Diet-cariogenicity and Health-fullness Index (DCHI) - a Novel, Comprehensive Index for Children; Rational and Development

Tailored, realistic dietary advice plays a vital role in Preventive Dentistry. Appropriate diet analysis forms the bases for precise dietary advice. Analysis of diet for its cariogenicity is a complex process. Performing meaningful diet analysis is a challenge in routine clinical practice. Currently, a very few tools are available for researchers or clinicians to assess children’s diet, as it relates to caries risk. To best of our knowledge an index that helps clinician to reduce composite diet dairy information to a simple quantiable interpretation is lacking. The current scientic paper presents a novel index that assesses the cariogenicity and health-fullness of child’s diet objectively and guides the professional to achieve pragmatic diet modication in prevention of Dental caries. Methods: A team comprised of specialist from Division of Pediatric dentistry, Community medicine and Diet and Nutrition along with a pilot parent-child population of number 50 were involved in initial structuring of Diet-Cariogenicity and Health-fullness Index. To obtain cut off values for cariogenicity of diet score a study was carried out with sample of 774 children correlating diet dairy with caries status. The receiver operating characteristic curve closest to the ideal of 100% sensitivity and 100% specicity was applied for statestical analysis. Results: Receiver Operating Characteristic curves plotted was 22.5 for diet scores for its cariogenicity. The sensitivity, specicity, and area under the curve of these cutoff values were 70 and 95. The current scientic paper presents a novel Diet-Cariogenicity and Health-fullness Index that assesses the cariogenicity and health-fullness of child’s diet objectively so as to guide the professional to achieve pragmatic diet modication. group and considered health full if it is equal or above the indicated serving by Food Guide Pyramid (FGP) for moderate calorie level (2002). Final phase was the diet counseling. Here the challenge was to guide the parent and child for a balanced diet which is less cariogenic. Question is who is the right person to counsel? As the present indices evaluates both cariogenic and healthfulness; the team felt that both dentist and dietician in combination can modify the child’s diet in an appropriate manner and can counsel the child and parent duo with a positive outcome.


Background
Diet is the sum of food consumed by a person and a balanced diet is the one which provides all the nutrients in required amounts and proportions. 1 Dietary habits and selections play an important role in human health. Eating nutrient-dense foods and balancing energy maintains the health essential at all stages of life. Unbalanced consumption of food high in energy and low in essential nutrients contributes to chronic diseases including Dental caries. 2 Dental caries, a major global public health concerned. 3,4 The harmful consumption of fermentable carbohydrates is recognized to be an essential etiological cause particularly among children from the lowest socio-economic groups. [5][6][7][8] So tailored pragmatic diet modi cation aimed at reducing fermentable carbohydrate and improving healthfulness of diet forms a key in prevention of Dental caries.
Analysis of diet for its cariogenicity is a complex process because fermentable sugars are often consumed in combinations. Also the properties of food like retention time, frequency, nutrient composition, and potentiality to stimulate saliva makes it further di cult to recognize its cariogenic potential. 9,10,11 Currently, however, few tools are available to experts to assess children's diet, as it relates to caries risk, and demonstrate how it can be successfully modi ed to reduce caries risk.
In 2002 American Academy of Paediatric Dentistry (AAPD) developed and advocated Caries risk assessment tool (CAT), which counts the frequency of inbetween-meal sugar attacks and bedtime exposure from bottles. 12 In 2004 dental health diet score 13 was discussed that gave points earned as a result of an adequate intake of food from each of the food groups essential for achieving and maintaining dental health. However this index does account for physical properties of food, also will not explain the guidelines for dietary modi cation. In the 2009 University of Iowa, The United States of America designed 'The Diet Assessment of Caries Risk tool' to help dental practitioners to identify dietary factors contributing to caries risk. 14 This collects information on frequency, amount, timing and manners of intake and supplemented with speci c responses represented as low, moderate or high caries risk. However, it is subjective in nature. Further in 2013 cariogenicity index was explained, however, the author concluded that because of the multifactorial nature of caries only liquid cariogenicity index has considerable potential in clinical settings. 15 In 2016 Moynihan P in contradiction to World Health Organization (WHO) issued guidelines (free sugars ≤10% )recommended intake of ≤5% free sugars to protect dental health throughout life. 16 So to best of our knowledge an index that helps clinician to reduce composite diet dairy information to a simple quanti able interpretation is lacking in literature. The current scienti c paper presents a novel index that assesses the cariogenicity and health-fullness of child's diet objectively and guides the professional to achieve pragmatic diet modi cation in prevention of Dental caries.

Structuring of DCHI
A team comprised of specialist from Division of Pediatric dentistry, Community medicine and Diet and Nutrition along with a pilot parent-child population of number 50 were involved in initial structuring of DCHI.
The rst challenge was to collect a meaningful and near infallible diet history from child parent duo which helps specialist to convert the gathered information rationally in to a numerical data for objective outcome. Based on information gathered from literature, present variations reported among Indian urban and rural scenario and opinion from team member's different diet dairy formats were prepared and were circulated among pilot population. Based on the inference of the pilot data it was decided to adopt 4 day (including a week end) prospective diet history collection method with added time component, detailed description of the food including dressings/dips, quantity of consumption and post-diet oral rinsing.
The next task was to convert the gathered information rationally in to a numerical data. Globally diet consists of a wide variety of regional and traditional cuisines native to the region. These cuisines vary substantially from each other in method of preparation and consumption. Based the composition and method of preparation food items prepared using the same base ingredient will pose different cariogenic potentials; listing each food item and assigning a score becomes an impossible task. The earlier attempts made to resolve above said task have achieved partially in categorizing subjectively to either cariogenic or non-cariogenic ignoring healthfulness of diet. The health-full ness of foods is determined by its nutrient composition whereas the cariogenic potential of foods and beverages is determined by the potential of food to decrease the plaque pH which in turn depends upon the form of the food, fermentable carbohydrate, hidden sugars, retention time, and frequency, quantity, between meals, near bedtime, prolonged exposure, and sequence. So the diet which is rich in nutrient might be cariogenic and should not be judgmental as a harmful diet. So it was decide to independently score each and every intake for its cariogenicity and healthfulness which aid in meaning fully modifying the food item during diet counseling phase.
Considering above said facts it was decided to categorize each and every intake based on food group and scored based on its form, additives (hidden sugar), retention time, frequency, between meals, near bedtime and sequence. The details for scoring criteria are explained in detail with illustrations in Diet's Cariogenicity and Health-fullness Index section. Cut off values for cariogenicity of diet score was estimated in yet another pilot study that was carried out with sample of 1500 children correlating diet dairy with caries status. The details of the same are explained in resultsection.
The decision of health fullness of diet for each food groups as consumed by the child was calculated based on average servings for individual food group and considered health full if it is equal or above the indicated serving by Food Guide Pyramid (FGP) for moderate calorie level (2002).
Final phase was the diet counseling. Here the challenge was to guide the parent and child for a balanced diet which is less cariogenic. Question is who is the right person to counsel? As the present indices evaluates both cariogenic and healthfulness; the team felt that both dentist and dietician in combination can modify the child's diet in an appropriate manner and can counsel the child and parent duo with a positive outcome.

Diet's Cariogenicity and Health-fullness Index
The index consist of 3 phases

Phase 1: Collection of Diet history
The child and parent duo should be provided with a diet diary template ( Figure 1) along with verbal and written instructions to help them complete the diary along with examples of completed diaries. They have to be instructed to maintain a real-time record of what they drink and eat for 4 consecutive days including one weekend in the template provided to them. The diet diary template has made provision to record the time of consumption, alongside to describe the item consumed in detail (especially for the platter of multiple types), the amount in a household measuring systems and post-diet oral-cavity cleansing (rinsing).They should provide details of each dietary intake such as the name of the food, brand names if any, additional items (sugar or sauces) as well as any medicine if consumed. Children should be instructed and encouraged to keep the diary with them all the time to instantly record any dietary intakes and avoid using atypical days that might be complicated by travel, illness, or unusual circumstances. Phase 2 A: Analysis of diet dairy for assessment of cariogenicity From the information collected through diet history, every intake of the child should be analyzed by the clinician and scored as follows.
a. For natural food items, i. Identify which food group it belongs to?
Scoring: For food groups: Grain, Fruit or dairy assign score 0.5 For food groups: Protein or vegetable assign score 0 ii. Identify whether food is in solid, semisolid or liquid state?
Scoring: For solid add score 1, for semisolid add score 0.5 and for liquid add score 0 iii. Identify the nature of the food, sticky or non-sticky?
Scoring: If sticky add score 1 If non-sticky add score 0 b. For processed food items, i. Based on its major ingredient identify which food group it belongs to?
Scoring: For food groups: Grain, Fruit or dairy assign score 1.5 For food groups: Protein or vegetable assign score 0.5 ii. Identify whether external sugar has been added ? # Scoring: If yes add score 1, If no add score 0 iii. Identify whether food is in solid, semisolid or liquid state?
Scoring: For solid add score 1, for semisolid add score 0.5 and for liquid add score 0 iv. Identify the nature of the food, sticky or non-sticky?
Scoring: If sticky add score 1 If non-sticky add score 0 **Processed food is de ned as food that has had some sort of chemical or industrial treatment in order to cook it, preserve it, or improve its taste or appearance: # Food item with added sugar or food belonging to miscellaneous food item consumed consecutively within 60 minutes interval then add 1 for the later score.
If child after every intake does not follow or is inconsistent in following the oral hygiene regime then add a score of 2 to per day diet score. If the child consumes food item with added sugar just before bed and skips oral hygiene regime add another score of 2 to per day diet score.
Based on the above criteria each intake of child should be scored and added to obtain a cumulative score of four days.
The child's diet cariogenicity score should be computed as follows Child's Diet cariogenicity score = 4 day cumulative score /4 Inference A score of 23 and above should be considered cariogenic, and a score below 23 is to be considered non-cariogenic (based on Receiver Operating Characteristic curves results obtained in pilot work) Phase 2 B:Analysis of diet dairy for its health-fullness ( Figure 3) Identify Food items consumed by the child at any given point of time, whether the single type or a platter multiple types?
a. If it is a Single type, check if it is a part of Miscellaneous (Table 1) Scoring if yes, assign score 0 for ve basic food groups.
if No Identity which one of the ve basic food groups the intake belongs to and quantify the intake in terms of servings*** and note under respective food group.
b. If it is a platter of multiple types, check if it contains any food items belonging to Miscellaneous?
Scoring For food items belonging to Miscellaneous assign score 0 for ve basic food groups.
For the rest of the food, for each food items identify which one of the ve basic food groups the intake belongs to and Quantify the intake in terms of servings.*** ***-Convert house hold measurements written in diet dairy in to serving using table 3 Based on the above criteria each intake of child should be scored and the servings under each food group consumed by the child should be added for 4 consecutive days added to obtain a cumulative four day score.

Inference
Calculated average servings for individual food group; if is equal or above the indicated serving by FGP (2002)  Illustration for Diet diary analysis Table 6 Phase 3 -Diet counseling Children falling in Category I, need no counseling, instead, reinforcement for good diet practice and follow-up is needed. For children falling in Category II, counseling by the Dentist is advised; For Category III and IV counseling by a dietician in collaboration with the Dentist is advised.
Guideline for diet counseling from the cariogenic point of view of the diet for Dentist For every child educate oral hygiene protocols to be followed using age-appropriate oral hygiene aids needs to be provided. Every intake should follow oral rinsing.
From diet diary received, Step1: Aim: To reduce miscellaneous food items to the maximum extent possible.
To do: Identify and mark all the dietary intakes by the child that are not associated with food groups but sweetened by the addition of sugars (miscellaneous food).eg: Chocolates, candy, pastry, chips and sweetened medicine Correction: Child and parents should be made aware of the ndings and instructed to reduce the frequency of above-said intakes. They are asked to club the intake of miscellaneous food with either lunch or dinner and absolutely refrain these intakes just before bed. If possible sugared medicines changed to arti cially sweetened ones. Whenever they consume miscellaneous food oral rinsing should be compulsory.
Step 2: Aim: To reduce the intake of fermentable sugar as much as possible without disturbing intake of food group servings.
To do: Identify and mark all the dietary intakes by the child that are associated with basic ve food groups but sweetened with the addition of sugars.
eg: milk with sugar, bread with jam, Chapati with ghee and sugar Correction: Child and parents should be made aware of the effect of the addition of sugars and advised on a realistic type of correction. Each day one food item is considered for correction starting from the rst meal of the day, Breakfast. The parents are instructed to wean the added sugars without disturbing the main food group ingredient. Parents can substitute's sugar, with honey or jiggery. Try to substitute sugar with no-sugar or permitted arti cial sugar-based products without affecting the intake of the main course associated with food groups. This is expected to be followed for 4 weeks consecutively and advised on a recall follow up. Whenever they consume miscellaneous food oral rinsing should be compulsory Step 3: Aim: To improve the intake of health-full diet.
To do: Identify and mark all the dietary intakes by the child that are associated with basic ve food groups.
Correction: Child and parents consuming adequate quantity of health-full diet should be appreciated and encouraged for consuming diet of a varied selection that contains an adequate quantity of the nutrients.
Illustration depicted in Table 7 shows post diet counseling modi cations suggested for day1 diet dairy of child. Modi cation has been done in the time of intake and emphasizing on the oral hygiene instructions without omitting the miscellaneous diet of the child and converting the cariogenic diet score to noncariogenic score. The healthfulness of diet was also improved by adding varied food groups to the diet that were lacking.
Diet cariogenicity score cut-off value methodology and results To con rm the cut-off values of Diet score for predicting cariogenicity score of diet a cross-sectional study was carried out. The study plan was approved by the institutional ethical committee. Permission to visit the schools and examine the children to collect data regarding Children's diet and dental caries was obtained from concerned Government & the school authorities. A total of 1500 school-going children aged 8-10 years were screened for selection criteria. The children were screened and clinically assessed by two trained, calibrated examiners. Inter and intra-examiner reliability were measured and a kappa value of 0.8 was observed, which indicated good agreement. The Dental caries of children was assessed using lifelong cumulative disease index the Decayed, Missing, Filled, (DMF) and decayed extracted lled (def). Based on ndings 450 children with low and 450 children with high DMF index values were selected for diet evaluation. The child and parent duo of 900 selected children were provided with 4 days diet diary template and asked to ll as explained above.
Of 900 diet dairy format distributed 774 formats were completed and returned yielding a response rate of 86 %. The diet scores of each child were calculated as explained above. The receiver operating characteristic curve analyses were performed to determine the optimal cut-off values for cariogenicity of diet scores in relevance to dental caries. The optimal cut-off values were obtained from the point on the receiver operating characteristic curve closest to the ideal of 100% sensitivity and 100% speci city.
To con rm the cut-off values for diet scores for their cariogenicity, a Receiver Operating Characteristic curves was plotted and area under the curve was calculated. As shown in, the receiver operating characteristic curve optimal cut-off value was 22.5 for diet scores for its cariogenicity . The sensitivity, speci city, and area under the curve of these cut-off values were 70 and 95. Figure 4 and Table 5 Discussion Diet affects oral health both systemically and topically. Of both, the latter plays a key etiological role in the causation of dental caries. 18 Although, implementing lifestyle interventions that promote healthier eating has been recommended in many international oral health promotion guidelines and policy documents yet they are not being followed. To ensure effectiveness of these guidelines, the Interventional dietary advice needs certain modi cations such as more realistic, comprehensive, and tailored to patients' needs. [19][20][21] Primarily, Collection of typical eating habits forms a requisite for a convincing diet analysis. There have been retrospective and prospective 7 days, 3 days, and 24 hours diet diaries that have been discussed in literature with their advantages and disadvantages. Retrospective diet diary methods even though were considered ideal for older children with low literacy, is time-consuming. This leads to recall bias and may not be a representative of either usual eating habits or typical eating habits. 22,23,24 Prospective diet diaries with the elimination of memory bias were considered to be of higher validity due to their expected accuracy and representativeness of habitual dietary intake. 22, 25-28 Among all prospective 3-day diet diary emerged as the most reliable tool for dietary assessment 22,25,28 However, in the recent past globalization has brought many changes in the lifestyle of both parents and children. Now the weekend consists of 2 days being Saturday and Sunday unlike the past and as a result eating pattern of both child and parent varies on both the days from that of a routine. Thus the 3-day diet dairy including weekend may not represent typical eating habits of the child. So in the present study, we have proposed a 4-day prospective diet dairy including at least one weekend that balances above-said variability by including 2 working days with 2 holidays to record both the typical and atypical eating patterns. The present study diet diary was designed to collect information on the quantity and timing of food consumption and oral hygiene maintenance protocols of the child.
Over the years analysis of diet for appropriate diet counseling using complex diet dairy has been a challenging issue. Studies have shown that dentists' analysis and judgments of diet dairy information are in uenced by their knowledge, values, and beliefs as well as available treatment. [29][30][31][32][33] To nullify this bias, in the present study a simple yet comprehensive analytical method based on the scienti c background was developed and explained.
The cariogenic potential of foods and beverages is determined by the potential of food to decrease the plaque pH which in turn depends upon the form of the food, fermentable carbohydrate and sugar including hidden sugars, retention time, and frequency of consumption, amount/quantity, in between meals, near bedtime, prolonged exposure, and sequence. The health-full ness of foods is determined by its nutrient composition. [34][35][36][37][38] In the present study the rst step of diet analysis was to investigate the form of the food whether it is natural or processed. Second and third steps will investigate regarding the food group to which the diet belonged to and information on addition of fermentable carbohydrate and external sugars. Later steps explores on the retention time based on information about the consistency of the food and the tackiness. Retentiveness of food is determined by its physical as well as chemical properties such as consistency, particle size, solubility, tackiness, cohesiveness and adhesiveness to the tooth surface. [40][41][42] There is a variation in the clearance time for each and every individual food as they exhibit different retentive properties. 43 Literature reports higher rates of dental caries incidence to be associated with the consumption of re ned carbohydrates in the retentive form (sticky). [44][45][46][47][48] Frequency and amount of dietary sugar is another important aspect that determines cariogenicity of diet. Continuous exposure to re ned carbohydrates prolongs the duration of a pH drop below the critical level and that it also limits the buffering capacity of dental plaque and saliva by draining their reserves of minerals. 22,[49][50][51][52] Of frequency and amount of dietary sugar, targeting the frequency of sugar consumption rather than the amount may be a more realistic approach when addressing at an individual level. 51 So, in the present study dietary analysis will check frequency of food with added sugar consumed within 60 minutes interval between the meals, an additional score of 1 to diet score.
In the present indices, the baked and processed foods with the combination of sugar and starch (high-starch snacks) like Deep Fried Fruits, vegetables, Legumes, Pulses, re ned grains/ cereals, bakery items were categorized to miscellaneous group and assigned a higher score as in past literature it is found that high-starch snacks was associated with an increased cariogenicity. 46,52 In the present indices, the food items like Medicines in liquid or semi-solid forms with added sugar either sucrose or fructose or with a combination of fructose and sorbitol and Carbonated drinks with arti cial avors produced a marked and long term drop in plaque pH. The cariogenic potential of pediatric liquid medications is due to high concentration of fermentable carbohydrates and their acidogenicity. Various authors have expressed concern over the presence of fermentable carbohydrates in syrup medications and their adverse effects on the oral health of children on a long term. [53][54][55] The decision of health fullness of diet for each food groups as consumed by the child was calculated based on average servings for individual food group and considered health full if it is equal or above the indicated serving by FGP for moderate calorie level (2002) 17 As per the FGP protocol a total calories 2,200 is right for children, as the amount of calories depends on how many calories you need and is inter dependent on the age, sex, size and how active the person/child is. [56][57] Based on the inference availed post diet analysis the children were categorized as discussed previously. Children assigned in Category I, need no counseling, instead, reinforcement for good diet practice and follow-up is needed. For children falling in Category II, counseling by the Dentist is advised; For Category III and IV counseling by a dietician in collaboration with the Dentist is advised.
In the previous literature, diet counseling was planned to primarily reduce the intake of fermentable sugar as much as possible without considering the nutritive value of the intake of food groups. Therefore, the diet counseling was carried out in a swift manner aiding in reducing the caries. In the present study, the diet consumed by the child is segregated in terms of the basic ingredient, method of preparation/processing, addition of external sugars etc to aid in the etiology of the dental caries. In this process the concentration is primarily focused only on the caries and its causation and absolute negligence towards the healthfulness of the diet. Therefore, in the category III and IV the diet would de netly consist of more cariogenic food and if these food items are advised to be weaned off or eliminated from the food plate it would also hamper the nutritive component of the child's diet. Considering the healthfulness of the diet it is important to consume a balanced diet to facilitate the satisfactory growth and development. Another important aspect being the time constraints by the dentist to evaluate the details of the diet completely in cases of advanced diet counseling for children. The need for the dietitian has a vital role in systematic, feasible and achievable goal to make the child caries resistant without affecting the nutrition.
Validity and reliability of the DCHI An index should be valid, reliable, and pragmatic in its use and results should be easily reportable. Validating and testing the index's reliability are underway. Results will be presented in future.

Limitations
The cut off scores computed for cariogenicity of diet in present study are applicable only for the Indian population and therefore it is suggested that further research from different regional and traditional locations based on their diet practices to be validated considering the same protocol to execute the cutoff values of diet score.

Conclusion
The current scienti c paper presents a novel Diet-Cariogenicity and Health-fullness Index that assesses the cariogenicity and health-fullness of child's diet objectively so as to guide the professional to achieve pragmatic diet modi cation. Availability of data and materials The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Competing interests
The authors declare no Competing interests  While scoring for following food items assign scores as follows 1. Medicines in liquid or semi-solid forms with added sugar -assign score 4.5 2. Direct intake of Honey, Sugarcane -assign score 2 3. Food products with the main ingredient that has not been included in basic food groups like ower, if consumed naturally score 0 will be assigned, if with addition of sugar -assign score 4 (eg-Gulkand) 4. Bakers' confectionery, Sweet condiments, sweets deserts, Sugary sweets-assign score 4.5 5. Carbonated drinks with arti cial avours and added sugar-assign score 4.5
Above mentioned miscellaneous food item if is part of platter of multiple types or consumed along with meal slash 1 from above mentioned scores 2. Food item with added sugar or food belonging to miscellaneous food item consumed consecutively within 60 minutes interval then add 1 for the later score.    Table  spoon Step Step 1   Figure 1 Analysis of diet dairy for assessment of cariogenicity-Step 1 Figure 2 Analysis of diet dairy for assessment of cariogenicity-Step 2 Analysis of diet dairy for its health-fullness Receiver operating characteristic curve comparing Dental caries and Diet cariogenic score for children