-demographic variables. The intervention group participated in two one-to-one counseling sessions with a nutritionist, and received a tailored, written package. The control group received normal care only (see Fig. 1). Six wks after receiving replacement dentures, all participants were mailed a second food diary and questionnaire, which they brought back to the Dental Hospital the following week. The same nutritionist delivered and evaluated the intervention.
Evaluation
Stage of Change
Stage of Change was assessed pre- and post-intervention by means of an algorithm that divides precontemplators into those who are and are not aware of their low intake, by taking into account fruit and vegetable intake (see Fig. 2) (Lechner et al., 1998).
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Height was measured to the nearest 0.5 cm. Participants were weighed (EKS Compact Digital Scales) pre- and post-intervention, wearing light clothing, to the nearest 0.1 kg, and Body Mass Index (BMI) was calculated [weight (kg)/height (m)2].
Perceived chewing ability
Five items (scored 1–7 on a Likert Scale, = 0.90), selected from the questionnaire used in the oral health component of the National Diet and Nutrition Survey (Steele et al., 1998), assessed the participants’ satisfaction with their ability to bite and chew foods, and their satisfaction with denture fit and comfort. Item scores were summed to give a score for perceived chewing ability: A higher score indicated greater chewing difficulty and less satisfaction.
Intervention content
The theoretical framework underpinning the intervention was Stages of Change (Prochaska et al., 1992) and Optimistic Bias [a tendency to overestimate one’s chances, relative to those of others, of "positive life events" (Weinstein, 1980)]. The intervention consisted of two individual counseling sessions with the nutritionist, and the provision of an individually tailored nutrition education package. A tailoring questionnaire comprised of 16 questions addressing knowledge of diet-disease relationships, barriers such as lack of time and money, particular issues with chewing, and special dietary requirements guided the content of the written package. At least two nutrition messages were written for each question, depending on the participant’s answer, sex, and BMI. The messages consisted of both factual and skill-enhancing information, reflecting the appropriateness of different types of information for different stages of change. In addition, information on serving sizes, and recipes modified for denture-wearers (e.g., seed-free), were included, as was an action plan which participants could choose whether to complete. To provide ongoing feedback, six self-completion monitoring sheets were included that measured the previous day’s intake.
We addressed Optimistic Bias by comparing the previous day’s fruit and vegetable intake with the UK average (Finch et al., 1998) and the recommended intake (World Health Organization, 2003). A tendency to overestimate consumption has been demonstrated (Lechner et al., 1997), and providing dietary feedback is effective in increasing consumption (Brug et al., 1999).
Statistical Analyses
Analyses presented are for participants for whom complete data were available (T0 and T1). Categorical data are presented as percentages, and differences were analyzed by a Chi-square test. Movement through Stages of Change was analyzed by the Wilcoxon Signed-ranks Test. Continuous baseline data are presented as means (± SD), and differences between groups were compared by Student’s t tests. The effect of the intervention on fruit and vegetable and nutrient intake was assessed by one-way analysis of covariance (ANCOVA), adjusted for baseline intake and perceived chewing ability with replacement dentures, as was change in perceived chewing ability, adjusted for baseline score. Analyses were conducted by SPSS (version 10.0), and the criterion for statistical significance was P < 0.05.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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500 g/day were excluded, as were three due to medical reasons or dietary restrictions, resulting in 66 participants (control, 32; intervention, 34). Of these, 58 completed the evaluation (control = 28, 13 female; intervention = 30, 20 female). One participant was excluded because her food diary was mailed back rather than collected with interview; seven did not return to the Dental Hospital and were assumed to have withdrawn. Although the UK-recommended minimum fruit and vegetable intake is 400 g/d, because of the tendency to overestimate intake, a cut-off point of 500 g/d was chosen. All the participants who did not complete the study were female, but they did not differ significantly on any other variable.
There were no significant differences at T0 between groups for any of the measured socio-demographic variables (Tables 1 and 2). Participants had been edentulous for a median (range) of 30.0 yrs (2.0–57.0 yrs); median age of the current upper denture was 8.0 yrs (1.5–54.0 yrs), and that of the lower denture was 8.0 yrs (0.0–54.0 yrs).
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Stage of Change
The percentage of participants in each Stage of Change at T0 was not significantly different (fruit, 
2 = 2.084, df = 4, P = 0.720; vegetables, 2 = 1.299, df = 4, P = 0.862). Fig. 2 illustrates movement between stages for eating more fruit and vegetables from T0 to T1. The intervention group showed significant movement from pre-action to action Stages of Change (fruit, z = –2.560, P = 0.010; vegetables, z = –3.204, P = 0.001), unlike the control group (fruit, z = –0.383, P = 0.702; vegetables, z = –1.387, P = 0.166).
Fruit and Vegetable Intake
Total fruit and vegetable intake was significantly increased post-intervention in the intervention group [+209 (242) g/d] compared with the control group [+26 (106) g/d] (P = 0.001; observed power = 0.94) (Table 2).
At T0, 77% of the intervention group and 72% of the control group consumed some fruit during the three-day recording period. This increased at T1 to 97% in the intervention group (2 = 9.768, df = 1, P = 0.002), while the control group remained unchanged at 68% (2 = 0.000, df = 1, P = 1.000). Few in either group drank fruit juice at T0 (intervention, 20% vs. control, 4%). This number increased in both groups at T1 (intervention, 43% vs. control, 25%). The change within groups was significant for the intervention group only (2 = 4.887, df = 1, P = 0.027).
Nutrient Intakes
Mean BMI was not significantly different at T1 within (intervention, P = 0.129; control, P = 0.714) or between groups (Table 2). Energy and macronutrient intakes were not significantly different between groups at T1; for micronutrients, only vitamin C (15.57 mg/MJ vs. 8.50 mg/MJ, P < 0.0005) and ß-carotene (464.27 µg/MJ vs. 297.58 µg/MJ, P = 0.036) were significantly different.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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In common with other fruit and vegetable interventions, participants were more successful at increasing fruit and juice rather than vegetable consumption (Cox et al., 1998; Campbell et al., 1999). This may be due to taste preferences, but also to convenience, since fruit is easier to integrate into current eating patterns (Cox et al., 1998). Fruit juice has the additional advantage of requiring no chewing. Recommending one glass of fruit juice a day to patients with more severe eating difficulties is a useful strategy to move their fruit and vegetable intake toward the recommended target.
The increased intake of vitamin C and ß-carotene (nutrients associated with fruits and vegetables) is consistent with the reported increased fruit and vegetable intake. The trend for increased non-starch polysaccharide (NSP) intake in the intervention group is encouraging, given the low baseline intake, although it still falls short of the UK-recommended 18 g/d (Department of Health, 1991). A non-controlled intervention with denture wearers (Olivier et al., 1995) that sought to increase NSP intake by increasing fruit and vegetable consumption increased NSP derived from fruit and vegetables, but failed to increase total NSP intake. Although fruit and vegetables can make a useful contribution to NSP intake, promoting increased consumption of whole-grain cereals is more likely to achieve this objective (Gibney, 1999).
The participants in this study tended to be overweight (BMI > 25). Despite the intervention group’s increased consumption of fruit and vegetables, the reduction in their BMI was not significant, suggesting that fruit and vegetables were added to the usual diet rather than replacing other, higher calorie, foods (e.g., fruit instead of confectionary). Although not an objective of the study, moderate weight loss would have been a desirable outcome for many of the participants. However, it would be unrealistic to expect a large weight loss over a period of 6 wks.
Despite the lower-than-anticipated participant numbers, due to throughput of patients and exclusion of those consuming 500 g/d, the study was still powerful enough to detect a substantial increase in fruit and vegetable intake. The difficulties in evaluating diet in a blind manner (i.e., those who have received dietary intervention inevitably mention it to the evaluator) may introduce bias in dietary measurement. However, the observed movement between Stages of Change in the intervention, but not the control, group supports the dietary data. Since questionnaires were self-reported, these measures were not open to the biases of clinical judgment. Bias may also be introduced through socially desirable reporting by participants; inclusion, in future studies, of more objective dietary biomarkers, such as serum concentrations of carotenoids and vitamin C, is recommended.
The present findings indicate that denture patients are receptive to receiving dietary advice in a dental setting. The reasons for low intakes of fruits and vegetables in edentulous individuals are varied and complex, involving psychosocial, cultural, and lifestyle factors, in addition to compromised dentition. However, since eating problems are a primary reason for seeking dental treatment, the dental clinic provides an opportunistic setting for the provision of dietary counseling that deserves further exploration.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Received April 8, 2005; Last revision November 30, 2005; Accepted January 2, 2006
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REFERENCES |
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An impression made for treatment planning or the construction of an impression tray. 
The impression used for making the master cast.