Intake, Oral Health, and Frailty Among Older

3 Study of the interrelationships between dietary

4 intake, oral health, and frailty among older

5 Australian men

7 Kate Lenore Milledge

11 This thesis is submitted to fulfil requirements for the degree of Doctor of Philosophy

17 UNIVERSITY OF SYDNEY

18 Faculty of Science

19 School of Life and Environmental Sciences

20 2021

24 TABLE OF CONTENTS

25 TABLE OF CONTENTS ...... 1

26 ACKNOWLEDGEMENTS ...... 4

27 LIST OF PUBLICATIONS ...... 7

28 LIST OF CONFERENCES ...... 9

29 THESIS STRUCTURE ...... 11

30 THESIS ABSTRACT ...... 12

31 AUTHOR’S CONTRIBUTION ...... 15

32 LIST OF TABLES...... 16

33 LIST OF FIGURES...... 20

34 ABBREVIATIONS ...... 21

35 CHAPTER 1: INTRODUCTION ...... 25

36 1.1 Ageing, Nutrition, Oral Health ...... 26 37 1.2 Systematic Review: The relationship between dietary intake of nutrients and food groups 38 with dentition in community dwelling older adults: A systematic review ...... 31 39 1.3 Periodontal disease and Nutrition ...... 83 40 1.4 Tooth Decay and Nutrition ...... 92 41 1.5 Frailty, Nutrition and Oral Health ...... 98 42 1.6 Thesis Objectives ...... 102

43 CHAPTER 2: METHODS ...... 104

44 2.1 CHAMP Study overview ...... 105 45 2.1.1 Participant recruitment ...... 105 46 2.2 Assessment and Examination ...... 110 47 2.2.1 Self Completed Questionnaire ...... 110 48 2.2.2 Clinical Assessment ...... 112 49 2.2.3 Diet History ...... 113

50 2.2.4 Oral Health Examination ...... 114 51 2.3 Statistical Analysis ...... 116

52 CHAPTER 3: STUDY PARTICIPANTS ...... 118

53 3.1 Characteristics of the Population ...... 119 54 3.2 Respondents vs non-respondents ...... 124

55 CHAPTER 4: ASSOCIATIONS BETWEEN THE COMPOSITION OF FUNCTIONAL 56 TOOTH UNITS AND NUTRIENT INTAKE IN OLDER MEN: THE CONCORD 57 HEALTH AND AGEING IN MEN PROJECT...... 130

58 4.1 Abstract ...... 131 59 4.2 Introduction ...... 132 60 4.3 Methods ...... 133 61 4.4 Results ...... 142 62 4.5 Discussion ...... 149

63 CHAPTER 5: ASSOCIATIONS BETWEEN NUTRIENT INTAKE AND 64 PERIODONTITIS IN OLDER MEN: THE CONCORD HEALTH AND AGEING IN MEN 65 PROJECT ...... 156

66 5.1 Abstract ...... 157 67 5.2 Introduction ...... 158 68 5.3 Methods ...... 159 69 5.4 Results ...... 169 70 5.5 Discussion ...... 175

71 CHAPTER 6: ASSOCIATIONS BETWEEN NUTRIENT INTAKE AND TOOTH DECAY 72 IN OLDER MEN: THE CONCORD HEALTH AND AGEING IN MEN PROJECT ...... 183

73 6.1 Abstract ...... 184 74 6.2 Introduction ...... 186 75 6.3 Methods ...... 187 76 6.4 Results ...... 196 77 6.5 Discussion ...... 199

78 CHAPTER 7: HOW FRAILTY IMPACTS THE RELATIONSHIP BETWEEN DIET AND 79 ORAL HEALTH IN COMMUNITY DWELLING OLDER MEN ...... 214

80 7.1 Introduction ...... 215 81 7.2 Methods ...... 216 82 7.3 Results ...... 226 83 7.4 Discussion ...... 239

84 CHAPTER 8: DISCUSSION ...... 255

85 8.1 Discussion ...... 256 86 8.2 Limitations ...... 262 87 8.3 Strengths ...... 263 88 8.4 Implications and Recommendations ...... 264

89 REFERENCES ...... 267

90 APPENDICES ...... 303

91 Appendix A: PRISMA 2009 Checklist ...... 304 92 Appendix B: Project Protocol ...... 307 93 Appendix C: Database Search Terms ...... 310 94 Appendix D: Poor dietary intake of nutrients and food groups are associated with increased 95 risk of periodontal disease among community-dwelling older adults: a systematic literature 96 review ...... 313 97 Appendix E: Oral Health and Ageing Self-Completed Questionnaire ...... 328 98 Appendix F: Oral Health and Ageing Clinic Questionnaire ...... 373 99 Appendix G: Oral Health and Ageing Nutrition Questionnaire ...... 398 100 Appendix H: Manual for Nutritional Data Entry ...... 412 101 Appendix I: Oral Health and Ageing Oral Health Questionnaire ...... 498 102

103 ACKNOWLEDGEMENTS

104 I could not have completed this thesis without a great number of people’s support. First and

105 foremost, I wish to thank the CHAMP participants and their families. Without them the

106 CHAMP project, and subsequently this thesis, would not be possible. I had the great privilege

107 of helping collect data for CHAMP, which included being invited into the homes of our

108 participants. The CHAMP men, as well as their families, showed me such wonderful

109 hospitality.

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111 The other crucial person to the completion of my thesis is my supervisor, Vasant Hirani.

112 Without her guidance I think I would have struggled to succeed in completing my thesis.

113 Vasant has been an excellent supervisor, mentor, and great friend over the last 6 years. I was

114 able to approach her with any question or query, and she was incredibly encouraging and

115 kind, something that always boosted my confidence in myself and in my work when

116 encountering obstacles. I am also incredibly grateful how patient Vasant was as I balanced

117 work with completing my thesis. She never made me feel harried or pressured, only

118 encouraging me to keep going. I cannot thank Vasant enough for taking me on as her student.

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120 I would also like to thank Professor Robert (Bob) Cumming for his guidance, as well as for

121 the opportunity to work while I completed my thesis. To be able to manage the CHAMP

122 Project was an incredible opportunity to be offered as a PhD student, and one that provided a

123 range of skills and experiences I might not have gained otherwise. I am very thankful to have

124 had Bob as both an associated supervisor and employer. My other associated supervisor Fiona

125 O’Leary played a key role in helping me complete my first systematic review. Fiona was

126 gracious enough to offer her extensive experience on systematic reviews and has also been a

127 constant source of encouragement.

128 I’d like to thank a number of CHAMP investigators and researchers who have aided me over

129 the last few years. Firstly I want to thank Professor Frederick Wright, or Clive as we all know

130 him. As my background is in nutrition and dietetics, oral health was an unfamiliar territory.

131 Clive was a wonderful mentor to have guide me through the complexities of oral health. A

132 thank you to others in the CHAMP oral health team Gary Law, Steven Chu, Sandra Taylor,

133 Juliette Tran, Eduardo Valdez and Abi Srishanmuganathan.

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135 Jeorg Eberhard, Ben Hsu, Rosie Waern, and David Le Coutuer also provided excellent advice

136 and guidance. I would like to provide special thanks to Vasi Naganathan and Fiona Blyth for

137 the help and support they provided me as both a student and as project manager. Fiona

138 Stanaway, Saman Soltani, Arpita Das, Naomi Noguchi, and Ellie Shu, all of whom not only

139 gave me valuable advice but also friendship. Ellie regularly ensured there was a supply of

140 encouragement, and chocolate, during periods of increased stress.

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142 I also had wonderful support from the CHAMP team. Melissa Casey, Mari Wright, Jan Koh,

143 Janet Gilchrist, Mandy Leung, and Glenda Fraser were some of the amazing members of the

144 CHAMP team I have befriended and worked with since I started my PhD six years ago. A

145 special thanks to Tala Moradi and Anurina Das, and how hard they worked over the recent

146 years on the CHAMP project when I was project manager. They made my job, and as such

147 completing my thesis, much easier.

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149 Leanne Kearney has been a constant source of professional and emotional support over the

150 passing years. The many times I have been in her office to ask for help or even just chat when

151 I have been stressed, upset, or struggling she has always been there. I hope to become half the

152 leader that Leanne has been to myself and the CHAMP office.

153 Personally, I want to thank some of my closest friends I made during my time at CHAMP.

154 Sarita Lo and Kate Flinders have become my great friends and close confidants. They have

155 given me professional and life advice and were a constant source of comfort when I needed

156 it most. I have cherished the regular lunches, and ramen dinners, as well as our boozy

157 Christmas celebrations every year. They have been true friends. Thank you also to another

158 good friend Terry Jin, who always had lunch with me, and listened to my endless chatter.

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160 I also have countless friends outside CHAMP who have come from all walks of my life, high

161 school, university, old jobs and soccer (SWG/Fs and Cs). Completing this PhD has often

162 meant I have had to miss social events and gatherings, and I have not been able to see as many

163 of them as often as I like. Not a single friend made me feel neglectful or deficient. All my

164 friends have been nothing but a source of encouragement and support, and I am so thankful

165 to every single one of them.

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167 Most importantly I want to thank the two most influential people in my life, my mum and

168 dad. Thank you for working so hard to give me every opportunity I now have before me. And

169 thank you for giving me endless unconditional love and support. I hope I have made you

170 proud. Also to Claire, my sister, for always encouraging me and keeping me modest. My

171 family has been the source of my strength and endurance while completing my thesis.

172 And finally, I want to thank my partner Scott. I could not have asked for a better partner, both

173 patient and kind when I was at my most stressed moments, yet there to lift me up and celebrate

174 my achievements with me. He has been my rock, especially during these final years. I hope

175 to be there for you as you complete your thesis.

176 LIST OF PUBLICATIONS

177 No publications have yet resulted from this thesis. However I have been an author on

178 several related publications, which are listed below.

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180 Wright, F., Chu, S., Milledge, K., Valdez, E., Law, G., Hsu, B., Naganathan, V., Hirani,

181 V., Blyth, F., Le Couteur, D., Waite, L., Handelsman, D., Seibel, M., Cumming, R., et al.

182 (2018). Oral health of community-dwelling older Australian men: The Concord Health

183 and Ageing in Men Project (CHAMP). Australian Dental Journal, 63(1), 55-65

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185 Tran, J., Wright, F., Takara, S., Shu, C., Chu, S., Naganathan, V., Hirani, V., Blyth, F., Le

186 Couteur, D., Waite, L., Handelsman, D., Seibel, M., Milledge, K., Cumming, R. (2019).

187 Oral health behaviours of older Australian men: the Concord Health and Ageing in Men

188 Project. Australian Dental Journal, 64(3), 246-255.

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190 Wright, F., Law, G., Milledge, K., Chu, S., Hsu, B., Valdez, E., Naganathan, V., Hirani,

191 V., Blyth, F., Le Couteur, D., Waite, L., Handelsman, D., Seibel, M., Cumming, R. (2019).

192 Chewing function, general health and the dentition of older Australian men: The Concord

193 Health and Ageing in Men (CHAMP) Project. Community Dentistry and Oral

194 Epidemiology, 47(2), 134-141.

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196 O'Connor, J., Milledge, K., O'Leary, F., Cumming, R., Eberhard, J., Hirani, V. (2020).

197 Poor dietary intake of nutrients and food groups are associated with increased risk of

198 periodontal disease among community-dwelling older adults: a systematic literature

199 review. Nutrition Reviews, 78(2), 175-188

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201 Valdez, E., Wright, F., Naganathan, V., Milledge, K., Blyth, F., Hirani, V., Le Couteur,

202 D., Handelsman, D., Waite, L., Cumming, R. (2020). Frailty and oral health: Findings

203 from the Concord Health and Ageing in Men Project. Gerodontology, 37(1), 28-37

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226 LIST OF CONFERENCES

227 Milledge, K. Cumming, R. Wright, F. Blyth, F. Naganathan, V. Le Couteur, D. & Hirani,

228 V. ‘Associations between nutrient intake and composition of Functional Tooth Units in

229 older men: the Concord Health and Ageing in Men Project.’ The 15th National Conference

230 of Emerging Researchers in Ageing Conference, November 2016, in Canberra, Australia

231 – Oral Presentation.

232 Milledge, K. Cumming, R. Wright, F. Blyth, F. Naganathan, V. Le Couteur, D. & Hirani,

233 V. ‘Dietary intakes of nutrients and tooth decay: the Concord Health and Aging in Men

234 Project.’ The 51st AAG Conference, November 2018, in Melbourne, Australia – Oral

235 Presentation.

236 Milledge, K. O’connor, J. Oleary, F. Wright, F. Cummings, R. & Hirani V. ‘The

237 relationship between dentition and diet: a systematic review.’ The Dietetics Association

238 of Australia 35th National Conference, May 2018, in Sydney, Australia – Oral

239 Presentation.

240 Milledge, K. Cumming, R. Wright, F. Blyth, F. Naganathan, V. Le Couteur, D. &

241 Hirani, V. ‘Associations between nutrient intake and composition of Functional Tooth

242 Units in older men: the Concord Health and Ageing in Men Project (CHAMP)’. The 21st

243 IAGG World Congress of Gerontology and Geriatrics, July 2017, in San Francisco,

244 USA – Poster Presentation.

245 Milledge, K. Cumming, R. Wright, F. Blyth, F. Naganathan, V. Le Couteur, D. & Hirani,

246 V. ‘Associations between nutrient intake and periodontal health of older men: the

247 Concord Health and Ageing in Men Project’. The IUNS 21st International Congress of

248 Nutrition, October 2017, in Buenos Aires, Argentina – Oral Presentation.

249 Milledge, K. Cumming, R. Wright, F. Blyth, F. Naganathan, V. Le Couteur, D. & Hirani,

250 V. ‘Associations between nutrient intake and periodontal health of older men: the

251 Concord Health and Ageing in Men Project’. The 50th AAG Conference, November 2017,

252 in Perth, Australia – Oral Presentation.

253 Milledge, K. Cumming, R. Wright, F. Blyth, F. Naganathan, V. Le Couteur, D. & Hirani,

254 V. ‘Associations between nutrient intake and periodontal health of older men: the

255 Concord Health and Ageing in Men Project’ The Dietetics Association of Australia 34th

256 National Conference, May 2017, in Hobart, Australia – Oral Presentation.

257 Milledge, K. Hirani V. Cummings, R. & Oleary, F. ‘The relationship between Oral health

258 and Nutrition: Results from the CHAMP Study’. The 4th Asia Pacific Regional Congress

259 of the International Association for Dental Research, in Brisbane from the 28th to the 30th

260 of November 2019

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273 THESIS STRUCTURE

274 This thesis is based on data obtained from the Concord Health and Ageing in Men Project.

275 It contains eight chapters in total: CHAPTER 1 (Introduction), CHAPTER 2 (Methods),

276 CHAPTER 3 (Study Population), CHAPTER 4 (Associations between the composition of

277 Functional Tooth Units and nutrient intake in older men: The Concord Health and Ageing

278 in Men Project), CHAPTER 5 (Associations between nutrient intake and periodontitis in

279 older men: the Concord Health and Ageing in Men Project), CHAPTER 6 (Associations

280 between nutrient intake and tooth decay in older men: The Concord Health and Ageing in

281 Men Project), CHAPTER 7 (How frailty impacts the relationship between diet and oral

282 health in community dwelling older men), and CHAPTER 8 (Discussion).

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284 CHAPTER 1 provides background on issues covered by this thesis, including ageing,

285 nutrition and oral health in older adults, the relationship between diet with periodontal

286 disease and tooth caries older adults, as well as the role frailty plays in this relationship.

287 This chapter also includes the review: The relationship between dietary intake of nutrients

288 and food groups with dentition in community dwelling older adults: A systematic review.

289 CHAPTER 2 provides a description of the CHAMP study recruitment and methods of

290 data collection, as well as details on study variables. CHAPTER 3 provides a detailed

291 description of the study population’s characteristics. CHAPTERS 4, 5 and 6 are written

292 as papers that have been submitted or are intended to be submitted, to peer-review

293 journals. For this reason there is some cross-over in the literature review and method

294 descriptions. CHAPTER 7 has also been written with the intention of publishing in peer-

295 reviewed journals; however, this may result in multiple publications. Finally, CHAPTER

296 8 synthesises the overall results of the previous chapters, as well as implications and future

297 recommendations.

298 THESIS ABSTRACT

299 Objective: The aim of this thesis is to explore the interrelationship between diet and oral

300 health in community dwelling older men. Specifically this study focused on investigating

301 the associations between composition of Functional Tooth Units (FTUs) and nutrient

302 intakes in older men, the associations between diet with periodontitis and tooth caries in

303 older men, and the interrelationship between frailty, diet quality, and oral health.

304 Methods: A cross-sectional study was done with a standardized validated diet history

305 assessment and comprehensive oral health assessments in 608 community dwelling

306 Australian men (mean age: 84 years) participating in the Concord Health and Ageing in

307 Men Project. A subsection of 520 dentate participants and 294 men who completed the full

308 periodontal examination were also analysed. FTUs were categorised by dentition type; (i)

309 Group A (Natural FTUs Only) (ii) Group B (Natural and Replaced FTUs) and (iii) Group

310 C (Replaced FTUs Only). Severe periodontitis was based on the classifications of the Center

311 for Disease Control and Prevention (CDC) and American Academy of Periodontology

312 (AAP): Severe periodontitis ≥2 interproximal sites with a Clinical Attachment Loss (CAL)

313 of ≥6mm, and ≥1 site with a Probing Depth (PD) of ≥5mm, moderate periodontitis as ≥2

314 interproximal sites with a CAL of ≥5mm, or ≥2 interproximal sites with a PD of ≥5mm, and

315 mild periodontitis as ≥2 interproximal sites with a CAL of ≥3mm, and ≥2 interproximal site

316 with a PD of ≥4mm. Total Periodontitis was defined as the presence of severe, moderate, or

317 mild periodontitis. Presence of coronal decay was defined as ‘≥1 coronal decayed surfaces,’

318 while presence of severe coronal decay was defined as ‘≥3 coronal decayed surfaces.

319 Presence of root decay was categorized as ‘≥1 decayed root surfaces,’ while presence of

320 severe root decay was categorized as ‘≥3 decayed root surfaces’. Nutrient Reference Values

321 (NRVs) were used to determine if participants’ were meeting micronutrients and

322 macronutrients recommendations. Attainment of Nutrient Reference Values (NRVs) for 16

323 micronutrients was incorporated into a Micronutrient Risk variable, dichotomised 'good' 12

324 (≥12) or 'poor' (≤11), and for 7 macronutrients into a Macronutrient Risk variable,

325 dichotomised 'good' (≥5) or 'poor' (≤4). Attainment of Nutrient Reference Values (NRVs)

326 for energy intake and six other nutrients were also incorporated into a ‘key nutrients’

327 variable, dichotomized as 'good' (meeting recommendations for ≥5 key nutrients) or 'poor'

328 (meeting recommendations for ≤4 key nutrients). The main sample and subsample

329 populations were stratified by frailty into the categories ‘Robust’ and ‘Non-Robust’ (pre-

330 frail and frail). Backwards stepwise elimination was used to fit the final adjusted models,

331 which all included age and energy intake as well as other potential confounders which were

332 screened for. Logistic regression models were applied to the separate populations stratified

333 by frailty status, and statistical interactions were assessed using the Breslow Day test for

334 homogeneity.

335 Results: In adjusted logistic regression analysis No Natural FTUs, compared to only

336 Natural FTUs, was associated with intakes below NRV recommendations for fibre and

337 magnesium. Men with No Natural FTUs, compared to men with Only Natural FTUs, were

338 more likely to have poor intake of macronutrients. Adjusted analysis also showed that poor

339 intakes of key nutrients was associated with the presence of total periodontitis, while not

340 meeting the recommended intakes for zinc, and thiamin were associated with presence of

341 severe root decay. Adjusted analysis also showed that participants who were outside the

342 recommended AMDR for fat were less likely to have coronal tooth decay, and men who did

343 not meet fibre recommendations were more likely to have root decay present. Stratification

344 of populations by frailty revealed no relationship between diet and oral health in a robust

345 population. However, adjusted analysis found a number of associations between diet and

346 oral health in the non-robust population, notably poor intake of key nutrients was

347 significantly associated with the presence of total periodontitis.

348 Discussion: Results of this thesis show clear interrelationships between diet and oral health,

349 including composition of FTUs, periodontitis and tooth caries. Notably the association 13

350 between meeting fibre recommendations with composition of FTUs and severe root decay

351 provides some evidence of a bi-directional relationship between fibre intakes and oral

352 health. Furthermore, frailty appears to be an effect modifier for the relationship between

353 overall diet quality and periodontitis.

354 AUTHOR’S CONTRIBUTION

355 As part of my PhD candidature and for the development of my thesis I participated in the

356 8 -year follow up (the 4th Wave) of the Concord Health and Ageing in Men Project. My

357 role included the collection of data for the clinical and dietary assessment of

358 approximately 300 participants. This included data entry for the dietary assessment. I also

359 had key oversight for all aspects of the dietary assessment, including coding and entry,

360 which I co-ordinated with two other team members. I had the main responsibility of

361 overseeing the cleaning of the 8-year data.

362 Finally, I am the main contributor to the four chapters, and systematic literature review,

363 included in this thesis. I conducted the descriptive and analytical analyses for each chapter,

364 using statistical software and with guidance from my supervisors. I interpreted the analysis

365 with guidance from my supervisors and was responsible for writing the manuscripts. My

366 supervisors Vasant Hirani, Robert Cumming, and Fiona O’Leary have provided extensive

367 review of the manuscripts. Clive Wright, David Le Couteur, Fiona Blyth, Vasi

368 Naganathan, David Handelsman, Joerg Eberhard and Louise Waite, have also reviewed

369 the manuscripts and approved final versions. The CHAMP chief investigators were

370 involved in the establishing the CHAMP study and attaining the NHMRC project funding

371 for the study.

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379 LIST OF TABLES

380 Table 1.1 PICOS for inclusion and exclusion criteria ...... 36

381 Table 1.2 Characteristics of systematically reviewed studies (n=20) ...... 41

382 Table 1.3 Data extracted from systematically reviewed studies (n=20) ...... 51

383 Table 1.4 Assessment of Quality of overall evidence from systematically reviewed 384 studies, and studies broken down by different definitions of dentition, using GRADE .. 78

385 Table 1.5 Population studies on diet and periodontal disease in older adults ...... 85

386 Table 1.6 Population studies on diet and dental caries in older adults ...... 94

387 Table 2.1 Data collected at baseline, 2nd Wave, 3rd Wave and 4th Wave of follow ups 108

388 Table 3.1 Demographic, lifestyle, and socio-economic characteristics of the sample 389 population (n=608)...... 121

390 Table 3.2 Health status characteristics of the sample population (n=608) ...... 123

391 Table 3.3 Food access characteristics of the sample population (n=608) ...... 124

392 Table 3.4 Oral health characteristics of the sample population (n=608) ...... 125

393 Table 3.5 CHAMP Nutrition assessment and oral health examination respondents 394 (n=608) vs non-respondents (n=173) ...... 126

395 Table 3.6 CHAMP Nutrition assessment and oral health examination respondents 396 (n=608) vs 4th Wave non-respondents (n=202) ...... 128

397 Table 4.1 Characteristics and dentate status of the study population (n=608) ...... 143

398 Table 4.2 Median daily intake (and 5th/95th percentile) of energy and nutrients, 399 percentage and number of participants not meeting the recommended intake for each 400 nutrient by FTUs composition ...... 147

401 Table 4.3 Univariate analysis of oral health variables and micronutrient and 402 macronutrient intakes ...... 150

403 Table 4.4 Multivariate logistic regression model of FTUs composition and FTU number, 404 and micronutrient (11 or fewer) and macronutrient (4 or fewer) risk variables ...... 155

405 Table 5.1 Characteristics and periodontitis status of the study population that 406 participated in the periodontal assessment (n=294), compared against characteristics of 407 participants who were excluded (n=225) ...... 170

408 Table 5.2 Median daily intake (and 5th/95th percentile) of energy and nutrients, 409 percentage and number of participants not meeting the recommended intake for each 410 nutrient, and top food sources ...... 173

411 Table 5.3 Associations between intake of key nutrients and dietary intake of 412 macronutrients and micronutrients with the presence of total and severe periodontitis 179

413 Table 6.1 Characteristics and decay status of the study population ...... 197

414 Table 6.2 Median daily intake (and 5th/95th percentile) of energy and nutrients, 415 percentage and number of participants not meeting the recommended intake for each 416 nutrient by presence of Coronal and Root Decay ...... 200

417 Table 6.3 Multivariate logistic regression model of higher fat, lower carbohydrate diet, 418 macronutrient (4 or fewer) risk variables, energy intake, and individual macronutrients 419 and the presence of Coronal Decay ...... 202

420 Table 6.4 Multivariate logistic regression model of higher fat, lower carbohydrate diet, 421 macronutrient (4 or fewer) risk variables, energy intake, and individual macronutrients 422 and the presence of Root Decay ...... 205

423 Table 6.5 Multivariate logistic regression model of higher fat, lower carbohydrate diet, 424 micronutrient (11 or fewer) risk variables, energy intake, and individual micronutrients 425 and the presence of Severe Root Decay ...... 209

426 Supplementary Table 6.1 Multivariate logistic regression model of higher fat, lower 427 carbohydrate diet, micronutrient (11 or fewer) risk variables, energy intake, and 428 individual micronutrients and the presence of Severe Coronal Decay ...... 212

429 Table 7.1 Characteristics and dentate status of the study population stratified by robust 430 vs non-robusta, (n=596) ...... 228

431 Table 7.2 Characteristics and decay status of the study population included in the tooth 432 decay examination stratified by robust and non-robusta population, (n=511) ...... 231

433 Table 7.3 Characteristics and periodontitis status of the study population included in the 434 periodontal examination stratified by robust and non-robusta population, (n=292) ...... 234

435 Table 7.4 Multivariate logistic regression model of FTUs composition and FTU number, 436 and micronutrient (11 or fewer) risk variable, stratified by robust and non-robust 437 (prefrail and frail) population ...... 236

438 Table 7.5 Multivariate logistic regression model of FTUs composition and FTU number, 439 and macronutrient (4 or fewer) risk variable, stratified by robust and non-robust (prefrail 440 and frail) population ...... 240

441 Table 7.6 Multivariate logistic regression model of FTUs composition and FTU number, 442 and key nutrient intake, stratified by robust and non-robust (prefrail and frail) population 443 ...... 241

444 Table 7.7 Multivariate logistic regression model of the micronutrient risk variable (11 or 445 fewer), macronutrient risk variable (4 or fewer), and intake of key nutrients, with the 446 presence of coronal decay, stratified by robust and non-robust (prefrail and frail) 447 populations ...... 243

448 Table 7.8 Multivariate logistic regression model of the micronutrient risk variable (11 or 449 fewer), macronutrient risk variable (4 or fewer), and intake of key nutrients, with the 450 presence of root decay, stratified by robust and non-robust (prefrail and frail) 451 populations ...... 244

452 Table 7.9 Multivariate logistic regression model of the micronutrient risk variable (11 or 453 fewer), macronutrient risk variable (4 or fewer), and intake of key nutrients, with the 454 presence of severe coronal decay, stratified by robust and non-robust (prefrail and frail) 455 populations ...... 248

456 Table 7.10 Multivariate logistic regression model of the micronutrient risk variable (11 457 or fewer), macronutrient risk variable (4 or fewer), and intake of key nutrients, with the 458 presence of severe root decay, stratified by robust and non-robust (prefrail and frail) 459 populations ...... 249

460 Table 7.11 Multivariate logistic regression model of the presence of total periodontitis 461 with micronutrient risk variable (11 or fewer), macronutrient risk variable (4 or fewer), 462 and intake of key nutrients, stratified by Robust and Non-Robust (prefrail and frail) 463 populations ...... 252

464 Table 7.12 Multivariate logistic regression model of the presence of severe periodontitis 465 with micronutrient risk variable (11 or fewer), macronutrient risk variable (4 or fewer), 466 and intake of key nutrients, stratified by Robust and Non-Robust (prefrail and frail) 467 populations ...... 253

468 Table 8.1 Summary of thesis findings ...... 257

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470

471 LIST OF FIGURES

472 Figure 1.1: PRISMA Flow Chart of systematic screening process ...... 40

473 Figure 1.2: Nutrition and Oral health theoretical framework…………………………102

474 Figure 2.1: Concord Health and Ageing Men Project baseline recruitment ...... 107

475 Figure 3.1: Flow chart of sample size at baseline, 2nd wave, 3rd wave, and 4th wave of 476 data collection, and reason for non-reporting at each follow-up ...... 120

477 Figure 5.1: Flow chart of 4th wave of CHAMP follow up, diet history and periodontal 478 assessment participation ...... 168

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ABBREVIATIONS

AA Arachidonic acid

AAP American Academy of Periodontology

ABL Alveolar Bone Loss

ACE Addenbrooke’s Cognitive Examination

ADG Adequate Dietary Guidelines

ADLs Activities of Daily Living

AI Adequate Intake

ALA alpha-Linolenic acid

ALP Alkaline phosphatase

ALT Alanine Aminotransferase

AMDR Acceptable Macronutrient Distribution Range

AMT Abbreviated Mental Test

AUSNUT 2007 Australian Nutrient Database 2007

BDHQ Brief Self-Administered Diet History Questionnaire

BGLs Blood Glucose Levels

BMD Bone Mineral Density

BMI Body Mass Index

BMR Basal Metabolic Rate

CAGE Cut-down, Annoyed, Guilty, Eye-opener

CAL Clinical Attachment Loss

CD Complete Dentures

CDC Center for Disease Control and Prevention

CHAP Community Health Agents Program

CHS Cardiovascular Health Study

CI Confidence Intervals.

CPI Community Periodontal Index

CRP C-reactive Protein

DASH Dietary Approaches to Stop Hypertension

DEXA Duel-Energy X-ray Absorption

DHA Docosahexaenoic Acid

DII Dietary Inflammatory Index

DQII Diet Quality Index-International

DQI-R Diet Quality Index-Revised

DRI Daily Recommended Intake

EAR Estimated Average Requirements

EER Estimated Energy Requirements

EPA Eicosapentaenoic acid

FEV1 Forced Expiratory Volume in 1 second

FFQ Food Frequency Questionnaire

FHP Family Health Program

FTUs Functional Tooth Units

FV Fruit and Vegetables

GDS Geriatric Depression Syndrome

GI Glycemic Index

GRADE Grading Recommendations, Assessment, Development and Evaluation

system

HCU Health Care Utilization.

HDL High Density Lipoproteins

HEI Healthy Eating Index

HR Hazard Ratios

ICIQ International Consultation on Incontinence Questionnaire

IPSS International Prostate Symptoms Score

IQCODE Informant Questionnaire on Cognitive Decline in the Elderly

IRR Incidence Rates Ratio

KNHANES Korean National Health and Nutrition Examination Survey

LA Linoleic Acid

LSM Least-Squares Method

MDS Mediterranean Diet Score

MEC Mobile Examination Centre

MeSH Medical Subject Headings

MMSE Mini-Mental State Examination

MNA Mini-Nutritional Assessment

MOW Meals on Wheels

MUFA Mono-Unsaturated Fatty Acids

ND No Dentures

NHANES National Health and National Examination Survey

NNS National Nutrition Survey

NOHSA National Oral Health Study of Australia

NPI Neuropsychiatric Inventory

NRV Nutrient Refernce Values

NSAOH National Survey of Adult Oral Health

OHIP Oral Health Impact Profile

OR Odds Ratio

PASE Physical Activity Scale for the Elderly

PD Probing Depth

PICOS Population Intervention Comparison Outputs Study

PIR Poverty Income Ratio

POPs Posterior Occluding Pairs

PPD Periodontal Probing Depth

PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PSA Prostate-Specific Antigen

PUFA Poly-Unsaturated Fatty Acids

RDA Recommended Daily Allowances

RPD Removable Partial Dentures

RR Relative Risk

SCQ Self-Completed Questionnaire

SD Standard Deviation

SDD Survey Dental Disease

SF12 Short Form-12

SFA Saturated Fatty Acid

SIGN Scottish Intercollegiate Guidelines Network

SRH Self-Reported Health

SROH Self-Rated Oral Health

TEI Total Energy intake.

UL Upper Level

WHO World Health Organisation

495

496

497

498

499

500

501

502

503

504

505

506

507 CHAPTER 1. INTRODUCTION

508

509

510

511

512

513

514

515

516

517

518

519

Ageing nutrition and oral health

520 1.1 Ageing, nutrition and oral health

521 Ageing in Australia

522 An estimated 9 percent of people worldwide are aged 65 years older, and this is

523 projected to increase by more than 60 percent over the next 12 years (1, 2). By 2050,

524 the global population of people aged 65 years and older is expected to double (3). As a

525 continent, Europe continues to have the greatest of percentage of adults aged 65 years

526 and older at 18.8%, while in North America 15% of the population are 65 years and

527 older (2). In Eastern Asia and South-Eastern Asia 11.2% of the population are aged 65

528 years and older (2). Notably, Japan has the highest percentage with 28 percent of the

529 population made up of people aged 65 years and older (2). As such ageing populations

530 are an increasing phenomenon in countries across the globe, and Australia is no

531 exception (2, 4).

532

533 In 2019, 15.9% of the population in Australia were aged 65 years and older, nearly

534 triple the percentage of Australian’s in 1927 (4, 5). Additionally, since 1996 the

535 population of adults aged 85 years and older has nearly doubled from 1.1% to 2% (5,

536 6). Females aged 65 years and older outnumber males in the same age category, a trend

537 reflected globally (1, 5). Future estimations predict that by 2061 between 22.4% to

538 24.5% of the Australian population will be 65 years and older, while 4.5% to 6% will

539 be 85 years and older (7). Furthermore the median age will increase from 37.3 years to

540 between 41.0 and 44.5 years (7).

541

542 An ageing population in Australia poses particular health, social and economic

543 challenges (8). The upcoming generation of retirees are more likely than previous older

544 generations to be living alone, ethnically diverse, and less likely to be reliant on the

Ageing nutrition and oral health

545 aged pension, due to superannuation (8). Older adults have a greater burden of disease

546 such as functional decline, falls, depression, dementia and poor nutritional status (9).

547 Consequently, older adults have greater health and long-term care needs, that will

548 impact on the Australian economy due to increased government expenditure on health,

549 aged care and pension services (8, 9). Furthermore one third of older adults live in inner

550 regional, outer regional or remote areas, which may limit access to public health

551 services (4).

552

553 Planning for an ageing population, in conjunction with good policy at the federal, state

554 and local level is essential (8). It is important research into the issues related to the

555 changing burden of disease is undertaken (8-10). In particular, a focus on health

556 promotion and prevention could aid in minimizing burgeoning future health costs (10).

557 As such it is important that research is conducted focusing on older adult’s health, and

558 potentially disease prevention (10).

559

560 Population-based studies of diet in older Australians

561 Older adults have different, and sometimes greater nutritional requirements than

562 younger populations (11, 12). However, due to biological and physical function decline,

563 as well as social and economic factors, older adults are at higher risk of not meeting

564 these nutritional requirements that can then lead to nutritional deficiency and protein-

565 energy malnutrition (11, 13-17). Energy and protein deficient malnutrition can lead to

566 complications such as increased risk of falling, higher length of stay in hospitals, as

567 well as loss of independence (18-20). Prevalence of malnutrition is high amongst

568 institutionalized and hospitalized older adults, with many studies showing fifty percent

569 or more patients are at risk or suffering from malnutrition (15, 21, 22). Amongst

Ageing nutrition and oral health

570 community dwelling older adults’ prevalence of malnutrition is lower, with limited

571 research suggesting that anywhere between five and forty percent are at risk or suffering

572 from malnutrition (23, 24).

573

574 Old age is also associated with a decline in micronutrient intake (11, 25). Older adults

575 generally do not meet the recommended dietary intakes of minerals such as iron, zinc

576 and calcium (11, 25). Significant numbers of older adults also do not meet the

577 recommended dietary intakes of vitamins such as riboflavin, thiamin, folate and vitamin

578 E (11, 25).There are a number of factors influencing protein-energy malnutrition and

579 poor nutritional intake of micronutrients (13, 15, 17, 26). These include physiological

580 health issues such as changes in energy requirements, alterations in taste and smell,

581 difficulties chewing or swallowing (13, 15, 17, 26). Socio-economic factors like

582 isolation, cost, access to food and loss of the ability to shop and cook independently,

583 also impact protein-energy malnutrition and the intake of micronutrients. (13, 15, 17,

584 26). Other demographic factors such as poverty, country of birth and living status also

585 impact on intake of malnutrition and protein-energy malnutrition (15, 27, 28). Chronic

586 and acute diseases increase specific nutrient requirements, which require special

587 nutritional interventions (17, 26). Furthermore, oral health issues such as poor dentition,

588 edentulism, denture quality and chewing capacity are also likely to impact negatively

589 on the nutritional status of older adults (29-31).

590

591 Population based studies on oral health and older adults

592 Poor oral health can have significant consequences on the health of older people.

593 Ageing is typically associated with loss of teeth, which is associated with poor

594 mastication and lower quality of life (35). Compared to younger age groups, older

Ageing nutrition and oral health

595 populations are more likely to be edentulous (the loss of all natural teeth) (32). The

596 National Survey of Adult Oral Health (NSAOH) carried out between 2004 to 2006

597 reported that among adults aged 75 years and older, 35.7% were completely edentulous

598 (32). This was markedly lower among adults aged 55 to 74 years (13.9%), 35 to 54

599 years (1.7%) and 0% were edentulous in adults aged 15 to 34 years (32). Furthermore,

600 older age groups are less likely to have the minimum number of 21 natural teeth

601 required for optimal chewing function, compared to younger groups (32). Over 55% of

602 adults aged 75 years and older retained less than 21 natural teeth, while 28.6% of adults

603 between the ages of 55 and 74 had less than 21 teeth present (32). Less than 10% of

604 people aged 54 years and younger had fewer than 21 teeth left (32).

605

606 This has also been reflected in other national studies (33, 34). In Canada 42.2% of adults

607 aged 60 to 79 years have less than 21 natural teeth, compared to 16.5% of adults 40 –

608 59 (34). Globally prevalence of severe tooth loss increases with age (33). Yet these

609 population studies show that post war generations of adults are retaining more of their

610 natural teeth than their predecessors (32). In 1979, 59.7% of men and 71.5% of women

611 65 years or older were edentulous (35). In 2002, edentulous rates in men and women

612 aged 65 and older had fallen to 26.5% of men and 40.3% respectively (35). This may

613 be due to improved dentistry, better access to oral health services, and public health

614 initiatives, such as water fluoridations (36, 37). Unfortunately, reduced rates of

615 edentulism have also lead to a rise in the prevalence of periodontal disease and tooth

616 decay in older populations, increasing the burden of oral health treatment (32).

617

618 Nearly half of adults in the USA (47%) have either mild, moderate or severe periodontal

619 disease (38). Among adults aged 65 years and older, 64% have either moderate or

Ageing nutrition and oral health

620 severe periodontal disease (38). Among Australian adults 55 to 74 years of age, 43.6%

621 had moderate to severe periodontal disease, while 60.8% of adults aged 75 years and

622 older had moderate to severe periodontal disease (32). Prevalence of periodontal

623 disease was lower in younger adults, only 24.5% of adult aged 35 to 54 years had

624 moderate to severe periodontal disease (32). Periodontal disease is associated with

625 systemic diseases such as obesity, diabetes and cardiovascular disease (39-41).

626

627 In contrast the presence of active coronal decay, that is decay on the crown of the tooth,

628 is slightly lower in older age groups than in younger age groups (32). Over a fifth of

629 adults aged 55 to 74 years (22.6%), and adults aged 75 years and older (22.0%), had

630 the presence of untreated coronal decay (32). In comparison over a quarter of adults

631 aged 35 – 54 years (27.1%), and adults aged 15 to 34 years (25.8%) had untreated

632 coronal decay (32). Yet untreated root decay prevalence is higher in older aged groups

633 (32). In adults aged 75 years and older, 17.3% had untreated root decay, and 12.6% of

634 adults aged 55 to 74 years had untreated root decay, compared to adults aged 35 to 54

635 years where 7.1% had untreated root decay (32). Similarly the average number of

636 decayed missing or filled teeth is higher among older than younger adults (32).

637

638 Demographic and socioeconomic determinants can have significant impact oral health

639 status across all age groups (42). However these factors can exacerbate the poor oral

640 health comes associated with the biology of ageing (32). Notably income status had

641 poor outcomes across the key measures of oral health; dentition, periodontal disease

642 and tooth decay (43-46). Other possible risk determinants in older adults include

643 education, country of birth and health behaviours such as oral hygiene and smoking

644 (43-47).

Diet and dentition in older adults: A systematic review

645 1.2 The relationship between dietary intake of nutrients and food groups with

646 dentition in community dwelling older adults: A systematic review

647 (As submitted to the Journal of Gerodontology, submitted the 20.02.2021 )

648 Authors: Kate L Milledge, Fiona O’Leary, Jessie-Leigh P O’Connor, Robert Cumming,

649 Frederick A.C. Wright, Vasant Hirani.

650

651

652 Abstract

653 Context: Dentition, or the status of teeth, is an important factor for health, which may

654 decline with age. Poor dentition has been associated with poorer dietary intakes of

655 nutrients and food groups.

656 Objective: The aim of this review is to 1) describe the association between dietary

657 intake of nutrients and food groups with the dentition of community dwelling older

658 adults, and 2) assess the direction of this relationship.

659 Methods: Using the PRISMA protocol, a systematic search was conducted in databases

660 MEDLINE, CINAHL, Embase, Cochrane, Informit, Science Direct and Cochrane

661 Library from the earliest possible date through to the 13th of May 2019. Terms related

662 to dentition and nutrition variables, as well as target population were used including

663 ‘dentures’, ‘tooth loss’, ‘functional tooth units’, ‘diet’, and ‘aged’. There were 734 titles

664 and abstracts screened. Twenty papers were included in the final analysis.

665 Data Extraction: Sample size, participant characteristics, inclusion and exclusion

666 criteria, periodontal measures, dietary measures, confounders, and results were sorted

667 by study type, author, year, and country.

668 Data Analysis: Quality of extracted data was analysed using Grading of

669 Recommendations, Assessment, Development and Evaluation (GRADE) system.

Diet and dentition in older adults: A systematic review

670 Conclusions: Clear associations between dietary intake of nutrients and food groups

671 with dentition were found, specifically between the number of natural teeth and number

672 of posterior occluding pairs. There was also an association between dentures and dietary

673 intake of nutrients and food groups, although this was more complex in participants

674 who also retained natural teeth.

675 PROPERO Registration number: CRD42017062193

676

677 Introduction

678 Dentition is an important component of oral health and diet in older adults (48, 49).

679 However natural dentition is generally lost as we age (32) Dentition may include

680 numbers of teeth or functionally important natural occluding teeth known as Functional

681 Tooth Units (FTUs) (50). Sometimes the FTUs are molars and pre-molars, which are

682 usually referred to as Posterior Occluding Pairs of teeth (POPs) (51). Adequate

683 dentition in the literature has been defined as the presence of 21 or more natural teeth,

684 or having four or more POPs of natural teeth (52, 53). When natural teeth are lost partial

685 or full prosthesis, such as fixed prosthodontics or replaceable dentures, are used to

686 replace natural teeth to aid in the retention of chewing capacity (49, 54). Inadequate or

687 poor dentition is associated with numerous health issues, including cardiovascular

688 disease, metabolic syndrome and protein-energy malnutrition (55-57).

689

690 Poor intake of nutrients and inadequate consumption of key food groups are also an

691 important issue (58, 59). Many studies have shown that intake of key food groups and

692 nutrients are associated with various definitions of inadequate dentition, including

693 numbers of teeth and POPs (60-63). It is suggested that it is the loss of mastication

694 ability, through inadequate dentition, which leads to poor diets, lacking in fruit and

Diet and dentition in older adults: A systematic review

695 vegetables and nutrients commonly associated with these food groups (49, 60, 64, 65).

696 This would likely negatively impact the absorption of nutrients, and therefore the

697 nutritional status, of older adults (66).

698

699 A study amongst male veterans found objectively measured masticatory function was

700 associated with low fibre intakes and poor intake of various micronutrients (49).

701 Increased intakes of foods which are easier to chew but high in saturated fat, sugar, and

702 salt, also contribute to the poorer quality of diets (60, 61). However, some studies have

703 not found an association between perceived chewing ability and quality of diet (67, 68).

704 A study on community dwelling adults found no associations between masticatory

705 ability and subjects that met diet quality standards as measured by the Healthy Eating

706 Index (HEI), developed by the US Department of Agriculture (67).

707

708 Poor nutrition may also contribute to other oral health issues, such as periodontal

709 disease and tooth decay, which are key risk factors for tooth loss (69-72). Periodontal

710 diseases have been associated with poor intakes of nutrients such as vitamin C, vitamin

711 E, beta-carotene, fibre and calcium, as well as poor intakes of fruit and vegetables in

712 older adults (72). Tooth decay has also been associated with high intakes of fermentable

713 carbohydrates and sugar sweetened beverages, and low intakes of dairy products and

714 fibre intake (72-75).

715

716 To our knowledge there has been no review of the evidence of the association between

717 the dietary intake of nutrients and food groups and categories of dentition, as defined

718 in the literature, in community dwelling older adults. Furthermore, there has been no

719 assessment of the direction of this relationship i.e. does tooth loss affect nutritional

Diet and dentition in older adults: A systematic review

720 intake or does nutritional intake impact oral health. Therefore, the first aim of this

721 review is to describe the association between dietary intake of nutrients and food groups

722 with dentition in community dwelling older adults. The second aim of this review is to

723 assess the direction of this relationship.

724

725

726 Methods

727 This systematic review was registered in the PROSPERO International Prospective

728 Register of Systematic Reviews (registration ID: CRD42017062193) and conducted

729 using PRISMA guidelines (Appendix A and B).

730

731 Literature Search

732 A systematic search was conducted in databases MEDLINE, CINAHL, Embase,

733 Cochrane, Informit, Science Direct and Cochrane Library from the earliest possible

734 date through to the 13th of May 2019 (Appendix C). The final search strategy

735 predominantly utilized Medical Subject Headings (MeSH) nomenclature terms,

736 although these were adapted for other databases. Search terms related to the exposure

737 and outcome variables, as well as target population were used. These included

738 ‘dentures’, ‘denture, complete’, ‘denture, partial’, ‘mouth, edentulous’, ‘jaw,

739 edentulous’, ‘jaw, edentulous, partially’, ‘dental arch’, ‘tooth loss’, ‘functional tooth

740 units’, ‘diet’, ‘energy intake’, ‘nutrition assessment’, ‘nutrient intake’, ‘food intake’,

741 ‘dietary intake’, ‘aged’, ‘aged 80 and over’, ‘frail elderly’, ‘geriatrics’, ‘older adult’ and

742 ‘elderly’. Some search terms were truncated. Search terms of Medline database can

743 be found in the supplementary file. Citation details including abstracts, were

Diet and dentition in older adults: A systematic review

744 downloaded for screening in EndNote X8 reference management software (Thomson

745 Reuters).

746

747 Screening

748 After duplicate results were removed, titles and abstracts were screened for inclusion

749 by a single reviewer, according to pre-determined inclusions and exclusion criteria

750 (Table 1.1). Studies for inclusion had their full texts retrieved and were examined by

751 two independent reviewers against the inclusion criteria. Screening results were

752 compared between the two reviewers, with a third reviewer available if consensus could

753 not be reached.

754

755 Quality assessment

756 Quality assessment of individual studies was conducted by two independent reviewers

757 using the Scottish Intercollegiate Guidelines Network (SIGN) checklist for Cohort

758 studies. The SIGN checklist for Cohort studies is a 14-item checklist, that assesses each

759 article for potential biases, including selection bias, performance bias, attrition bias, and

760 detection bias. All papers were assigned a quality score of either ‘high quality (++),’

761 ‘acceptable (+),’ or ‘unacceptable, reject paper (−)’. Two reviewers discussed and

762 compared results until a consensus was reached. A third reviewer was available if a

763 consensus could not be reached. Papers that were assigned a quality score of

764 ‘unacceptable, reject paper (-)’ were excluded for poor quality.

765

766 Data extraction

767 One researcher performed the data extraction. Data included author, country, study

768 type, number of subjects included, participation rate and follow up, recruitment criteria,

Diet and dentition in older adults: A systematic review

Table 1.1 PICOS Criteria for inclusion and exclusion criteria Parameter Inclusion Criteria Exclusion Criteria Population • Human • Population’s selected on an acute or chronic disease, (e.g. diabetes • Older adults aged 60 + years (including stratified) type II) • Community dwelling/independently living • Animal studies • Generally healthy • <60 years of age, or includes participants <60 years and not stratified • Institutionalised population

Intervention Must be either Dietary or Dentition variable Not Dietary or Dentition variable Dietary Variables: Dietary Variable: • Whole food intake/diet quality/nutrient intake • Measures of nutritional status (BMI, Malnutrition status, weight, • Valid measurements of diet (e.g. 24 hour recall, FFQ, nutrient biomarkers). WFR). • Measuring food avoidance/grocery item intake • Conducted by trained professionals. • Measuring supplement intake Oral Health: Oral Health: • Measure of dentition (FTUs/POPs, numbers of teeth, • Self-reported numbers of teeth, FTUs/POPs. edentulism, presence of dentures) • Comparison of different dentures. • Not self-reported (except presence of dentures). • Non-dentition measures Decay, periodontal disease. • Conducted by trained professionals

Comparison/Outcomes Must be either Dietary or Dentition variable Not Dietary or Dentition variable Dietary Variables: Dietary Variable: • Whole food intake/diet quality/nutrient intake • Measures of nutritional status (BMI, Malnutrition status, weight, • Valid measurements of diet (e.g. 24 hour recall, FFQ, nutrient biomarkers). WFR). • Measuring food avoidance/grocery item intake

Diet and dentition in older adults: A systematic review

• Conducted by trained professionals. • Measuring supplement intake Oral Health: Oral Health: • Measure of dentition (FTUs/POPs, numbers of teeth, • Self-reported numbers of teeth, FTUs/POPs. edentulism, presence of dentures) • Comparison of different dentures. • Not self-reported (except presence of dentures). Non-dentition measures Decay, periodontal disease. • Conducted by trained professionals

Study Design • Cross-sectional study • Case Studies • Case-control study • Narrative Literature Review • Cohort study • Conference abstracts • Ecological study • Opinion pieces • Randomised Control Trials • Non-study based sources • Systematic Literature Review

FFQ, Food Frequency Questionnaire. WFR, Weighted Food Record. BMI, Body Mass Index. FTUs, Functional Tooth Units. POPs, Posterior Occluding Pairs. 769

770 dentition measurements, dentition variables (FTUs, POPs, numbers of teeth, denture presence), dietary measurements, dietary variables,

771 confounders the results, and conclusions.

Diet and dentition in older adults: A systematic review

772 Grading of Recommendations, Assessment, Development and Evaluations (GRADE):

773 The overall strength of the body of evidence in relation to the research question was

774 assessed using an adapted version of the Grading of Recommendations, Assessment,

775 Development, and Evaluation system (76). This system assesses risk of bias,

776 directness, consistency, precision, and publication bias of the included studies and

777 provides a recommendation on the overall quality of the evidence (76).

778

779

780 Results

781 Study description

782 The PRISMA flow diagram can be found in Figure 1.1. After the final screening 37

783 studies were assessed for their quality. Sixteen studies were excluded for poor quality.

784 One study was excluded as it provided the same results, on the same population, as

785 another study already included in the systematic review (31, 48).

786

787 A total of 20 studies were included for review, 19 were cross-sectional, one was

788 longitudinal (31, 52, 67, 77-93). Populations were based in the United States of America

789 (n=7), Japan (n=4), Great Britain (n=1), Brazil (n=2), South Korea (n=2), Israel (n=1),

790 Thailand (n=1), Italy (n=1), and Canada (n=1) (31, 52, 67, 77-93). Characteristics of

791 studies can be found in Table 1.2 (94-96).

792

793 Number of Teeth/ Edentulous

794 All six cross-sectional studies that looked at numbers of teeth and diet found an

795 association (Table 1.3) (31, 52, 83, 86, 88, 91). Mean numbers of teeth were associated

796 with higher intakes of protein and various minerals and vitamins including potassium,

Diet and dentition in older adults: A systematic review

797 iron, magnesium, vitamin D, vitamin B6, thiamin, riboflavin, vitamin E, niacin and

798 folic acid (91). One study found that compared to 20 teeth or more, having fewer than

799 20 teeth was associated with lower intakes of various macro and micronutrients (91).

800 Tooth loss was also associated with lower intake of vitamin C in Japanese males (83).

801 One study compared having 10 or less teeth, compared to 11 or more teeth (88). This

802 study found that participants having 10 or less teeth had poorer intakes of HEI

803 categories such as fruit, meat and beans, and oils, and higher energy contributions from

804 solid fat, alcohol, and sweet food sources compared to having 11 or more teeth (88).

805 Overall subjects with less than 11 teeth had a significantly lower HEI score than those

806 with 11 or more teeth (88).

807

808 When compared to participants with natural teeth, edentate participants had poorer

809 intakes of protein, fibre, and various minerals and vitamins (31, 86). Furthermore,

810 edentate participants had lower intakes of fruit and fruit juices, yet higher intakes of

811 ‘fats, oils and sweets,’ and a greater percentage of energy contributed by ‘sweet and

812 dessert’ foods (86). When compared to participants with 21 or more teeth, edentate

813 participants had poorer intakes of fruit, alpha and beta carotene, and vitamin C (52).

814

815 Presence of prosthesis

816 Five cross-sectional studies assessed the relationship between the presence of prosthesis

817 and diet (Table 1.3) (78, 82, 89, 90, 92). Three studies found an association between

818 the presence of dentures and diet, without taking into account numbers of teeth (78, 90,

819 92). One study found dentures to be a negative determinant of diet quality in men aged

820 67 years and older (90). The second study found that participants categorized as

Diet and dentition in older adults: A systematic review

821

Records identified through Additional records identified database searching through other sources (n = 986) (n = 29)

Records after duplicates removed

(n = 734)

Records screened Primary Exclusions: (n = 734) • Study Design: n = 66 • Outcomes: n = 407 • Population: n = 120 • Setting: n = 44

Full-text articles assessed Secondary Exclusions: for eligibility • Study Design: n = 8 (n = 97) • Outcomes: n = 11 • Population: n = 24 • Setting n = 1 • Language: n = 7 Studies included in • Method: n = 9 qualitative synthesis (n = 20) Quality assessment: n = 16 Repeated results: n = 1

Figure 1: PRISMA Flow Chart of systematic screening process 822

823 wearing partial or complete dentures had lower daily intakes of energy, protein, fat,

824 calcium, phosphorus and thiamin, than participants without a prosthesis (78).

Diet and dentition in older adults: A systematic review

Table 1.2 Characteristics of systematically reviewed studies (n=20) Author, Year, Study Sample Size, Attrition Rate, Inclusion / Exclusion Subject Characteristics Recruitment type and Quality Criteria Assessment Appollino et al. (1997) Inclusion criteria: living in the area and at home. Age range: 70 - 75 years. Population of Brescia, Italy. Italy, Cross-sectional Sample: 1189/1303 participated, 52 were lost to follow Gender: 67.4% female. analysis, Acceptable (+) up, final sample was n=1137 (87.2% participation). Non-smokers: 58.2% were non- (77). smokers. Income: 35.6% insufficient income.

Choi et al. (2014), Inclusion criteria: 65 years and older, and completed Age: 65 y and older. Korea, the 4th Korean Korea, Cross-sectional, the nutrition and oral health component. Gender: 59.2% female (weighted). National Health and Acceptable (+) (78). Sample: 71.2% (4594) of people agreed to participate. Income: 52.8% in lowest quartile of Nutrition Examination 58.1% (3751) completed the nutrition and oral health income. Survey (‘KNHANES IV’). component. Of these only 722 were 65 years and older.

De Andrade et al. Inclusion criteria: those 60 years and older, mentally Age: Range 60 to 89 years (median Sample selected from (2011), Brazil, Cross- and physically able to complete assessments & who 70 years). participants in the Family sectional, Acceptable completed interview and dental examination. Gender: 57.1% female. Health Program (FHP) and (+) (79). Sample: 816/1000 were included in the analysis Income: 157 (55.7%) had monthly Community Agents Health (81.6%). income above the minimum wage. Program (CHAP), Vitoria, Comorbidities: 61.7% had ≤1 Espirito Santo state, Brazil. chronic conditions. De Marchi et al. Inclusion criteria: aged 60 years and older, Age: Range 60 to 89 years. Sampled from Carlos (2011), Brazil, Cross independently living, and generally healthy, with all Gender: 57.1% were female. Barbosa, Brazil. sectional, Acceptale (+) study components completed. Income: 620 Reais average monthly (80). Sample Size: 282/471 (60%) were included. income.

Diet and dentition in older adults: A systematic review

Comorbidities: 38.2% had at least 2 or more chronic conditions.

Ervin et al. (2009), Inclusion criteria: diet history, ‘other’ race or ethnic Age: 15.6% were 80 years and Cross-sectional sample of USA, Cross-sectional, group and no missing info on education, smoking, self- older. civilian, non-institutionalised Acceptable (+) (52). rated health, BMI, or dentate status. Gender: 50.1% female. US population, NHANES Sample Size: Size: 2560/4976 (51.4%) eligible to Non-Smokers: 45% non-smokers. 1999 – 2002. participate in National Health and National BMI: 39% optimal BMI. Examination Survey (NHANES). Education: 38% greater than high school education.

Ervin et al. (2012), Inclusion Criteria: 60 years and those who completed Age: 17% aged 80 years and older. Cross -sectional sample of USA, Cross-sectional, the household interview and MEC. Of the 4984 those Gender: 50% female. civilian, non-institutionalised Acceptable (+) (81). who had abnormal caloric intake (n=2), had missing Non-smokers: 12% current US population, NHANES dentition and nutrient recall data were excluded. smokers. 1999 – 2004. Sample Size: 7729 people were eligible for NHANES. Education: 42% education beyond The final sample size was 4462 (58%) for unadjusted high school. analysis and 4442 (57%) for adjusted analysis.

Gaewkhiew et al. Inclusion Criteria: Adults aged 60 years and older, Age: 32.9% aged 70 – 79 years, Phetchaburi Province, (2019), Thailand, independently living, and registered with the national 13.6% aged 80 years and older. Thailand. Cross-sectional (+) healthcare system. Anyone without normal scores in the Gender: 70%. (93). AMT. Wealth: 33.4% in the lowest Sample Size: A total of 788 participants were recruited. income. Smoking status: 70.4% never smoked.

Diet and dentition in older adults: A systematic review

Han et al. (2016), South Inclusion criteria: 65 years and older, and individuals Age: 55.8% were 75 years and KNHANES 2008 – 2010, Korea, Cross-sectional, edentulous in both arches. older. Mean age 75.1. South Korea. Acceptable (+) (82). Sample Size: 1168 individuals out of 4258 (27.4%). Gender: 61.5% Female. Income: 61.7% on 'low' income. Education: 17.6% have an education beyond elementary.

Hanoika et al. (2007), Inclusion criteria: Only those linked with the National Age: 44.5% 70 years and older. The electronic linkage of Japan, Cross-sectional, Nutrition Survey (NNS) and Survey Dental Disease Gender: 57.5% were female. NNS and SDD, two national Acceptable (+) (83). (SDD) had smoking data available, aged 20 and older. Non-smokers: 62% never smoked. surveys conducted in Japan. Sample Size: 6805 were successfully linked with the Drinking: 67.6% reported never NNS and SDD. However only 5457 were included in drinking. the final analysis. 2200 were aged 60+ years.

Iwasaki et al., (2014), Inclusion criteria: 70 years of age and community Age: 80 yrs old. Niigata community-based Japan, Cross-sectional, based. Gender: 50.7% were female. cohort study, 1998 – 2008, Acceptable (+) (84). Sample Size: 353/600 (58.8%) participants included in BMI: 22 kg/cm. Niigata, Japan. the analysis. Education: 58.9% school greater than 10 years.

Iwasaki et al., (2016), Inclusion criteria: original members of the Niigita Age: 75 yrs old. Niigata community-based Japan, Longitudinal, study, who participated in both baseline and follow up, Gender: 49.6% were female. cohort study, 1998 – 2008, High quality (++) (85). and had complete data. BMI: 23 kg/cm. Niig ata, Japan. Sample Size: Of the 600 who participated, 192 were Education: 57.3% had low lost to follow up by 2003, 38 had no baseline, 79 lost to education level. follow up by 2008, 5 submitted incomplete dietary data at follow up. This left 286 participants for analysis, out of a possible 408 (70%).

Diet and dentition in older adults: A systematic review

Lee et al. (2004), USA, Inclusion criteria: elderly adults free of difficulties Age: Mean age 73.8 years for white The Health ABC Study, Cross-sectional, with ADLs, and lower extremity functions without edentate, 73.8 years for white Memphis/Philadelphia, Acceptable (+) (86). missing data. dentate, 73.8 years for black USA. Sample Size: 3075 included, and 3068 with information edentate, 73.3 years for black available at baseline. Final data analysis n=2360, for dentate. Gender: nutrient intake and food consumption. 43.2% male in black population, 52.5 male in white population. Income: 4.3% <10,000 dollars in white population, 26.2% <10,000 dollars in black population. Non-smokers: 6.2% current smokers in white population, 16.3% current smokers in black population.

Natapov et al. (2018), Inclusion Criteria: 65 years and older, independently Age: 65 years and over. Israeli residents medically Israel, Cross-sectional, living, residing in Israel. insured by two major health Acceptable (+) (92). Sample size: 1776/1852 (95.9%). funds.

Sahyoun et al., (2005), Inclusion criteria: excluded if they did not complete Age: mean 69.7 years for men, 70.7 NHANES III (1998 to 2004), USA, Cross-sectional, the dental exam, no social contact information, being in years for women. US population. Acceptable (+) (87). the 'other' racial category, and missing information on Gender: 51% were women. marital status, educational attainment, SRH, food Income: 3.28 PIR for men, 2.82 PIR security, supplement use. women. Sample Size: 4622/6264 were included in the analysis. Non-smokers: 73.5% men current/former smokers, 42.5% women current/former smokers.

Diet and dentition in older adults: A systematic review

Savoca et al., (2010), Inclusion criteria: aged 60 years and older, spoke Age: 35.5% aged 75 years and older. The Rural Nutrition and Oral USA, Cross-sectional, English, could give informed consent, and physically Gender: 54.7% are women. health study, rural USA. Acceptable (+) (88). able to complete the interview. Education: 55.7% had less than high Sample size: 635/859 dwellings were identified as school education. having an eligible participant. Income: 36.4% below poverty line. BMI: 37.9% overweight or obese (>30kg/cm).

Savoca et al., (2011), Inclusion criteria: aged 60 years and older, spoke Age mean: 71.5 years (+- 0.4). The Rural Nutrition and Oral USA, Cross-sectional, English, could give informed consent, and physically Gender: 54.1% are female. health study, rural USA. Acceptable (+) (89). able to complete the interview. Education: 55.7% had less than high Sample Size: 635/859 dwellings were identified as school education. having an eligible participant. Income: 39.7% of women and 23.2% of men were below the poverty line.

Shatenstein et al. Inclusion criteria: aged 67 to 84 years and community Age: 67 – 84 years. NuAge Study recruited from (2013), Canada, Cross- dwelling. Gender: 52.4% female. Quebec Medicare database. sectional Acceptable Sample Size: 1793 participated. Education (mean): 11.9 years for (+) (90). males, 11.4 years for females. BMI (mean): 27.9 for males, 27.6 for females.

Sheiham et al. (2001), Inclusion Criteria: Households with adults aged 65 Dentate participants took less Sub sample of participants in Great Britain, Cross- years and older, and community dwelling. medication and reported better the national diet and sectional, Acceptable Sample Size: A targeted sample size of 1000 health than edentate. nutrition survey, Great (+) (31). participants from the food diary sample was set. After Edentate were more likely to have Britain. correction for sub sampling of the edentate group 69% of severe restrictions on mobility or be the independently living food diary sample were housebound, and had a lower mean

Diet and dentition in older adults: A systematic review

included. 54% were dentate. Complete details for BMI than dentate participants, sampling, weighting procedures, and response rate can Steele et al. (96). be found here, Finch et al. (94). Steele et al. (95). Complete details for weighted data are reported elsewhere, Steele et al. (95).

Shinkai et al. (2001), Inclusion Criteria: Only subjects aged 65 and older, Gender: 54% were female. The sample was established USA, Cross-sectional, with no incomplete data. Age: 47% aged 65 years and older. as a subset of the original San Acceptable (+) (67). Sample Size: Final subset sample was 731. Income: 17% had monthly income of Antonio Longitudinal Study $999 or less. of Ageing. Education: 24% had 12 or less years of education.

Yoshihara et al. (2005), Inclusion criteria: aged 70 years or older and with Age: 74 years. Subset of the Niigata Japan, Cross-sectional, complete data. Gender: 45.6% were female. community - based cohort Acceptable (+) (91). Sample Size: 4562 surveys, 600 were randomly Current smoker: 46.4% of males, study, 1998 – 2008, Niigata, selected. Follow up surveys were conducted every year. 7.4% of females. Japan. 436 participated in the follow up. Of these 62 Education: 10.4 years of education participants volunteered, however only 57 had completed for males, 9.8 years of education for data. women.

BMI, Body Mass Index. MEC, Mobile Examination Centre. AMT, Abbreviated Mental Test. ADLs, Activities of Daily Living. SRH, Self-Reported Health. PIR, Poverty Income Ratio. 825

Diet and dentition in older adults: A systematic review

826 The third study, based on older adults in Israel, found similar results, with those in the

827 non-denture group having higher energy, protein and fibre intake than those with

828 dentures (92). This study also found that those in the non-denture group had

829 significantly higher intakes of vegetables, but not fruit, than those with dentures (92).

830

831 Two other studies considered the confounding effect of number of natural teeth present

832 on the relationship between the presence of dentures and diet (82, 89). The presence of

833 dentures was compared not only to the absence of natural teeth, but also to numbers of

834 natural teeth (82, 89). In one study, among participants who were edentulous in one or

835 both arches, those not wearing a prosthesis had poorer intakes and were less likely to

836 meet nutrition recommendations for various micronutrients, compared to participants

837 who wore a prosthesis (82). The other study showed that participants with complete

838 dentures in both arches had significantly poorer intakes of the food group ‘meat and

839 beans’ than participants who had 11 or more teeth and no dentures (89). Participants

840 with complete dentures also had poorer intake of ‘vegetable’ food groups than people

841 with replaceable partial dentures (89).

842

843 Functional Tooth Units

844 Four studies looked at the relationship between the number of FTUs or POPs and diet,

845 three were cross-sectional and one was a longitudinal study (Table 1.3) (31, 79, 85, 87).

846 All studies showed a significant association between numbers of posterior functional

847 tooth units and meeting recommended intakes of nutrients (31, 79, 85, 87). De Andrade

848 et al. found that when compared to having five or more POPs, participants with no

849 POPs were more likely to have inadequate intakes of vitamin C, calcium, riboflavin and

850 zinc (79). Sahyoun et al. found that those participants with zero to four POPs, were

Diet and dentition in older adults: A systematic review

851 more likely to have fruit and vegetable intake in the lowest quartile, compared to

852 participants with five or more POPs (87). Finally the one longitudinal study looked at

853 the changes in nutrient and food group intake between participants at baseline who had

854 five or less FTUs, compared to those with more than five FTUs, (out of a possible 14)

855 (84). After five years those with five or less FTUs had significantly greater decline in

856 the intake of protein, sodium, potassium, calcium, vitamin A, vitamin E, dietary fibre,

857 vegetables and meat compared to those with five or more FTUs (84).

858

859 Number of FTU/Teeth and presence/quality or presence of dentures

860 Six cross-sectional studies looked at the relationship between diet and composite

861 dentition variables, categorised according to the presence of dentures and the number

862 of teeth (Table 1.3) (67, 77, 80, 81, 84, 93). As there is no gold standard for optimal

863 dentition each study determined its own criteria for optimal dentition. The optimal

864 category of dentition status was consistently listed as a specified number of teeth or

865 POPs and without dentures (77). A study found that optimal dentition (ten or more

866 FTUs, including six anterior and four posterior)was significantly associated with intake

867 of fibre intake and vitamin B1 (93). One study found no relationship between the HEI

868 score and dentition status, while five studies found significant associations (67, 77, 80,

869 81, 84, 93). Appollonio et al. looked at nutrient intakes as a percentage of recommended

870 intakes and found a significant association between adequate dentition status (16 or

871 more teeth and no dentures) and higher percentage intakes of vitamin B6, folic acid,

872 niacin, vitamin A and protein (77). Another study found that participants categorized

873 as either edentulous or edentulous and using one denture were significantly less likely

874 to meet recommended vegetable and fruit consumption, compared to those with 8 or

875 more teeth, with or without a prosthesis (80). Male participants with complete natural

Diet and dentition in older adults: A systematic review

876 dentition, (21 to 28 teeth and no replaced teeth) had significantly higher intakes of

877 energy and various macro- and micro-nutrients than males with complete mixed

878 dentition, incomplete natural dentition, incomplete mixed dentition (81). In the same

879 study, male participants with incomplete dentition, ‘one to 20 teeth,’ had lower intakes

880 of energy than those with complete dentition, ‘21 to 28 teeth’, regardless of denture use

881 (81). On the other hand female participants with complete natural dentition had higher

882 intakes of various micronutrients than female participants with complete mixed

883 dentition, incomplete natural dentition and incomplete mixed dentition (81).

884

885 Finally, one study looked at diet and the number of POPs and self-reported quality of

886 dentures (84). Participants categorized with good dentition, ‘8 POPs and no dentures’,

887 had better intakes of various macronutrients, and micronutrients, as well as total

888 vegetable intake, and the intake of fish and shellfish, than participants with less than 8

889 POPs and self-reported ill-fitting dentures, or participants categorized with less than 8

890 POPs and no dentures (84). Furthermore, this study considered overall nutritional

891 deficiencies, by categorizing participants as having 9 or more nutrients below

892 recommended intakes, or less than 9 nutrients below recommended intakes (84). No

893 relationship was found between nutrient intake and dentition status after adjustment for

894 confounders (84).

895

896 Quality of evidence

897 Grading of Recommendations, Assessment, Development and Evaluations:

898 The overall evidence using the GRADE tool has been summarized in Table 1.4. Out of

899 20 studies, 19 found statistically significant associations between dentition and dietary

900 intake, although differences in measures of exposure and outcomes meant results could

Diet and dentition in older adults: A systematic review

901 not be directly compared. Heterogeneity, publication bias, and the low-quality design

902 of included studies meant that overall evidence was downgraded to very low.

903

904 Risk Bias

905 Out of 20 studies, only one was considered high quality (85), while the other 19

906 studies were deemed as acceptable in quality (31, 52, 67, 77-84, 86-93). All studies

907 had single group populations and dentition and dietary categorical variables created

908 after data collection. Hence, two of the SIGN Checklist statements relating to

909 selection bias, one relating to performance bias, and two relating to detection bias

910 were labeled as ‘Does not apply’ or ‘Can’t say’. Furthermore, as the majority of

911 studies were cross-sectional, ‘Drop-out rate’ and ‘Comparison against participants lost

912 to follow up’ (attrition bias), were also labeled as ‘Does not apply’ or ‘Can’t say’. The

913 one longitudinal study had a 22.7% drop out between baseline assessment and 5-year

914 follow up, which is an acceptable loss (85).

915

916 The majority of studies had clearly defined exposures and outcomes and used measures

917 that were reliable and valid. All studies looked at potential confounders and included

918 confidence intervals in their results. As per the SIGN checklist, detection bias was a

919 key risk identified, as the majority did not repeat exposure measures more than once.

920 All studies were observational therefore key risks such as randomization of participants

921 and blinding were not accounted for or addressed. The overall GRADE scores for risk

922 of bias of the overall body of evidence, and sub-categories for dentition, were

923 downgraded to low.

924

925

Diet and dentition in older adults: A systematic review

Table 1.3 Data extracted from systematically reviewed studies (n=20) Study and Dentition Measurements Dietary Intake Measures Statistical Adjusted Results Quality Methods and Assessment Confounders Appollino et al. Method: Trained Clinical Method: 24 hour recall and ANCOVA, & Regression coefficients for significant (1997) Italy, investigators. nutrient intake calculated using logistic and independent predictors: Cross-sectional Measures: Numbers of natural computerized system based on regression. Group A vs Group C: Acceptable (+) teeth and use of dentures. National Department of Backwards step Vitamin A (β: -0.016, CI: 0.98 – 0.99, (77). Outcomes: Participants were Nutrition Of Italy. elimination was p<0.001) classified into three categories. Measures: Nutrient intake. used. Vitamin B6 (β: -0.042, CI: 0.93 – 0.98, Group A: Adequate dentition (10 Outcomes: Percentage intake Confounders: p=0.002) natural teeth in the upper jaw, 6 in compared to RDAs was Education, the lower minimum), and no use of calculated for energy, protein, economic dentures. vitamin A, C, B12, thiamine, situation, Group B vs Group C: Group B: Those with partial or riboflavin, niacin, folate and dyspepsia, HCU Vitamin B6 (β: -0.042, CI: 0.92 – 0.99, complete dentures. iron. scale, appetite, p=0.024) Group C: Those with inadequate smoking, marital Niacin (β: 0.022, CI: 1.00 – 1.04, dentition and no dentures. status, living p=0.036) situation. Folic Acid (β: -0.037, CI: 0.93 – 1.00, p=0.043)

Group A vs Group B: Vitamin A (β: -0.009, CI: 0.98 – 0.99, p<0.001)

Diet and dentition in older adults: A systematic review

Choi et al., Methods: Trained dentists. Methods: 24 hour recall. Multiple logistic Significant regression coefficients for (2014), Korea, What: Prosthodontic status. Measured and Outcomes: regression. mean daily nutrient intakes those with Cross-sectional, Outcomes: 'Without or fixed Daily intakes of macro and Confounders: ‘Partial or full dentures’, compared to Acceptable (+) prosthesis': those with sound or micronutrients, water, energy, gender and those ‘Without or fixed prosthesis’: (78). filled teeth, a single crown or protein, fat, carbohydrate, fibre, income. Energy (β: -0.10, P<0.05)⬇ bridge. ash, calcium, phosphorus, iron, Protein (β: -0.10, P<0.05)⬇ 'With partial or full prosthesis': sodium, potassium, vitamin A, Fat (β: -0.18, P<0.05)⬇ those with partial or full dentures. carotene, retinol, thiamin, Calcium (β: -0.14, P<0.05)⬇ riboflavin, niacin, vitamin C. Phosphorus (β: -0.08, P<0.05)⬇ Thiamin (β: -0.11, P<0.05)⬇

De Andrade et al. Method: Conducted by calibrated Method: 24 hour recall. Student T-test and Inadequacy of nutrient intake (2011), Brazil, and trained examiners. Measured: Nutrient intake. ANOVA, significantly (P<0.05) related to Cross-sectional, What: Numbers of teeth, number Outcomes: Ten nutrients were categorical was number of POPs (Reference 5 or > Acceptable (+) of POPs. compared with gender and age chi-analysis or POPs, OR: 1.0) : (79). Outcomes: specific dietary requirements, likelihood ratio 0 POPs: Number of POPs: 0 POPs, 1-4 calcium, phosphorus, vitamin C, analysis. Forward Vitamin C (OR: 2.79, 95%CI: 1.16 – POPs, 5 or > POPs. iron, carbohydrate, protein, zinc, stepwise method 6.71) niacin, riboflavin and thiamin. was used for Calcium (OR: 3.74, 95%CI: 1.69 – Mean number of nutrients multivariate 8.25) consumed at 'adequate intakes'. analysis. Riboflavin (OR: 2.49, 95%CI: 1.10 – Confounders: 5.64) included Zinc (OR: 3.43, 95%CI: 1.07 – 10.94) socioeconomic variables, lifestyle, oral health

Diet and dentition in older adults: A systematic review

measurements and family cohesion.

De Marchi et al. Method: Examination carried out Method: 24 hours recall Chi-squared test Consuming <400g FV consumption: (2011), Brazil, by trained, experience clinical through a direct interview. for categorical >8 teeth with or without prosthesis Cross sectional, dentist. Measured: Grams of fruit and variables. Student (Reference >8 teeth with or without Acceptale (+) Measured: Number of teeth and vegetables calculated. t-test for prosthesis, OR: 1.0) (80). use of dental prosthesis was Outcomes: Participants continuous. recorded. dichotomised according to if Confounders Edentulous, wearing 1 denture (OR: Outcomes: they met the recommendation considered for the 1.75, 95%CI: 1.11 – 2.74). 1. Edentulous wearing 1 denture. for fruit and vegetable multivariate 2. Edentulous wearing both consumption model included dentures. 1. Those who consumed 400g or age, income, 3. Dentate with 1 to 8 teeth, more FV. geographical wearing no prosthesis or 1 2. Those who consumed less location, marital prosthesis. 4. than 400g of FV. status, smoking Dentate with 1 to 8 teeth, wearing status, race, two prosthesis. gender, schooling 5. Dentate with more than 8 teeth. and comorbidities.

Ervin et al. How: Trained dentists. How: Single 24 hour dietary Multivariate Significant associations between tooth (2009), USA, Measured: All teeth except third recall by trained interviewers analysis and retention and HEI Components and Cross-sectional, molars were counted. Dental using an automated collection Satterwaite overall score. Acceptable (+) implants were counted as natural system. significance F - (52). teeth. Measured: Nutrient intakes test. Males Confounders: age,

Diet and dentition in older adults: A systematic review

Outcomes: Three categories to Outcomes: Daily Nutrient race/ethnicity, Fruit : define dentate status. intakes, HEI components and education, Overall (P=0.013) 1. Edentulous (no natural teeth, overall HEI score. smoking status, Edentulous⬇ vs 21+ teeth (P=0.017) regardless of denture use). BMI and SRH. 2. 1-20 teeth. Stratified for Women: 3. 21 or more teeth (definition of gender. HEI total score: functional tooth status). Overall (P=0.046)

Significant associations between tooth retention and selected nutrient intakes.

Males Alpha-carotene: Overall (P=0.009) Edentulous⬇ vs 21+ teeth (P=0.017) Beta-carotene: Overall (P=0.026) Edentulous⬇ vs 21+ teeth (P=0.017).

Females: Vitamin C: Overall (P<0.001) Edentulous⬇ vs 21+ teeth (P=0.017)

Ervin et al. Method: Trained dentists How: Single 24 hour dietary Linear regressions Regression coefficients for numbers of (2012), USA, performed the oral health recall by trained interviewers models. Used beta natural teeth (continuous) and nutrient Cross-sectional, examination. using an automated collection co-efficient and intakes.

Diet and dentition in older adults: A systematic review

Acceptable (+) Measures: Count, and system. LSM for reports. Males: (81). classification, of all teeth Measures and Outcomes: Confounders: age, Kilocalories (β: 15.1, P<0.001) (excluding third molars) and Nutrient intakes of kilocalories, ethnicity, identify denture use. dietary fibre, alpha and beta education, Females: Outcomes: Numbers of natural carotene, vitamin C and total smoking status. Beta-carotenes ( β: 0.011, P=0.022) teeth (continuous variable). folate. Stratified for Dentate status was classified into gender. Dentate status and nutrient intakes. five possible classifications: Males: 1. Complete natural dentition, (21- Kilocalories (P=0.004) 28 natural teeth, no replaced teeth). Vitamin C (P=0.021) 2. Incomplete natural dentition, (1- 20 teeth, no replaced teeth. Females: 3. Complete mixed dentition, (21- Beta-carotene (P=0.038) 28 teeth, including replacement dentition). Comparison of dentition status 4. Incomplete dentition (1-20 teeth. categories by nutrient intakes: including dentition). (Reference ‘Complete Natural’. b: 0.0) 5. Edentulous, no natural or replaced teeth. Males: Kilocalories Incomplete mixed (β: -323.8, P<0.001)⬇

Dietary fibre Complete mixed (β: -1.0, P=0.029)⬇

Beta-carotene

Diet and dentition in older adults: A systematic review

Incomplete mixed (β: -0.24, P=0.040)⬇

Vitamin C Incomplete mixed (β: -0.23, P=0.010)⬇

Folate Incomplete mixed (β: -0.04, P=0.044)⬇

Females: Alpha -carotene Incomplete mixed (β: -0.51, P=0.023)⬇

Beta-carotene Complete mixed (β: -0.07, P=0.037)⬇ Incomplete natural (β: -0.16, P=0.017)⬇ Incomplete mixed (β: -0.19, P=0.037)⬇

Folate Incomplete mixed (β: -0.06, P=0.024)⬇

Diet and dentition in older adults: A systematic review

Comparing nutrient intakes between complete and incomplete dentition categories⬇.

Males: Kilocalories (P<0.001)

Females: Beta-carotene (P=0.009)

Comparing nutrient intakes between Complete natural vs complete mixed dentition⬇ categories . Males: Dietary fibre (P=0.029)

Females: Beta-carotene (P=0.037)

Comparing nutrient intakes between Incomplete natural vs Incomplete mixed dentition⬇ categories.

Males: Beta-carotene (P=0.016) Vitamin C (P=0.009)

Diet and dentition in older adults: A systematic review

Gaewkhiew et al. Method: Performed by two trained Method: 154 item semi Adjusted linear Significant association (P<0.05) (2019), Thailand, dentists. quantitative validated FFQ. regression model: between Functional dentition vs neither Cross-sectional Measures: Numbers of teeth, Measures: Energy intake, Confounders: functional dentition nor dentures⬇: (+) (93). FTUs, use of dentures. macronutrients and Age, gender, Dietary Fibre: Coef 2.69 (CI: 0.02 – Outcomes: Three categories of micronutrients. residence area, 5.37) dentition: Outcomes: Average daily wealth, education, Vitamin B1: Coef 0.66 (0.03 – 1.29) 1. Functional dentition (10+ FTUs, servings of macronutrients and smoking status, including 6 anterior and 4 + micronutrients. physical activity, posterior). chronic health 2. Non-functional dentition and conditions. dentures. 3. Non-functional dentition and no dentures.

Han et al. (2016), Method: Oral examination was Method: 24hour recall. Generalised linear Comparing Nutrient intake ratio and South Korea, conducted by trained dentists. Measures: Nutrient intake. analysis, chi- AMDR intakes in edentulous between Cross-sectional, Measures: Teeth in upper and Outcomes: Nutritional intake square tests, denture wearers vs Non-wearers. Acceptable (+) lower arches, and presence of ratio: proportion of energy or logisitic All participants: (82). dentures. nutrient intake to the DRIs. regression Phosphorus (P=0.016) Outcomes: Participants were Percent of with inadequate analysis. Iron (P= 0.000) separated into denture and non- nutrient intake: the proportion of Confounders: age, Potassium (P=0.002) denture wearers. people whose energy intake or gender, Niacin (P=0.015) nutrient intake is less than 75% socioeconomic Vitamin C (P=0.010) of EER or EARs. variables. Undernourishment: The Edentulous in one arch: percentage of energy intake is Phosphorus (P=0.024) 75% or below of EER or EARs Vitamin A (P=0.019) Niacin (P=0.022)

Diet and dentition in older adults: A systematic review

for calcium, iron, vitamin A and riboflavin. Edentulous in two arches: Iron (P=0.000) Potassium (P=0.003) Thiamin (P=0.018) Vitamin C (P=0.009)

Percentage of participants with inadequate intake between denture wearers vs Non-wearers. Total: Iron (P=0.004) Thiamin (P=0.035)

Edentulous in one arch: Energy (P=0.009) Protein (P=0.021) Iron (P=0.015) Vitamin A (P=0.007)

Edentulous in two arches: Iron (P=0.044)

Risk of undernourishment: Denture Wearers (Reference Denture Wearers, OR: 1.0)

Diet and dentition in older adults: A systematic review

Non-wearers (OR: 1.89, 95% CI:1.013 – 3.514)

Hanoika et al. Method: Calibrated dentists who Method: Dietitian visited Stratified by Tooth loss relationship with vitamin C (2007), Japan, performed the oral examination. individual households to collect gender. Logistic sufficiency vs deficiency. Cross-sectional, Measured: Erupted teeth, except data. Meal patterns, semi- regression used to Acceptable (+) third molars and implants. weighed and semi-weighed analyse tooth loss Males (83). Outcomes: Lost teeth defined as household dietary records. as outcome 100mg or more (OR: 1.0) teeth removed due to extraction. Measured: Vitamin E and C variable. <100mg (OR:1.68, 95% CI 1.11 – intake. Confounders: age, 2.53), Outcomes: Vitamin E and C smoking, alcohol intakes were categorised into consumption, two separate classifications BMI, vitamin E 'deficiency' and 'sufficiency'. and C intake, These were based on RDA. BGL. Vitamin C: 100mg or more (sufficiency), <100mg (deficiency). Vitamin E: 10mg or more (sufficiency), <10mg (deficiency).

Iwasaki et al., Method: Conducted by calibrated Method: BDHQ which is a Multivariate Association between oral health status (2014), Japan, dentists. validated self-administered diet analysis and and nutrient intake means. Cross-sectional, Measured: Counted number of history. logistic (Referent category Good Dentition). Acceptable (+) POPs, and a SCQ on the quality Measured: Dietary intake of regression. (84). and fit of Dentures. energy, nutrients and food Confounders: Protein Outcomes: Oral health status was groups. gender, income, Ill-fitting denture (P=0.005)⬇

Diet and dentition in older adults: A systematic review

defined into 4 categories according Outcomes: Intake per day of 13 education, Compromised Dentition (P=0.006)⬇ to number of POPs and denture nutrients and 7 food groups. smoking status, quality. Nutrients were then compared to education, n-3 PUFAs 1. Good dentition: 8 POP and no DRIs for adults aged 70 years alcohol, BMI. Ill-fitting denture (P=0.022)⬇ removable prosthesis. and older. The number of Compromised Dentition (P=0.013)⬇ 2.Well-fitting dentures: <8 POPs nutrients that didn't meet and SR well-fitting dentures. recommendations w ere counted. Potassium 3. Ill-fitting dentures: <8 POPs and 9 or more nutrients not meeting Ill-fitting denture (P=0.023)⬇ SR ill-fitting dentures. recommendations was 4. Compromised dentition: <8 POP considered a poor diet. Compromised Dentition (P=0.003)⬇ and no dentures.

Calcium Ill-fitting denture (P=0.001)⬇ Compromised Dentition (P=0.026)⬇

Vitamin A Compromised Dentition (P=0.033)⬇

Vitamin D Ill-fitting denture (P=0.010)⬇ Compromised Dentition (P=0.017)⬇

Vitamin E Ill-fitting denture (P=0.024)⬇ Compromised Dentition (P=0.002)⬇

Diet and dentition in older adults: A systematic review

Vitamin B6 Ill-fitting denture (P=0.035)⬇ Compromised Dentition (P=0.001)⬇

Vitamin B12 Ill-fitting denture (P=0.018)⬇ Compromised Dentition (P=0.050)⬇

Folate Compromised Dentition (P=0.024)⬇

Dietary Fibre Compromised Dentition (P=0.031)⬇

Associations between oral health status and food group consumption.(Referent category Good Dentition).

Vegetables Ill-fitting denture (P=0.025)⬇ Compromised Dentition (P=0.016)⬇

Fish and shell-fish Ill-fitting denture (P=0.007)⬇ Compromised Dentition (P=0.021)⬇

Diet and dentition in older adults: A systematic review

No relationship between oral status and recommended nutrient intake level.

Iwasaki et al., Method: Carried out by four Method: BDHQ which is a Mann Whitney U Adjusted differences in changes in (2016), Japan, trained dentists. validated self-administered diet test and Student t- dietary intake of nutrients and food Longitudinal, Measured: Grade of tooth history. test for baseline to groups, (not impaired dentition vs High quality (++) mobility, denture presence and Measured: Estimates for dietary follow up impaired dentition changes in dietary (85). denture quality (stability/retention), intake of energy, nutrients and comparison. intake): Outcomes: Dentition status which food groups. Multivariate was defined as FTU a pair of Outcomes: Dietary intake of regression Protein (-5.5, 95%CI -10.9 – -0.1 opposing natural or prosthetic teeth nutrients (adjusted for energy) models. P=0.046) ⬇ excluding third molars (0-14), 5 or and food groups. Change in Confounders: less FTU was considered impaired nutrient intake from baseline to Gender, Sodium (-5.0, 95%CI -9.9 – -0.2, dentition. follow up. education, P=0.042) ⬇ income, smoking status, ADL, Potassium (-6.3, 95%CI -11.9 – -0.7 BMI, P=0.026) ⬇ comorbidities.

Calcium (-9.3, 95%CI -16.9 – -1.6, P=0.018) ⬇

Vitamin A (-9.5, 95%CI -18.2 – -0.7, P=0.035) ⬇

Vitamin E (-8.6, 95%CI -14.8 – -2.3, P=0.007) ⬇

Diet and dentition in older adults: A systematic review

Dietary Fibre (-6.2, 95%CI -12.3 – - 0.1, P=0.045) ⬇

Vegetables (-13.6, 95%CI -25.2 – -0.1 P=0.021) ⬇

Meat (-15.5, 95%CI -28.3 – -2.7, P=0.018) ⬇

Lee et al. (2004), Method: Self-reporting. Method: Modified block 48 Multivariate Average nutrient intake differences USA, Cross- Measured: Edentulism. FFQ, administered by a trained regression and (P<0.05) between dentate and edentate sectional, Outcomes: Participants were dietary interviewer. logistic participants: Acceptable (+) categorised as edentate or dentate. Measured: Energy intake and regression. Protein (% of energy)⬇ (86). 15 other nutrients: protein, Stratified by race Sweets and Dessert (% of energy)⬆ vitamin A, vitamin C, vitamin E, Confounders: age, Dietary Fibre⬇ thiamin, riboflavin, vitamin B-6, race, sex, income, Vitamin C⬇ folate, niacin, iron, magnesium education, study and zinc. site, smoking, Calcium⬇ Outcomes: Mean intakes of drinking, living Magnesium⬇ nutrients and whether or not alone, chewing intakes met 2/3rds of pain, SRH. Average nutrient intake differences recommendations or not. (P<0.05) between dentate and edentate white participants: Fat (% of energy)⬆ Total fat (g)⬆ Saturated fat⬆

Diet and dentition in older adults: A systematic review

Cholesterol⬆ Vitamin A⬇ Beta-carotene⬇ Meats⬆

Average nutrient intakes significantly different (P<0.05) between dentate and edentate black participants: Phosphorus⬇

No significant results when looking at % of edentate vs dentate participants and meeting <67% of recommendations for selected nutrients.

Significant results of % of edentate vs dentate participant and meeting 67% of recommended servings and daily intake frequencies of food groups: Fruit and fruit juice⬇ Fats, oils and sweets ⬆

Natapov et al. Method: Self-reported via Method: 24hr dietary recall Multiple Linear Significantly different nutrient intakes (2018), Israel, questionnaire administered by during an interview regression. between no dentures and those with Cross-sectional, trained interviewers. administered by trained Confounders: dentures: Measure: Presence of dentures. interviewers. education, interest Energy (P<0.0006)⬇

Diet and dentition in older adults: A systematic review

Acceptable (+) Variable: Denture vs No Dentures. Measure/Variable: Daily in association Fibre (P<0.001)⬇ (92). intake of energy (kcal), fibre (g), between nutrition Protein (P<0.0014)⬇ protein (serves), fruit (serves) and oral health, Vegetables (P<0.0004)⬇ and vegetables (serves). and reading nutrition labels.

Sahyoun et al., Method: MEC performed by a Method: FFQ during the Logistic Association of lowest vs upper (2005), USA, licensed dentists. household interview. regression quartiles of fruit and vegetable Cross-sectional, Measured: Number of pairs of Measure: Daily intake of fruit models, consumptions with categorisation of Acceptable (+) posterior teeth. and vegetables. univariate, and POPs 5 to 8 pairs (Referent category 5 (87). Variables: These were categorised Variable: Frequency of various adjusted to 8 pairs, OR: 1.00) as 0, 1-4, 5-8, & full denture consumption of fruit and models were 1 to 4 pairs (OR:1.37, 95%CI 1.10 – wearers. vegetables broken down into used. 1.72) quartiles. Confounders: None (OR1.51, 95%CI 1.04 – 2.21) Model 1 - Age, ethnicity, gender, education, income, marital status. Model 2 - smoking, BMI, social contact, Model 3 – SRH. physical functioning, Dental health.

Diet and dentition in older adults: A systematic review

Savoca et al., Method: Dental examinations Method: 1998 Block food Rao Scott X test, Association between estimated intake (2010), USA, conducted by two dental hygienists. questionnaire in face to face linear regression, of HEI components and Total HEI Cross-sectional, Measured: Numbers of teeth, with trained interviews. logisitic scores by numbers of tooth Acceptable (+) FTUs. Variables: Categorised as Measured: HEI-2005 scores, regression. (categorised): (88). 1. 0 teeth. and individual components - Confounders: age, Total Score (P<0.0001)⬇ 2. 1-10 teeth. total fruit, whole fruit, total gender, poverty Total fruit (P=0.015)⬇ 4. 11-20 teeth. vegetables, dark green and status, dental Meat and Beans (P=0.01)⬇ 5. 21+ teeth. orange vegetables and legumes, insurance and Oils (P=0.011)⬇ Functional tooth units were counted milk, meat and beans, total ethnicity. based on whether it was two natural grains and whole grains, oils, Energy from solid fat, alcohol, and functioning units, one natural one sodium, percentage of energy added sugar (P=0.0001)⬆ prosthetic, or two prosthetic from saturated fat and solid fat, functional units. alcohol and sugar. Association between percentage of Variables: Intakes of HEI participants meeting HEI components components and percentage of and total score recommendations by participant meeting tooth category: recommended intakes of HEI Total Score (OR :0.092, 95%CI 0.02 – components. 0.50) Total Vegetables (OR :0.54, 95%CI 0.30 – 0.70) Dark Green and Orange Vegetables (OR: 0.48, 95%CI 0.33 – 0.70) Energy from solid fat, alcohol and added sugar (OR:0.52, 95%CI 0.35 – 0.77)

Savoca et al., Method: Dental examinations Method: 1998 Block food Linear HEI components by dentition status: (2011), USA, conducted by two dental hygienists, questionnaire in face to face Regression. Total Score (P <0.0001)

Diet and dentition in older adults: A systematic review

Cross-sectional, and a SCQ. with trained interviews. Confounders: CD vs ND (11+)/RPD/RPD +CD Acceptable (+) Measured: Dentures and numbers Measured: HEI-2005 scores, Age, gender, (P<0.05)⬇ (89). of teeth. and individual components - ethnicity, ND (0 - 10) vs ND Variables: Categorised into four total fruit, whole fruit, total education, and (11+)/RPD/RPD+CD (P<0.05)⬇ denture groups: vegetables, Dark green and poverty status. 1. No dentures (ND). orange vegetables and legumes, Whole fruit (P0.0025) 2. Removable partial dentures milk, meat and beans, total ND (0-10) vs ND (RPDs). grains and whole grains, oils, (11+)/RPD/RPD+CD/CD (P<0.05)⬇ 3. Removable partial dentures with sodium, percentage of energy

a complete denture (RPD/CD). from saturated fat and solid fat, Total vegetable (P=0.0021) 4. Complete dentures (CD). alcohol and sugar. ND (0-10) vs ND No dentures was further split into (11+)/RPD/RPD+CD/CD (P<0.05)⬇ two groups: 5. CD 0-10 teeth. CD vs RPD/ND(0-10) (P<0.05)⬇ 6. CD 11+ teeth. CD vs ND(0-10) (P<0.05)⬆

Dark green and orange vegetables and legume (P=0.05) CD vs RPD (P<0.05)⬇ ND (0-10) vs RPD (P<0.05)⬇

Meat and Beans, (P=0.04) CD vs ND (11+)/ RPD+CD (P<0.05)⬇

Oils, (P=0.03)

Diet and dentition in older adults: A systematic review

ND (0-10) vs ND (11+)/RPD/RPD+CD/CD (P<0.05)⬇

Saturated fat (% of kcal) (P=0.0016) RPD vs ND (11+)/CD (P<0.05)⬇ RPD+CD vs ND (11+)/CD (P<0.05)⬇

Energy from solid fat, alcohol, and added sugar, (P=0.0029) CD vs ND (11+)/RPD (P<0.05)⬆

Shatenstein et al. Method: Face to face interviews Method: Face to face interviews Non-parametric ‘Wearing Denture’ was a determinant (2013), Canada, with nurses, self-reported. by trained dietitians using three tests Spearman’s of dietary quality (P=0.01) Cross-sectional Variable: Wearing Dentures. non-consecutive 24 hour recalls. test and Mann- Acceptable (+) Measured: Food and nutrient Whitney U. (90). intake. Confounder: Variable: Diet quality was Education, evaluated by the C-HEI score. household income, alcohol, diet knowledge, perceived physical health, number of meals per day, eats in restaurant.

Diet and dentition in older adults: A systematic review

Sheiham et al. Method: Trained and calibrated Method: Four day weighed For comparison of Association between daily intake of (2001), Great examiner. dietary survey. mean two sample nutrients between dentate and edentate Britain, Cross- Measured: Numbers of natural Measured: Dietary intake of t-test, Manns participants: sectional, teeth, number of posterior nutrients including energy, Whitney or Protein (β: 3.4, 95%CI 0.9 – 5.8, Acceptable (+) occluding pairs of natural teeth, protein, fats, carbohydrate, Kruskal P=0.007)⬇ (31). spaces and partial dentures. intrinsic milk sugars, non-starch Wallistests . Outcomes: Participants categorized polysaccharide, calcium, haem Multivariate Intrinsic milk and sugars (β: 4.7, as dentate and edentate, Dentate iron, non-haem iron, thiamin, logisitic 95%CI 2.2 – 7.2, P<0.001)⬇ participants were grouped: riboflavin, niacin, pantothenic modelling was 1. ‘1-10 teeth’. acid, vitamin C, vitamin E. also used. Non -starch polysaccharide (β: 2.7, 2. ’11 – 20’. Outcome: Daily intakes of Confounders: 95%CI 1.6 – 3.8, P<0.001)⬇ 3. ‘21+’. above nutrients. Age, sex, social

class, and region Calcium (β: 56.6, 95%CI 12.9 – 100.3, of origin. P=0.01)⬇

Non-heme iron (β: 0.64, 95%CI 0.06 – 1.22, P=0.03)⬇

Riboflavin (β: 0.10, 95%CI 0.03 – 0.16, P=0.002)⬇

Niacin equivalent (β: 2.0, 95%CI 0.4 – 3.6, P=0.01)⬇

Pantothenic acid (β: 0.09, 95%CI 0.03 – 0.15, P=0.003)⬇

Diet and dentition in older adults: A systematic review

Vitamin C (β: 0.07, 95%CI 0.02 – 0.12, P=0.006)⬇

Vitamin E (β: 0.11, 95%CI 0.01 – 0.21, P=0.04)⬇

Association between daily intake of nutrients and grouped numbers of teeth in dentate participants: Energy (β: 11.4, 95%CI 4.3 – 18.4, P=0.002)⬇

Protein (β: 0.33, 95%CI 0.06 – 0.60, P=0.02)⬇

Fat (β: 0.41, 95%CI 0.05 – 0.78, P=0.03)⬇

Total carbohydrate (β: 1.8, 95%CI 0.8 – 2.7, P<0.001)⬇

Intrinsic and milk sugar (β: 0.53, 95%CI 0.24 – 0.81, P=<0.001)⬇

Non-starch polysaccharide (β: 0.23, 95%CI 0.09 – 0.36, P=0.001)⬇

Diet and dentition in older adults: A systematic review

Calcium (β: 8.0, 95%CI 3.0 – 13.0, P=0.002)⬇

Non-heme iron (β: 0.08, 95%CI 0.02 – 0.14, P=0.01)⬇

All nutrients, except non-milk extrinsic sugars and heme iron were significantly associated with the number of POPs (Results not shown).

Shinkai et al. Method: Calibrated examiners. Method: Trained interviewers Spearman, No relationship between dentition (2001), USA, Measured: Posterior FTUs, or dietitians using 24 hour Kruskal-Wallis, status and Mean HEI Score in Adults Cross-sectional, defined as natural, restored or fixed dietary recall method. P earson Chi - aged 65 years and older. Acceptable (+) prosthetic, post-canine teeth, and Measured: Dietary intake of analysis were (67). the presence number and type of food groups and nutrients. used. Pair wise removable dentures. Variable: Primary outcome is comparisons were Variables: There were four the HEI score, which was assessed by the categories: grouped into 3 categories, Mann-Whitney U. 1. Good dentition - 8 or more Good: score of 80 or more, Confounder: posterior FTU and no dentures. Needs improvement: scores ethnicity, age, 2. Compromised dentition group - 1 between 51 to 80, and poor: sex, income, to 7 posterior FTUs and no score of 51 or less. intake of 40 education, removable dentures. specific nutrients was also dentition but 3. Partial denture group - either assessed. unsure if this is upper or lower dentures with or taken into the without removable partial with or account for without partial dentures in the other analysis.

Diet and dentition in older adults: A systematic review

arch. 4. Complete denture group.

Yoshihara et al. Method: Four dentists. Method: Trained dietitians Multiple linear Association between nutrient intakes (2005), Japan, Measure: Number of teeth, and providing guidance to the regression. with number of teeth: Cross-sectional, presence of dentures. participants on how to Confounders: Total Protein (% of energy) (β: 0.53, Acceptable (+) Variables: Numbers of teeth as a conducted weighted food record, number of teeth, P<0.0001) (91). continuous variable, numbers of over November to December gender, smoking Animal protein (% of energy) (β: 0.47: teeth categorized as ‘0-19’, ‘20+’. period. habits and P<0.0001) Measured: Nutrient intakes educational level. Sodium (β: 0.37, P<0.01) Variables: Nutrient intakes of Potassium (β: 0.40, P<0.01) energy, protein, carbohydrates, Phosphorus (β: 0.40, P<0.01) minerals, vitamins, fatty acids Iron (β: 0.35, P<0.01) and dietary fibre. Magnesium (β: 0.33, P<0.05) Vitamin D (β: 0.31, P<0.05) Vitamin E (β: 0.29, P<0.05) Vitamin B1 (β: 0.39, P<0.01) Vitamin B2 (β: 0.34, P<0.05) Vitamin B6 (β: 0.53, P<0.0001) Niacin (β: 0.44, P<0.001) Folic acid (β: 0.35, P<0.01) Pantothenic acid (β: 0.37, P<0.01) Cholesterol (β: 0.32, P<0.05)

Association between nutrients intakes with grouped number of teeth. Total Protein (% of energy) (P<0.01)⬇

Diet and dentition in older adults: A systematic review

Animal Protein (%) (P<0.05)⬇ Sodium (P<0.05)⬇ Vitamin D (P<0.05)⬇ Vitamin B1 (P<0.001)⬇ Niacin (P<0.001)⬇ Vitamin B6 (P<0.01)⬇ Pantothenic acid (P<0.05)⬇

Association between food groups with grouped number of teeth. Total Vegetables (P<0.05)⬇ Other Vegetables (P<0.01)⬇ Fish, shellfish, and their products (P<0.05)⬇

RDA, Recommended Daily Allowances. HCU, Health Care Utilization. CI, Confidence Intervals. POPs, Post Occluding Pairs. FV, Fruit and Vegetables. OR, Odds Ratio. HEI, Healthy Eating Index. LSM, Least-Squares Method. FTUs, Functional Tooth Units. FFQ, Food Frequency Questionnaire. TEI, Total Energy intake. DRI, Daily Recommended Intake. EER, Estimated Energy Requirements. EAR, Estimated Average Requirements. AMDR, Acceptable Macronutrient Distribution Range. BGLs, Blood Glucose Levels. SCQ, Self-Completed Questionnaire. BDHQ, Brief Self-Administered Diet History Questionnaire. SRH, Self Reported Health. ND, No Dentures. RPD, Removable Partial Dentures. CD, Complete Dentures. 926

927

Diet and dentition in older adults: A systematic review

928 Inconsistency:

929 Nineteen studies suggested a generally positive association between dentition and diet,

930 while one study found no overall associations (67). However, some studies showed a

931 significant association between dentition with particular individual nutrients and food

932 groups, where other studies found no association with those same nutrients and food

933 groups. Statistical measures of effect sizes also varied.

934

935 Statistical testing of heterogeneity was not performed. However, heterogeneity was

936 likely high as the 20 studies used different measures of dentition and examined different

937 nutrients. Diet was measured using various tools, including questionnaires, diet history

938 interviews, and 24-hour recall, and the nutrients or food groups were analysed as either

939 mean daily intakes or categorized and compared to relevant nutrient recommendation.

940 Overall dentition was measured by numerous definitions counting natural teeth,

941 FTUs/POPs, the denture presence or a composite category combining these measures.

942 The overall GRADE score was downgraded due to likelihood of heterogeneity and lack

943 of consistency of assessment of individual nutrients and food groups. This was also true

944 for the GRADE score for each of the sub-categories for dentition definitions, except for

945 FTUs and POPs. Definitions among studies that defined dentition by FTUs or POPs

946 were more consistent (31, 79, 85, 87).

947

948 Indirectness:

949 All studies looked at community dwelling participants who were 60 years or older, and

950 generally healthy (31, 52, 67, 77-93). Direct measures of dietary intake of nutrients and

951 food groups as well as dentition were used. Conclusions were made from direct

Diet and dentition in older adults: A systematic review

952 comparisons. As such the overall GRADE quality score, and each of the sub-categories

953 for dentition, were not downgraded for directness.

954

955 Imprecision:

956 The overall number of participants assessed was large (n=27 418), and numbers of

957 participants was also large for each sub-category of dentition (Table 1.4) (31, 52, 67,

958 77-93). However, as the studies were not directly comparable, it was not possible to

959 calculate a pooled relative risk, with confidence intervals. No individual studies found

960 that poorer dentition was associated with better dietary outcomes.

961 The overall GRADE score, and scores for sub-categories of dentition, was neither

962 downgraded nor upgraded.

963

964 Publication bias:

965 Every study included in this review found a significant outcome, and the majority of

966 studies had large populations. As no summary estimate of the overall effect could be

967 calculated, a funnel plot could not be constructed to determine publication bias,

968 however, a review with all studies showing statistically significant results suggests

969 publication bias is likely. Due to this the overall GRADE score was downgraded as

970 well as the scores for subcategories of dentition, except for the subcategory that used

971 FTUs and POPs to define dentition (31, 52, 67, 77-93).

972

973

974 Discussion

975 The findings of this systematic review shows a clear association between dentition and

976 dietary intake of nutrients and food groups (31, 52, 67, 77-93). Specifically diet intake

Diet and dentition in older adults: A systematic review

977 and diet quality were positively associated with the number of natural teeth and number

978 of posterior occluding pairs (or functional tooth units) (31, 52, 67, 77, 79-81, 83-88,

979 91). The presence of dentures in edentulous subjects was clearly associated with better

980 quality diets, although this relationship was more complex in subjects with both

981 dentures and retained natural teeth (78, 82, 89, 90, 92). However, the quality of the

982 overall evidence was low as determined by the GRADE assessment tool. No studies

983 were found that assessed the impact of dietary intake on subsequent dentition status.

984

985 Loss of natural teeth or FTUs was a clear indicator of poor intake of various nutrients

986 and food groups (31, 52, 83, 86, 88, 91). Defining dentition status by categorising

987 participants according to both denture status and number of natural teeth, or

988 FTUs/POPs, showed a clear relationship with diet (77, 80, 81, 84). The optimal

989 category of dentition status as defined in various ways by each study was consistently

990 associated with better nutrient intakes and dietary quality (77, 80, 81, 84).

991

992 However, the relationship between diet and dental prosthesis, such as dentures, was

993 complex (78, 82, 89, 90). The presence of a prosthesis was associated with poorer diet

994 quality, except in edentulous participants, where the presence of a prosthesis was

995 associated with better dietary outcomes than edentulous participants without a

996 prosthesis (78, 82, 90). Yet one study showed that the severity of tooth loss, higher

997 numbers of missing teeth, may have a greater influence on how the presence of dentures

998 impacts dietary intake, and replacement of teeth with prosthetics may not adequately

999 restore nutrition (89). Participants with severe tooth loss with no dentures and

1000 participants with complete replacement of natural teeth with dentures had poorer

1001 dietary outcomes than participants with partial replacement with dentures, and

Diet and dentition in older adults: A systematic review

Table 1.4 Assessment of Quality of overall evidence from systematically reviewed studies, and studies broken down by different definitions of dentition, using GRADE Number of studies Risk Inconsistency Indirectness Imprecision Publication bias Quality (total number of bias participants)

Overall 20 (27418) -2 High -1 for No Neutral -1 Detected, Very Low Evidence (Very Heterogeneity Indirectness (suspected). serious) detected. Number of 6 (8185) -2 High -1 for No Neutral -1 Detected, Very Low teeth (Very Heterogeneity Indirectness (suspected). serious) detected. Presence of 5 (6094) -2 High -1 for No Neutral -1 Detected, Very Low Dentures (Very Heterogeneity Indirectness (suspected). serious) detected. FTUs/POPs 4 (6414) -2 High Not downgraded No Neutral Undetected, Low (Very for heterogeneity. Indirectness (suspected). serious) detected. Oral health 6 (7733) -2 High -1 for No Neutral -1 Detected, Very Low status (Very Heterogeneity Indirectness (suspected). serious) detected. GRADE, Grading of Recommendations, Assessment, Development and Evaluations

1002

Diet and dentition in older adults: A systematic review

1003 participants without severe tooth loss and no dentures present (89). The results of Ervin

1004 et al. similarly suggest that prostheses may not adequately replace natural dentition

1005 (81). Compromised quality of removeable prosthetics has been shown to be associated

1006 poor diet, possibly due to compromised mastication ability (97, 98). It is also possible

1007 removeable prosthesis do not adequately replace chewing capacity of natural teeth (30,

1008 99).

1009

1010 While there was consistency in results across studies that looked at food groups as an

1011 outcome, there were less consistent results across studies that looked at nutrient intake.

1012 One possible reason for this could be the different ways in which each study measured

1013 numbers of teeth, numbers of FTUs, dentures, and overall dentition (31, 52, 67, 77-91).

1014 Two studies similarly defined the optimal category of teeth as 20+ or 21+ natural teeth

1015 (52, 91). Yet another study used 11 or more teeth in their optimal category (88). On the

1016 other-hand, the optimal category for POPs, associated with better dietary intake of

1017 nutrients and food groups, was consistently defined as greater than five (85, 87).

1018 Advantageous diet quality was also statistically associated with the mean number of

1019 POPs or FTUs (31, 79).

1020

1021 When dentition status was defined in terms of number of teeth, there were some

1022 inconsistencies in how the optimal category of dentition was defined (77, 80, 81). One

1023 study defined the highest category of dentition status as no denture present and eight or

1024 more natural teeth, while another defined it as 10 natural teeth in the upper jaw and 6

1025 natural teeth in the lower jaw and no use of dentures (77, 80). Finally a third study

1026 defined the optimal category of dentition as 21 to 28 teeth and no dentures (81). The

Diet and dentition in older adults: A systematic review

1027 study that used FTUs or POPs, instead of numbers of teeth, defined the optimal category

1028 as 8 POPs or FTUs more and no dentures (84).

1029

1030 Individual nutrient intake results may also have differed from study to study because of

1031 the different way dietary intake was measured. Some studies looked at mean intakes of

1032 nutrients, while other studies compared nutrient intakes to the specific country’s

1033 national recommended intakes (31, 52, 77-79, 81-86, 91). Furthermore, the

1034 generalizability of results that focused on measuring diet by mean intake of nutrients

1035 and relevant recommendations were potentially limited. Studies that measured nutrients

1036 against nutritional recommendations provided potentially more meaningful results and

1037 also recommendations (31, 52, 77-79, 81-86, 91).

1038

1039 For example, Sheiham et al., found that the mean intake of calcium was higher in

1040 participants with the highest category of teeth compared to those in the two lowest

1041 categories and higher in dentate vs those who were edentulous (31). Yet the mean

1042 calcium intake across categories for natural teeth was above Britain’s nationally

1043 recommended intakes (700 mg for adults 19+) (31). Similarly, a study in the US found

1044 dentate participants had higher mean calcium intakes than edentulous participants,

1045 however the mean intakes of both dentate and edentulous participants was below the

1046 recommended intakes for calcium, due to higher recommendations (1200 mg for adults

1047 65+) (86).

1048

1049 Most studies measured food groups using the HEI or another measure for recommended

1050 intakes to evaluate food group intake, and overall dietary intake (52, 67, 80, 88-90).

1051 This may account for more consistent results across these studies, specifically finding

Diet and dentition in older adults: A systematic review

1052 that there was an inverse association between fruit and vegetable intakes and dentition

1053 (52, 80, 88, 89). Two studies that looked at the frequency of food group intake, also

1054 found an inverse association between fruit and vegetable intake and dentition (84-87).

1055

1056 The second aim of this review was to assess the direction of the relationship between

1057 dietary intake of nutrients and food groups with dentition in community dwelling older

1058 adults. All the studies, except one, examined how dentition impacts the dietary intake

1059 of nutrients and food groups, even the single longitudinal study (31, 52, 67, 77-91). Yet,

1060 despite the fact that most of studies were cross-sectional, two suggested the result might

1061 reflect how diet could impact dentition (86, 91). Lee et al. proposed that higher intakes

1062 of ‘sweets’ could indicate reverse causality, as the cariogenic nature of sweets could

1063 lead to dental decay, and which is a known contributor of tooth loss (86). Yoshihara et

1064 al. found that participants with less than 20 natural teeth had poorer intakes of shellfish

1065 and fish than participants with 20 or more natural teeth (91). The authors reflected that

1066 this could be due to a poor quality of diet, and poor intake of omega 3 fatty acids,

1067 impacting on possible causation of periodontal diseases, which can be a contributor to

1068 tooth loss (91). However, this study did not control for socioeconomic status as a

1069 confounder, only education. It is possible that socioeconomic disparities in the

1070 population could affect the relationship between shellfish and fish intake and dentition,

1071 as these are generally high cost items (91). A similar result was also found in a larger

1072 pool of participants from the same population, who were categorized by POPs and

1073 dentures (84). Participants with less than 8 POPs and no dentures, or ill-fitting dentures

1074 had poorer intakes of shellfish and fish than participants with 8 POPs and no dentures,

1075 after controlling for income (84). More research and high-quality studies need to be

1076 conducted to better determine whether dietary intake impacts dentition outcomes.

Diet and dentition in older adults: A systematic review

1077

1078 Limitations of this review include the fact that screening of titles and abstracts and data

1079 extraction was conducted by one reviewer. However, screening of full texts and quality

1080 assessment was completed by two reviewers, with a third for consultation.

1081

1082 Conclusions

1083 Significant associations were found between various categorisations of good dentition

1084 with diet quality, adequate dietary intake of nutrients and food groups, as shown by the

1085 20 reviewed studies. Each sub-category of dentition also had significant associations

1086 with diet quality suggesting the maintenance of natural teeth leads to improved nutrient

1087 and food group intake, although the relationship between presence of dentures and diet

1088 was complex. However, as the majority of studies were cross sectional, this review

1089 cannot determine if poor dentition causes poor diet quality. Measures of dentition need

1090 to be more consistent, and more longitudinal studies need to be conducted to establish

1091 the direction of exposure and outcome, as well as more research to examine if dietary

1092 intake of nutrients and food groups impacts dentition in older adults.

Periodontal health and nutrition

1093 1.3 Periodontal health and nutrition

1094 Although limited research has been conducted examining the association between

1095 periodontal health and nutrition, especially in older populations, diet is a possible

1096 modifiable risk factor for periodontal disease. As an inflammatory disease, periodontal

1097 disease has been linked to other inflammatory related diseases, such as cardiovascular

1098 disease and obesity (39-41). It has also been shown to be associated with elevated levels

1099 of C-reactive Protein (CRP), an inflammatory biomarker (100). A recent study found

1100 that adhering to an anti-inflammatory diet was associated with less tooth loss than

1101 among participants who consumed a pro-inflammatory diet, as measured by the Dietary

1102 Inflammatory Index (DII) (101). DII provides tool to assess the inflammatory potential

1103 of diet, based on the association of 45 possible food components with inflammatory

1104 biomarkers (101).

1105

1106 One systematic review looked at the relationship between nutritional deficiencies and

1107 periodontal diseases. The studies included in this review used 24 hour dietary recall and

1108 biological markers to assess micronutrient intakes (102). The review found no

1109 conclusive evidence of a relationship between periodontal disease and micronutrients:

1110 magnesium, vitamin D, vitamin B complex and calcium, and showed weak evidence of

1111 an association between vitamin C and periodontal disease (102).

1112

1113 A more recent systematic review assessed the association between dietary intake and

1114 periodontal disease and attempted to describe the direction of the association (I co-

1115 authored this publication, which can be found in Appendix D) (103). This review found

1116 evidence of an association between periodontal disease and a high intake in saturated

1117 fatty acids and a high ratio of n-6 to n-3 fatty acid intake (Table 1.5) (103-105).

Periodontal health and nutrition

1118 Periodontal disease was also inversely associated with high intakes of Docosahexaenoic

1119 Acid (DHA), vitamin C, vitamin E, and beta-carotene (103, 106, 107). There was an

1120 association between periodontal disease and lower intakes of milk, fermented dairy

1121 products, and fruits and vegetables, but higher intakes of ‘cereal, nuts and seeds, sugar

1122 and sweetener, and confectionary’ (72, 103). The review was unable to determine the

1123 direction of the association, as all included studies looked at how diet impacted on

1124 periodontal disease (103). The quality of the studies was assessed by GRADE and they

1125 were found to be low in quality (103). The main limitations highlighted were risk of

1126 bias among cohort and cross-sectional studies, and the lack of coherent definitions of

1127 periodontal diseases (103). The categorisation of ‘cereals, nuts and seeds’ with ‘sugar

1128 and sweetener, and confectionary’ was also criticized as an unusual grouping that does

1129 not allow for discerning which nutrients and food groups contribute to periodontal

1130 disease (103). However the study was able to summarize the current literature around

1131 diet and periodontal disease, and highlight the limited available research in this area

1132 (103).

Periodontal health and nutrition

Table 1.5 Population studies on diet and periodontal disease in older adults (103) Author Title Sample and Dietary Oral Health Nutrients Investigated Results (Year) location assessment Examination Adegboye Intake of dairy Adults aged 65 Diet history Examination Total dietary calcium Calcium intake (mg/day) IRR et al. products in years and older. interview conducted by single (mg/d) stratified by (95%CI) (2012) relation to Copenhagen, conducted by dentist. Number of dairy and non-dairy Total from Dairy: 0.97 (0.96 – (108) periodontitis in Denmark. a single teeth with CAL ≥ food sources. 0.99) P=0.021 older Danish dietitian 3mm. Total dairy food (g/d), Milk: 0.97 (0.95 – 0.99) P=0.025 adults. classified into four Cheese: 0.99 (0.96 – 1.03) P=0.701 groups, milk (whole and Fermented foods: 0.96 (0.92 – 0.99) skimmed), cheese (hard P=0.03 and soft), fermented foods (yogurt and lactic Dairy Food intake (g/day) IRR acid drinks), and other (95%CI) foods (butter, ice-cream, Total Dairy: 0.96 (0.96 – 0.99) creams). P=0.003 Milk: 0.96 (0.93 – 0.99) P=0.028 Cheese: 0.95 (0.78 – 1.16) P=0.625 Fermented foods: 0.97 (0.95 – 0.99) P=0.029 Iwasaki et Longitudinal Older adults aged Self-reported Examination Mean total/day: DHA intake/energy (mg/kcal) IRR al. (2010) relationship 70 years aged 70 3 day weight conducted by 4 Energy intake (95%CI), highest tertile as (106) between dietary years at baseline food record. calibrated dentists. DHA reference: omega-3 fatty (n=36). Niigata Periodontal disease EPA Middle Tertile: 1.18 (0.80 – 1.73) acids and city, Japan. event = CAL ≥ Omega-3 P=0.401) periodontal 3mm per site each Lowest Tertile: 1.49 (1.01 – 2.21) disease P=0.045

Periodontal health and nutrition

year over a five year period. EPA intake/energy (mg/kcal) IRR (95%CI), highest tertile as reference: Middle Tertile: 1.24 (0.80 – 1.94) P=0.336 Lowest Tertile: 1.47 (0.97 – 2.21) P=0.067

Iwasaki et Dietary ratio of Older adults aged Validated Examination Mean intakes/day: PUFA n-6/n-3 ratio RR (95% CI), al. (2011) n-6 to n-3 70 years at BDHQ. conducted by 4 Energy intake Lowest Tertile as reference (1.00): (104) polyunsaturated baseline (n=235). calibrated dentists. PUFA Middle: 1.14 (0.97 – 1.33) fatty acids and Niigata city, Periodontal disease ALA Highest: 1.29 (1.10 – 1.51)* periodontal Japan. event = CAL ≥ LA disease in 3mm per site each AA Total n-3 intake RR (95% CI), community- year over a five EPA Lowest Tertile as reference (1.00): based older year period. DHA Middle: 0.92 (0.79 – 1.07) Japanese: A 3- Total n-3 Highest: 0.88 (0.75 – 1.03) year follow-up Total n-6 study Total n-6/total n-3 ratio. Total n-6 intake RR (95% CI), Lowest Tertile as reference (1.00): Middle: 1.07 (0.92 – 1.25) Highest: 1.10 (0.94 – 1.28)

Iwasaki et Relationship Older adults aged Validated Examination SFA intake as a Periodontal Disease Events al. (2011) between 70 years at BDHQ. conducted by 4 percentage of energy Non-smokers SFA intake RR (105) saturated fatty baseline (n=265). calibrated dentists. intake. (95%CI), 1st quartile reference acids and Periodontal disease (1.00).

Periodontal health and nutrition

periodontal Niigata city, event = CAL ≥ 2nd Quartile: 1.19 (0.72 – 1.97) disease Japan. 3mm per site each 3rd Quartile: 1.55 (0.95 – 2.52) year over a 1 year 4th Quartile: 1.92 (1.19 – 3.11)* period. Smokers SFA intake RR (95%CI), Overall periodontal 1st quartile reference (1.00). attachment loss = 2nd Quartile: 1.18 (0.86 – 1.63) mean CAL at 3rd Quartile: 0.93 (0.65 – 1.34) follow up > mean 4th Quartile: 1.04 (0.74 – 1.45) CAL at baseline. Overall periodontal disease attachment Non-smokers SFA intake RR (95%CI), 1st quartile reference (1.00). 2nd Quartile: 2.04 (0.71 – 5.85) 3rd Quartile: 2.33 (0.81 – 6.75) 4th Quartile: 3.14 (1.04 – 9.47)*

Smokers SFA intake RR (95%CI), 1st quartile reference (1.00). 2nd Quartile: 0.73 (0.25 – 2.16) 3rd Quartile: 1.22 (0.40 – 3.68) 4th Quartile: 0.54 (0.17 – 1.70)

Iwasaki et Dietary Older adults aged Validated Examination Mean intake of Vitamin C intake IRR (95% CI), al. (2012) antioxidants and 70 years at BDHQ. conducted by 4 Nutrients: Lowest Tertile as reference (1.00): (107) periodontal baseline (n=264). calibrated dentists. Energy Middle: 0.76 (0.60 – 0.97)*

Periodontal health and nutrition

disease in Niigata city, Periodontal disease Vitamin C (mg/day) Highest: 0.72 (0.56 – 0.93)* community- Japan. progression = CAL Vitamin E (mg/day) based older ≥ 3mm at an inter- Alpha-carotene (ug/day) Vitamin E intake IRR (95% CI), Japanese: a 2- proximal site/tooth Beta-carotene (ug/day) Lowest Tertile as reference (1.00): year follow-up over a 2 year Middle: 0.79 (0.62 – 0.99)* study period. Mean intake of food Highest: 0.55 (0.42 – 0.72)* groups: Fruits (g/day) Alpha-carotene intake IRR (95% Vegetables (g/day) CI), Lowest Tertile as reference (1.00): Middle: 1.06 (0.82 – 1.36) Highest: 0.89 (0.68 – 1.15)

Beta-carotene intake IRR (95% CI), Lowest Tertile as reference (1.00): Middle: 1.02 (0.81 – 1.29) Highest: 0.73 (0.56 – 0.95)*

Vegetables IRR (95% CI), Lowest Tertile as reference (1.00): Middle: 0.94 (0.74 – 1.19) Highest: 0.68 (0.52 – 0.88)*

Fruit IRR (95% CI), Lowest Tertile as reference (1.00): Middle: 0.88 (0.69 – 1.11) Highest: 0.74 (0.57 – 0.95)*

Periodontal health and nutrition

Lee et al. The association Adults aged 60 24 hour Calibrated dentists. Vitamin C intake was Inadequate Vitamin C intake OR (2017) of dietary years and older dietary record. Periodontal disease: categorized as adequate (95%CI), reference adequate (109) vitamin C intake (n=2633). South CPI 3 (shallow intake and inadequate intake: with Korea periodontal pocket intake according to Age 60 – 69 years: 1.03 (0.797 – periodontitis 3.5 – 5.5 mm), and EAR, DRI. 1.342) among Korean CPI 4 (deep Age ≥70 years: 0.922 (0.668 – adults: Results periodontal pocket 1.272) from of ≥5.5mm). KNHANES IV Nishida et Calcium and the Adults aged 60 24 hour Examiner. CAL ≥ Calcium intake as a Calcium intake OR (95%CI): al. (2000) risk for years and older dietary recall 1.5 mm over a 6 continuous variable, and Males: 1.11 (0.71 – 1.71) P=0.6582 (110) periodontal (n=2806). United conducted by year period categorized as: Females: 1.13 (0.86 – 1.48) disease States nutritionist. 20 – 499 mg P=0.4037 500 – 799 mg ≥ 800 mg

Schwatrz et High-fiber foods Men aged 65 126-item Exam conducted by Total dietary fibre intake ABL progression HR (95%CI) al., (2012) reduce years and older Harvard FFQ. single periodontist. (g/day). Total dietary fibre intake: 0.93 (111) periodontal (n=204). United 19-items ABL progression= Total good to excellent (0.62 – 1.41) disease States. identified as ≥40% progression fibre foods Total good to excellent fibre foods: progression in good to or tooth loss (only (serving/day). 0.76 (0.60 – 0.95)* men aged 65 and excellent in a period of 2-24 Good to excellent fibre Good to excellent fibre grains: 0.93 older: the sources of years). grains (serving/day). (0.85 – 1.01) Veterans Affairs fibre. PPD progression = Good to excellent fibre Good to excellent fibre fruit: 0.86 Normative ≥ 2mm or tooth fruit (serving/day). (0.78 – 0.95)*. Aging loss (only in a Good to excellent fibre Study/Dental period of 2-24 vegetables PPD progression HR (95%CI) years) (serving/day). Total dietary fibre intake: 1.00

Periodontal health and nutrition

Longitudinal (0.86 – 1.16) Study Total good to excellent fibre foods: 0.98 (0.90 – 1.06) Good to excellent fibre grains: 0.99 (0.96 – 1.03) Good to excellent fibre fruit: 0.95 (0.91 – 0.99)*.

Tooth Loss only HR (95%CI) Total dietary fibre intake: 1.20 (0.67 – 2.17) Total good to excellent fibre foods: 0.72 (0.53 – 0.97)* Good to excellent fibre grains: 0.93 (0.82 – 1.05) Good to excellent fibre fruit: 0.88 (0.78 – 0.99)*.

Yoshihara A longitudinal Adults aged 70 Validated Conducted by four Food Groups: Dark green and yellow vegetables: et al., study of the years at semi- trained and 1. Fish, shellfish, meat, -0.64, P=0.001 (95%CI -1.00 - - (2009) (72) relationship baseline(n=261). quantitative experiences beans, and eggs 0.27) between diet Niigata City, FFQ during a dentists. 2. Milk and Milk intake and dental Japan. face to face Periodontitis Event products. Cereals, nuts and seeds, sugar and caries and interview by = CAL > 3mm over 3. Dark green and sweetener, confectioneries: 0.19, periodontal dietitians. a period of 6 years yellow vegetables P=0.042 (95%CI 0.01 – 0.38) disease in elderly 4. Other vegetables and Japanese fruit. subjects

Periodontal health and nutrition

5. Cereals, nuts and seeds, sugar and sweetener, confectioneries 6. Fats and oils.

CAL, Clinical Attachment Loss. IRR, Incidence Rates Ratio. CI, Confidence Intervals. DHA, Docosahexaenoic Acid. EPA, Eicosapentaenoic acid. BDHQ, Brief-type self- administered Diet History Questionnaire. PUFA, Poly-Unsaturated Fatty Acids. ALA, alpha-Linolenic acid. LA, Linoleic Acid. AA, Arachidonic acid. RR, Relative Risk. SFA, Saturated Fatty Acid. KNHANES IV, Korean National Health and Nutrition Examination Survey. CPI, Community Periodontal Index. EAR, Estimated Average Intake. DRI, Dietary Reference Index. OR, Odds Ratio. FFQ, Food Frequency Questionnaire. ABL, Alveolar Bone Loss. PPD, Periodontal Probing Depth. HR, Hazard Ratios. *P<0.05 1133

Decay and nutrition

1134 1.4 Decay and nutrition

1135 Previous studies show that diet, as well as oral hygiene, are indicated is a key risk

1136 factors for dental caries in younger age groups (112). Specifically diets high in sugar-

1137 sweetened beverages have shown significant associations with dental caries (113).

1138 Other studies have also shown a relationship between poor overall diet quality, such as

1139 not meeting recommended fruit and vegetable servings or a cariogenic diet, with

1140 increased prevalence of dental caries in children (114). A cross-sectional study

1141 examining the association between dairy products and dental decay in Japanese

1142 children aged three years found that the highest tertile of yoghurt consumption,

1143 compared to the lowest tertile, was significantly associated with a lower prevalence of

1144 dental decay (115). This study reflected the results of another on Italian children aged

1145 3-5 years, which found that higher yoghurt consumption correlated with a decrease in

1146 early childhood dental decay (116).

1147

1148 Apart from studies among children, other literature has examined associations between

1149 diet and dental caries in adults, with the focus on the role of sugar on dental caries. A

1150 recent systematic review was conducted to update the World Health Organisation’s

1151 (WHO) guidelines for informing acceptable sugar intakes amongst the population

1152 (117). It found moderate quality of evidence that dental caries is lower with free sugar

1153 intakes of less than 10% of total energy intake (117). This was reflected in WHO’s most

1154 up to date guidelines (118). A systematic review found there was enough evidence to

1155 suggest that reducing sugar intakes may contribute significantly to caries prevention,

1156 despite an increase in exposure to fluoride (119). A longitudinal study on adults found

1157 a linear dose response relationship between dietary intake of sugar and caries, which

1158 was reduced but not eliminated by the daily use of fluoride toothpaste (120). This study

Decay and nutrition

1159 also found that the amount of sugar intake, rather than the frequency of intake, was

1160 most important in this relationship (120).

1161

1162 There have been relatively few studies that have focused on the relationship between

1163 nutrition and dental caries in older adults (Table 1.6). Kaye et al. looked at how

1164 adherence to the Dietary Approaches to Stop Hypertension (DASH) was associated

1165 with the adjusted root caries increment, measured as the number of teeth with root

1166 caries incidence and root caries reversals, in older men aged between 47 and 90 years

1167 (73). They found an inverse relationship, where participants in the highest quartile of

1168 adherence scores to the DASH diet had 30% lower mean root-adjusted-caries-

1169 increment, than those in the lowest quartile (73). Higher total vegetable and total grain

1170 scores also had lower mean root-adjust-caries-increment (73). On the other hand, higher

1171 scores for sugar-sweetened carbonated beverage consumption were associated with

1172 higher root caries scores (73). A longitudinal study in both men and women, aged 70

1173 years and older found that intake of milk and milk products correlated with reduced

1174 number of root caries events across 6 years (72). This is a different outcome compared

1175 to younger populations (115, 116, 119). Overall, despite the increased risk of their

1176 prevalence, few studies have focused on overall dietary intake of nutrients and their

1177 relationship with dental decay in older adult population.

Decay and nutrition

Table 1.6 Population studies on diet and dental decay in older adults Author/Year Title Sample and Dietary Oral Health Nutrients/food groups Results location assessment Examination investigated Kaye, E.K. et DASH diet and Men aged 47 to Harvard Examination DASH Food groups: Root -ADJCI Mean (CI 95%) al., (2015) new and 90 (n=533), University performed by single Grains, vegetables, fruits, DASH total score*: (73) recurrent root from the Boston FFQ. calibrated periodontist dairy, lean meats, Quartile 1 - 2.68 (2.13 – 3.36) caries events in Greater examiner. Restorations legumes, fats and sweets. Quartile 2 - 2.37 (1.88 – 2.98) men Metropolitan and caries on root DASH Subgroups: High Quartile 3 - 2.15 (1.70 – 2.72) area. surfaces were fibre grains and low fat Quartile 4 - 1.86 (1.45 – 2.38)** recorded. Root-ADJCI dairy. was defined as the Total DASH Score DASH Vegetable score*: number of teeth with Quartile 1 - 2.45 (2.04 – 2.95) incident root caries Sugar Intake (sucrose, Quartile 2 - 2.80 (2.34 – 3.34) events minus the fructose, and lactose). Quartile 3 - 2.16 (1.79 – 2.60) number of teeth with Starch (carbohydrates, Quartile 4 - 1.88 (1.54 – 2.29)** reversals (surfaces that minus dietary fibre and change from decayed sugar) DASH total grain score*: to sound between Sugar Sweetened soft Quartile 1 - 2.84 (2.25 – 3.59) examination). Root drinks per week. Quartile 2 - 2.96 (2.36 – 3.72) caries events recorded Quartile 3 - 2.10 (1.64 – 2.68) between examinations Quartile 4 – 2.19 (1.72 – were adjusted for 2.80)** reversals. DASH sweets score: Quartile 1 – 2.51 (2.06 – 3.07) Quartile 2 - 2.85 (2.23 – 3.66) Quartile 3 - 2.48 (1.92 – 3.20)

Decay and nutrition

Sugar Sweetened Carbonated beverages*: Quartile 1 - 2.17 (1.68 – 2.79) Quartile 2 - 2.64 (2.06 – 3.37) Quartile 3 - 2.57 (2.01 – 3.29) Quartile 4 – 2.86 (2.28 – 2.60)**

Sugar, percentage of kcal/d: Quartile 1 - 2.60 (2.05 – 3.31) Quartile 2 - 2.64 (2.07 – 3.36) Quartile 3 - 2.56 (2.01 – 3.27) Quartile 4 – 2.51 (1.98 – 3.18)

Starch, percentage of kcal/d: Quartile 1 - 2.67 (2.10 – 3.40) Quartile 2 - 2.45 (1.92 – 3.11) Quartile 3 - 2.64 (2.08 – 3.35) Quartile 4 – 2.54 (2.00 – 3.24)

Yoshihara et A longitudinal Adults aged 70 Validated Conducted by four Food Groups: Milk and milk products: -0.10, al., (2009) study of the years at semi- trained and 1. Fish, shellfish, meat, P=0.035 (95%CI -0.20 - -0.07) (72) relationship baseline(n=261). quantitative experiences dentists. beans, and eggs between diet Niigata City, FFQ during a Root caries incidence: 2. Milk and Milk intake and Japan. face to face A lesion detected on products. dental caries and interview by an exposed root 3. dark green and yellow periodontal dietitians. surfaces, that was not vegetables

Decay and nutrition

disease in decayed or filled at 4. Other vegetables and elderly Japanese baseline. fruit. subjects 5. Cereals, nuts and seeds, sugar and sweetener, confectioneries 6. fats and oils.

Marshall et Oral health, Adults Aged 65 Three-day Conducted by four Nutrients: Coronal Caries: al., (2002) nutrient intake years and older food and trained calibrated Energy (kJ) Mean calcium intake: P=0.03 (97) and dietary (n=220). Iowa, beverage examiners. Protein (g) ⬆ quality in the United States record forms, Count of coronal and Thiamin (mg) very old assessed by root lesions Riboflavin (mg) Root Caries: dietitians for Niacin (mg) Inadequate Zinc intake: P=0.02 completeness. Folate (mg) ⬆ Pantothenic Acid (mg) Vitamin B6 (mg) Vitamin B12 (mg) Vitamin C (mg) Vitamin A (mg) Vitamin E (mg) Calcium (mg) Copper (mg) Iron (mg) Magnesium (mg) Phosphorus (mg) Selenium (mg) Zinc (mg)

Decay and nutrition

Nutrients were looked at as mean daily intakes and compared to the DRI.

CI, Confidence Interval. DASH, Dietary Approaches to Stop Hypertension. *P<0.05, Linear trend **P<0.05, Quartile 1 vs Quartile 4 1178

Frailty, nutrition, and oral health

1179 1.5 Frailty, nutrition, and oral health

1180 As the world ages, interest in the frailty status of older adults and how it impacts health

1181 increases. Frailty is thought to contribute to adverse health outcomes, including

1182 increased risk of disability, falls, institutionalisation and death (121-123). A variety of

1183 factors are thought to contribute to frailty syndrome (123, 124). In the Cardiovascular

1184 Health Study (CHS study) frailty is characterized by muscle weakness, sarcopenia,

1185 weight loss and exhaustion. Alternatively, other measures of frailty have looked at

1186 fitness, functional independence cognition, depression, and social support (125-127).

1187

1188 One important component of frailty is nutritional status (123, 128, 129). Numerous

1189 studies have a found a relationship between malnutrition and frailty status (123, 128,

1190 129). One cross-sectional study found that frail Taiwanese community dwelling older

1191 adults were at greater risk of malnourishment (130). However more studies have

1192 focused on how nutritional status and nutrition impacts frailty status (123). A cross-

1193 sectional study on older community dwelling adults in Singapore found participants,

1194 screened by the Mini-Nutrition Assessment (MNA), at risk of malnutrition or

1195 malnourished were significantly more likely to be prefrail or frail, compared to those

1196 with normal nutrition (129). A longitudinal study found that community dwelling older

1197 women with an energy intake below recommendations (25 to 30 kcal per kg) had higher

1198 risk of frailty and mortality (123, 131).

1199

1200 Multiple studies have found that high protein intakes are associated with lower

1201 prevalence of frailty in older populations (132-135). Bartali et al. found that a low

1202 intake of protein, measured as the lowest sex-specific quintile of protein intake, was

1203 significantly related with meeting frailty criteria in adults aged 65 years and older (133).

Frailty, nutrition, and oral health

1204 Meeting frailty criteria was also significantly related to low intake of vitamin D, E, C

1205 and folate in the same study (133). A recent systematic review found that there was an

1206 association between the quantity (energy intake) and quality (nutrient quality) of

1207 nutrition with the frailty syndrome (132). Across multiple studies included in the

1208 review, the authors found community dwelling older adults with the highest quality diet

1209 score had decreased risk of frailty, compared to those with the lowest diet quality scores

1210 (132). Increased diet quality, as categorised by the Diet Quality Index- International

1211 (DQI-I), was associated with reduced risk of frailty in community dwelling Chinese

1212 older adults (136). Bollwein et al. found that the highest quartile of diet quality,

1213 measured by the Mediterranean diet score, was significantly associated with a

1214 decreased chance of frailty, compared to the lowest quartile of diet quality (137).

1215

1216 Another possible determinant of frailty is oral health. In adults aged 60 years and older,

1217 those who needed dentures were found to be at higher risk of being pre-frail or frail

1218 (138). In the same population presence of 20 or more natural teeth was associated with

1219 lower risk of frailty, than being edentulous (138). Another study illustrated that

1220 participants with poor self-rated oral health and poor use of dental health services had

1221 higher probability of frailty (124). Yet the same study found no relationship between

1222 frailty and other oral health measures, including numbers of teeth and periodontal

1223 disease (124).

1224

1225 A study among community dwelling older adults found that oral pain and impaired

1226 masticatory ability were associated with the Fried’s frailty phenotype, and its

1227 components (139). Numbers of teeth were found to be a risk factor for weight loss, but

1228 no association was found with exhaustion in community dwelling older adults (140).

Frailty, nutrition, and oral health

1229 Higher numbers of teeth were associated with greater hand grip strength in older men,

1230 but not women (141). Yet change in handgrip strength over a five-year follow up was

1231 not associated with numbers of teeth at baseline in either men or women (141). The

1232 same study also found that a decline in handgrip strength over a five-year follow up

1233 was two-fold higher in older adults with periodontitis, than in those with no

1234 periodontitis (141). Tooth loss was also found to be associated with a decline in walking

1235 speed (142). Analyses of the association between frailty and oral health of older

1236 Australian men was explored in the CHAMP study (143). This study found that frail

1237 CHAMP participants were more likely to have active coronal decay, compared to

1238 robust participants (143). No relationship between numbers of teeth or periodontal

1239 disease was found with frailty status after adjustment for confounders (143).

1240

1241 However very little has been done to explore how frailty status impacts the relationship

1242 between nutrition and oral health, particularly in older adults. One study did provide a

1243 four element model to explain the relationship between oral health status and use of

1244 dental services with frailty (124). Within this model tooth loss and chewing problems

1245 could theoretically lead to change in food selection, low nutrient intake, which could

1246 contribute to weakness, slowness, low physical activity, fatigue and weight loss, all

1247 factors that could result in frailty (124). Frailty may then lead to the development of

1248 dependence and disability, which impact how older adults utilize dental health services

1249 (124). This study looked at the relationship between frailty and oral health conditions,

1250 as well as the utilization of dental health services, however diet was not included in the

1251 analysis (124).

1252

100

Frailty, nutrition, and oral health

1253 Considering the important relationship frailty has with both diet and oral health, it is

1254 possible that frailty acts as an effect modifier of the relationship between diet and oral

1255 health. No studies have looked at frailty’s role in the association between nutrient intake

1256 and oral health. The aim of Chapter 7 of this thesis was to assess how frailty status

1257 impacts the relationship between diet quality, overall micronutrient, and macronutrient

1258 intake with oral health.

101

Thesis objectives Frailty and other health 1259outcomes - Frailty syndrome: weakness, sarcopenia, weight loss, exhaustion, increased inflammation - BMI outside recommended range - Poor Cognition - Depression/anxiety - Alcohol intake Socio-economic, - Tobacco consumption demographic outcomes - Reduced Physical activity Poor diet and - Country of Birth - Comorbidities > 1 - Low Income inadequate nutrition - Housing - Marital status - Living alone - Poor oral hygiene habits Deterioration of Oral - Reduced use of oral health Dentition: services Health - Tooth Loss - Unable to shop for groceries - Prosthesis without help - Unable to prepare meals

Periodontitis Coronal Caries Root Caries

Figure 1.2: Nutrition and Oral health theoretical framework (Source: Castrejón-Pérez et al. BMC Public Health 2012;773:1-12)

102

Thesis objectives

1260 1.6 Thesis Objectives

1261 The aim of this thesis is to explore the interrelationship between diet and oral health in

1262 community dwelling older men. Figure 1 provides a theoretical framework which will

1263 be explored throughout this thesis. The framework, based on Castrejón-Pérez et al. four

1264 element model, theorises that poor dentition in the form of tooth loss and prosthesis

1265 leads to poor diet and inadequate nutrition (124). This dietary outcome then results in

1266 deterioration of oral health in the form of periodontitis and caries, possibly via poor

1267 inflammation and increased acidity and bacteria. The framework also considers how

1268 health, demographic and socio-economic variables may impact upon the relationship

1269 between diet and oral health.

1270 The specific objectives are:

1271 1. Examine the associations between composition of FTUs with nutrient intakes, and

1272 overall diet quality in community-dwelling older men. Chapter 4 examines how the

1273 composition, and numbers, of FTUs impacts on the dietary intake of macronutrients

1274 and micronutrients.

1275 2. Examine the association between nutrient intake and diet quality with periodontal

1276 health in older men. Chapter 5 examines how dietary intake of macronutrients and

1277 micronutrients, and over all diet, impacts the prevalence of periodontitis.

1278 3. Analyze the association between dietary intake of nutrients, and overall diet quality,

1279 and the presence of dental decay in community dwelling older men. Chapter 6 examines

1280 how dietary intake of macronutrients and micronutrients and overall diet, impacts the

1281 prevalence of tooth decay.

1282 4. Assess how different levels of frailty status affects the relationship between nutrient

1283 intake and oral health.

103

1284

1285

1286

1287

1288

1289

1290

1291

1292

1293

1294

1295 CHAPTER 2. METHODS

1296

1297

1298

1299

1300

1301

1302

1303

1304

1305

1306

1307

104

Methods

1308 2.1 The Concord Health and Ageing Men Project

1309 Data for this thesis is based on The Concord Health and Ageing in Men Project

1310 (CHAMP) 4th wave of data collection, at the eight-year mark. At the time of the study’s

1311 conception many epidemiological studies on ageing focused on women’s health,

1312 despite men having higher mortality and shorter life expectancies (144). As such, to

1313 contribute more detail to older men’s health, CHAMP was established in 2005 as an

1314 ongoing longitudinal study to investigate the health of men aged 70 years and older

1315 (144). Participants were recruited and assessed at baseline between January 2005 and

1316 June 2007 (144). A 2nd wave of data collection was collected at a two-year follow up

1317 between January 2007 and October 2009, and 3rd wave at five years occurred between

1318 August 2010 and July 2013 (144). Finally, the 4th wave of data collection began in June

1319 2014 and finished in July 2016. At baseline and 2nd wave CHAMP focused on initially

1320 on older men’s health and geriatric syndrome, specifically frailty, functional

1321 dependence, dementia, falls, bone structure, and urinary problems. At the 3rd wave

1322 nutrition data collected as part of a comprehensive diet history was added and continued

1323 in the 4th wave of follow up. An oral health examination was also added at the 4th wave

1324 of data collection.

1325

1326 2.1.1 Participant recruitment

1327 All the names and addresses of men aged 70 years and older inhabiting the three

1328 adjacent Local Government areas Burwood, Canada Bay and Strathfield in the inner

1329 West region of Sydney, were selected from the NSW electoral roll (144). The only

1330 exclusion criterion was anyone living in an aged care facility at time of recruitment

1331 (144). Invitation letters describing the study were sent out, via mail, to 3627 men. Those

1332 with a listed telephone number were called about one week later. Men who did not

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Methods

1333 respond to the first letter were sent, and who had no listed telephone number, were sent

1334 a second invitation letter (144).

1335

1336 Of the 3627 men who were sent invitations contact was made with 3005 (144). The

1337 majority of the 622 men, with whom contact was note made, did not have a listed

1338 telephone number. Of the contacted men, 190 were not eligible for the study because

1339 they had moved outside the study area, into a nursing home or had died. This left 2815

1340 eligible for participation, of whom, 1511 ultimately participated in the study (54%)

1341 (144). Another 194 men, aged 70 years or older and living within the designated study

1342 area, volunteered to be in the study independently of the invitation letter, having learnt

1343 about the study via friends or in reports by local newspapers (144).

1344

1345 Overall, 1705 men participated in the CHAMP study, yielding a 47% participation rate

1346 (1511+194/3627-190+194) (144). The baseline recruitment process is summarized in

1347 Figure 2.1. Other large epidemiological studies involving older male participants and a

1348 clinic visit, such as the Australian Longitudinal Study of Ageing (response rate = 55%)

1349 and the Dubbo Osteoporosis Epidemiological Study (response rate = 46%), have a

1350 comparable participation rate (144-146).

1351

1352 Repetition of baseline assessments occurred at two-years (2nd wave), five-years (3rd

1353 wave) and eight-years (4th wave), with the introduction of nutrition at the 3rd wave of

1354 data collection and the introduction of oral health at the 4th wave of data collection.

1355 Eighty percent of baseline (n = 1366) completed the 2nd wave, 56% (n = 954) completed

1356 3rd wave and 46% (n= 781) completed the 4th wave. The final sample (n= 608) consisted

106

Methods

1357 3627 men identified on electoral 1358 roll and sent an invitation letter 1359 622 unable to be 1360 contacted

1361

1362 3005 men were contacted 1363

1364

1365 190 were ineligible

1366

1367 2815 men met eligibility criteria 1368

1369

1370 1304 refused to participate

1371

1372 1511 men agreed to participate 1373

1374 194 joined the study independent 1375 of the invitation letter

1376

1377 1705 men in total participated in 1378 the baseline assessment.

1379 Figure 2.1: Concord Health and Ageing Men Project baseline recruitment

1380 of participants who completed both the dietary assessment (n=718) and the oral health

1381 examination (n= 614).

1382 107

Methods

Table 2.1 Data collected at baseline, 2nd Wave, 3rd Wave and 4th Wave of data collection Information Method Baseline 2nd Wave 3rd Wave 4th Wave SCQ Physical Activity PASE (147)     Psychological Health CAGE (148), Geriatric Depression Scale (15-item) (149,     150), Goldberg Anxiety Scale (GDS) (151), IQCODE (152, 153), Neuropsychiatric inventory (NPI) (153). Social support Duke Social Support Index (11-item) (154, 155)     Urinary Symptoms IPSS, ICIQ (156, 157)     Oral health related Quality of OHIP     Life Others Oral health services, medical history musculoskeletal     pain, SF12 (158), reproductive and sexual history and social- demographic characteristics Clinical Assessment Anthropometry Height and weight, hip, waist and neck circumference     Balance Sway metre, 6m narrow walk     Bone DEXA (hip and spine BMD), lateral vertebral     morphometry, heel ultrasound Cardiovascular system Blood Pressure (lying, standing), heart rate     Cognitive function ACE (159), MMSE (160), Colour form, Sorting Text,     Trials B, Logical Memory Gait Walking speed (6-metre walk)     Muscle strength Grip strength, quad strength, repeated chair stands     Respiratory system FEV1     Sarcopenia DEXA (lean body mass)     Urinary Function Uroflow, post-void residual    

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Methods

Vision Acuity, contrast sensitivity,     Depth perception Other Medications, Chronic pain. Diet Assessment Diet History Diet History Questionnaire     Nutrition Assessment Appetite, food accessibility, special dietary requirements     Oral Health Examination Oral Pain Mouth Pain and discomfort.     Dental care Oral hygiene habits     Mouth Assessment Saliva pH, saliva flow, denture presence, denture quality,     numbers of teeth, numbers of FTUs. Periodontal Assessment Recession, probing depth, gingival index, plaque,     calculus. Dental Assessment coronal decay, root decay, tooth wear.     Blood tests Routine biochemistry and ALP, ALT, Albumin, bilirubin,     haemotology calcium, cholesterol (total and HDL), creatinine, electrolytes, glucose, insulin, phosphate, PSA, triglycerides, urea, full blood count (haemoglobin, leucocytes, platelets)

SCQ, Self-Completed Questionnaire. PASE, Physical Activity Scale for the Elderly. CAGE, Cut-down, Annoyed, Guilty, Eye-opener. GDS, Geriatric Depression Syndrome. IQCODE, Informant Questionnaire on Cognitive Decline in the Elderly. NPI, Neuropsychiatric inventory. IPSS, International Prostate Symptoms Score. ICIQ, International Consultation on Incontinence Questionnaire. OHIP, Oral Health Impact Profile. OHIP, Oral Health Impact Profile. SF12, Short Form-12. DEXA, Duel- Energy X-ray Absorption. BMD, Bone Mineral Density. ACE, Addenbrooke’s Cognitive Examination. MMSE, Mini-Mental State Examination. FEV1, Forced Expiratory Volume in 1 second. FTUs, Functional Tooth Units. ALP, Alkaline phosphatase. ALT, Alanine Aminotransferase. HDL, High Density Lipoproteins. PSA, Prostate-Specific Antigen. 1383

109

Methods

1384 2.2 Assessment procedure

1385 A diverse range of information was collected at baseline and at each wave of the

1386 CHAMP study, although not all information was collected at every time point. Table

1387 2.1 documents the data collected for each wave of CHAMP. At each wave information

1388 was collected through a self-completed questionnaire, clinical assessment, dietary

1389 assessment (3rd and 4th wave only) and oral examination (4th wave only). For this thesis

1390 data used was predominantly obtained during the 4th wave of follow up, and only the

1391 information used for this thesis is described in detail.

1392

1393 2.2.1 Self-completed questionnaire

1394 The self-completed questionnaire was completed at four CHAMP waves and took

1395 approximately 45 minutes to complete (Appendix E). It measured socio-demographic

1396 information, lifestyle, and health factors such as age, marital status, living

1397 arrangements, income, education, lifestyle, depression, morbidity, and physical

1398 activity.

1399

1400 Source of income was grouped as ‘Age Pension’, ‘Age Pension and Other’ or ‘Other’

1401 (superannuation or private income, own business/farm/partnership, wage or salary,

1402 repatriation pension, veterans pension, other, or any possible combination of these

1403 options). Country of birth was grouped as ‘Australia/New Zealand’, ‘Greece/Italy’,

1404 and ‘Other Countries’. Post school qualifications were classified as ‘Bachelor degree

1405 or higher’, ‘trade/apprenticeship’, ‘certificate/diploma’ and ‘Highschool or below’.

1406 Main occupation was grouped as ‘manager’, ‘professionals’, ‘para-professionals’,

1407 ‘tradesperson’, ‘salesperson/personal-service worker’, ‘clerk’, ‘plant and machine

1408 operator’, ‘labourer’, and ‘inadequately described’. based on the Australian and New

110

Methods

1409 Zealand Classification of Occupations (ANZSCO), first edition (161). Living

1410 arrangements were categorized at ‘Living alone’ or ‘Living with others’, and marital

1411 status were categorised as ‘Married/Partner De facto’, ‘Widowed’,

1412 ‘Divorced/Separated’ or ‘Never Married/Other’.

1413

1414 Instrumental activities of daily living, like preparing own meals or shopping for food,

1415 were measured using the Older American Resource Scales (162). Activities of Daily

1416 Living (ADL) were measured using a modified version of the Katz index ADL (163).

1417 Participants were dichotomized according to whether they could complete the activity

1418 without help (‘Yes’), versus with some help, or unable to complete the task (’No’).

1419

1420 Smoking status was grouped as ‘Smoker’, ‘Ex-smoker’ and ‘Non-Smoker’. The

1421 Physical Activity Scale for the Elderly (PASE) was used to assess the physical activity

1422 of older adults and dichotomized at the lowest tertile (≤ 74 vs ≥75). The 12-item Short

1423 Form Health Survey (SF-12) was used to measure health related quality of life, and

1424 provided data for self-rated health (158). Answers were dichotomised as

1425 ‘Excellent/good/fair’ and ‘Poor/very poor’.

1426

1427 Participants reported on medical conditions through the self-completed questionnaire.

1428 They were asked whether a doctor or a health care provider had told them that they had

1429 any of the following diseases: diabetes, thyroid dysfunction, osteoporosis, Paget’s

1430 disease, stroke, Parkinson’s disease, epilepsy, hypertension, heart attack, angina,

1431 congestive heart failure, intermittent claudication, chronic obstructive lung disease,

1432 liver disease, cancer (excluding non- melanoma skin cancers), osteoarthritis and gout.

1433 For the purposes of this study, comorbidity burden was defined as the presence of two

111

Methods

1434 or more of these conditions (164). The shortened (15-item) Geriatric Depression Scale

1435 (GDS) was used to measure depressive symptoms, and a cut off of five or more was

1436 used to define clinically depressive symptoms (149, 165).

1437

1438 Oral health related quality of life was assessed using a modified version of the General

1439 Oral Health Assessment Index (GOHAI) and the Oral Health Impact profile 14 (OHIP-

1440 14). Self-rated oral health (SROH) was also measured and dichotomized into

1441 ‘excellent/very good/good’ versus ‘fair/poor/don’t know’.

1442

1443 2.2.2 Clinic assessments

1444 In the fourth wave of CHAMP, all assessments were conducted at the participant’s

1445 home and took approximately an hour and a half to complete. As the diet history was

1446 also included during this clinic, trained dietitians conducted the interview using a

1447 standardized form. Information collected included anthropometric data, alcohol

1448 consumption, cognitive tests, functional and neuromuscular tests, and information on

1449 current medication intake (Appendix F).

1450

1451 Anthropometric data, height and weight, were measured using standardised digital

1452 scales and portable stadiometer and BMI was calculated as kg/m2 and categorised as

1453 ‘underweight’ (<22kg/cm2), ‘normal weight’ (22-<30kg/cm2) and ‘obese’ (≥30kg/cm2)

1454 (166, 167). Alcohol consumption in participants were categorized as ‘current non-

1455 drinkers’, ‘lifelong abstainers’ and ‘ex-drinkers’. For those who consumed at least 12

1456 drinks in the past year frequency and quantity of alcohol consumption was assessed.

1457 Drinkers were then categorised as either ‘safe drinkers’ (1–21 drinks per week) or

112

Methods

1458 ‘harmful drinkers’ (>21 drinks per week) (168). Grip strength was measured using a

1459 Jamar dynamometer, and walking speed was measured via 6-metre walking circuit.

1460

1461 2.2.3 Dietary assessment

1462 Diet histories were administered using a standardized and validated interview method

1463 (169, 170). A structured questionnaire with open-ended questions, adapted from the

1464 Sydney South West Area Health Service outpatient diet history form, was the tool used

1465 by interviewers to ask participants about their usual dietary intake during the last three

1466 months (Appendix G) (169). Food quantities were established by food models,

1467 photographs and household measures, such as measuring spoons (169, 171). A checklist

1468 was included to corroborate commonly consumed foods items which may have been

1469 forgotten. Relatives, carers and/or family members of CHAMP men were encouraged

1470 to be present in the interview, to aid in participants’ memory recall (169, 172). Validity

1471 of this method was established in a previous study in a sub-group of 56 CHAMP men,

1472 which compared the diet history to a 4 day weighed food record (169). We used the

1473 interquartile range to identify potential outliers of energy intake (173). Individual diet

1474 histories of potential outliers were examined and only one outlier was identified as

1475 having an unrealistic intake of food and excluded from the data set (173).

1476

1477 Dietary records were converted to nutrient intakes using FoodWorks 7 Professional for

1478 Windows (Xyris Software (Australia) Pty Ltd), which uses the Australian Food,

1479 Supplement and Nutrient Database 2007 (AUSNUT 2007) (28). This database has a

1480 maximum of 37 nutrient values available for each of 4425 foods (174). Vitamin D

1481 values from AUSNUT 2007 need to be interpreted with caution due to the small set of

1482 analyses from which the values were obtained and the assumption that were made

113

Methods

1483 (175). A coding manual developed during the nutrition collection at the 3rd wave of

1484 CHAMP data collection was updated and utilized at the fourth wave of data collection

1485 to define and standardize 1,650 food items to ensure consistent coding of diet histories

1486 (Appendix H).

1487

1488 Participants’ median daily dietary intakes of energy, carbohydrates, sugar, protein, total

1489 fats, polyunsaturated fatty acids (PUFA), dietary fibre, alcohol, sodium, potassium,

1490 iodine, iron, phosphorus, calcium, magnesium, zinc, dietary folate equivalents, thiamin,

1491 niacin, riboflavin and vitamins A, C, D & E were compared to the respective NRV

1492 recommendations for males aged 71 years and older (176). Vitamin B6 and Vitamin B12

1493 were not analysed as these values are not available in AUSNUT 2007. Only sodium

1494 available naturally in foods and added during processing food products was included in

1495 the analysis. Percentages of energy from carbohydrates, protein and fat were compared

1496 to the Acceptable Macronutrient Distribution Range (AMDR) and protein intake per

1497 kilogram of body weight was calculated (176). Daily energy intakes were also

1498 compared to participants’ Estimated Energy Requirements (EER) calculated using

1499 Basal Metabolic Rate (BMR) (with a Physical Activity Level of 1.6 for light activity)

1500 (176, 177).

1501

1502 2.2.4 Oral health examination

1503 The oral health examination took place during a separate home visit and was conducted

1504 by one of two trained oral health therapists using a standardized clinical protocol.

1505 During the oral health assessment participants were asked by interviewers about

1506 perceptions of pain, chewing ability and dental care, before continuing to a dental

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Methods

1507 examination. Decay experiences on both coronal and root tooth surfaces were recorded

1508 (Appendix I).

1509

1510 Individual teeth were categorized as according to National Survey of Adult Oral Health

1511 criteria (32). Categories include ‘present permanent tooth’, ‘implant’, ‘missing and

1512 replaced’, ‘missing and not replaced’, ‘root fragment decayed’ & ‘root fragment not

1513 decayed’ (32). Assessments also recorded whether the participant had partial or full

1514 maxillary and mandibular dentures, and if the dentures were likely to be defective –

1515 that is, non-retentive, not in occlusion, unstable or had any large defects.

1516

1517 FTUs were defined as opposing molars and premolars that were natural teeth or

1518 artificial (prosthetic teeth on implanted-supported dentures, fixed bridge pontics and/or

1519 removable dentures) (43, 178). FTUs were counted according to the Total number of

1520 FTUs (defined as natural and prosthetic replacement molars and premolars), and the

1521 number of Natural FTUs, (defined as opposing natural molar and premolars only) (43,

1522 178). In total there was a possible maximum score of 12 FTUs (43, 178). The four

1523 occluding pairs of molars (not including third molars) were given a score of two per

1524 pair, and the four occluding pairs of pre-molars, were given a score of one per pair (43,

1525 178). Assessments also recorded whether the participant had partial or full maxillary

1526 and mandibular dentures, and if the dentures were likely to be defective – that is, non-

1527 retentive, not in occlusion, unstable or had any large defects.

1528

1529 Prior to the periodontal examination, men were screened by a clinical protocol

1530 compromising, questions about cardiac health (43). Participants were excluded from a

1531 full periodontal assessment if they answered ‘yes’ to one or more of the 12 clinical

115

Methods

1532 protocol questions on cardiac health (32, 43). Periodontal examination was conducted

1533 with a standardised intra-oral mirror and light source (Intra-oral light. Mirrorlite IN-

1534 7003.Mydent International: Hauppauge, N.Y.), using a Hu Friedy PCP 2 periodontal

1535 probe (HuFriedy Manufacturing Co, Chicago, IL), with 2 mm markings (43).

1536 Periodontal measurements included recession, and Probing Depth (PD). Measurements

1537 were taken at three sites: mesio-buccal, mid-buccal, and distal buccal for each natural

1538 tooth present, except third and second molars.

1539

1540 Decay experiences on both coronal and root tooth surfaces were recorded, and coded

1541 as ‘sound’, ‘Decayed’, ‘Recurrent Caries’, ‘Filled – unsatisfactory’, ‘Filled – okay’,

1542 and ‘No visible root surface’.

1543

1544 Ethics approval and informed consent

1545 All participants gave written informed consent. The study was approved by the Sydney

1546 South West Area Health Service Human Research Ethics Committee, Concord

1547 Repatriation General Hospital, Sydney, Australia (HREC/14/CRGH/17 CH62/6/2014-

1548 013).

1549

1550 2.3 Statistical analysis

1551 A sample of 608 participants will give a 95% Confidence Interval (CI) of 51% to 59%

1552 around an expected prevalence of 55% with less than 21 natural teeth and 95% CI of

1553 28% to 38% around a prevalence of 30% edentulous. The presence of moderate to

1554 severe periodontitis is estimated to be around 61%, a sample size of n= 294 will

1555 estimate a prevalence with a 95% CI of 55% to 67%. Furthermore, root decay has an

1556 expected prevalence of 17% and coronal decay has an expected prevalence of 20%.

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Methods

1557 Therefore a prevalence of approximately 20% can be estimated with a 95% CI of 17%

1558 to 23% in sample size n= 520.

1559

1560 Data collected for the thesis were in hard copy, before being entered into Microsoft

1561 Office Access Database and exported into Microsoft Office Excel. Dietary data was

1562 entered into FoodWorks 7 before being exported into Microsoft Office Access Database

1563 and Excel. All data were then imported into SAS OnDemand for Academics (SAS

1564 Institute Inc.) for analysis. A p-value less than 0.05 was considered statistically

1565 significant, and the null hypothesis was rejected.

1566

1567 Various methods were used for statistical analyses and are listed below. The analyses

1568 are discussed in details in relevant chapters:

1569 - Chi-square analysis to investigate differences between categorical variables

1570 (CHAPTER 3).

1571 - Descriptive statistics, including mean, median, and standard deviation (SD),

1572 (CHAPTERS 3, 4, 5, 6 & 7).

1573 - Logistic Regression (CHAPTER 4, 5, 6 & 7).

1574 - Mann-Whitney U test to investigate difference between continuous skewed-

1575 distributed data (CHAPTER 3).

1576

117

1577

1578

1579

1580

1581

1582

1583

1584

1585

1586

1587

1588 CHAPTER 3. STUDY PARTICIPANTS

1589

1590

1591

1592

1593

1594

1595

1596

1597

1598

1599

1600

118

Study Participants

1601 3.1 Characteristics of the study population

1602 Flow chart 3.1 shows the population from baseline (n = 1705) to the current population

1603 that participated in the 4th wave of data collection (n = 781) and the final sample used

1604 in this analysis (n = 608). The main reasons for not completing the fourth wave of data

1605 collection include death (72%), health problems or age (10%), withdrawal from study

1606 (6%), and participants had moved away or were unable to be contacted (3%).

1607

1608 Table 3.1 shows demographic, socio-economic and lifestyle characteristics data of the

1609 CHAMP participant sample used in this thesis. Table 3.2 presents information on health

1610 status, and Table 3.3 presents information on food habits, food access and factors

1611 influencing dietary intake. Table 3.4 shows oral health characteristics.

1612

1613 The age range of participants was 78 – 99 years, with a mean age of 84 years (SD

1614 ±4.08). Most men were married (or in de facto relationship), living with others, own

1615 their own home, and have a post-school education. Over half were Australian born, and

1616 nearly a quarter of participants were born in either Italy or Greece. The majority of

1617 participants were ex-smokers, consumed safe amounts of alcohol (1 – 21 alcoholic

1618 beverages a week), and had a normal BMI (mean 27.9 kg/m2). Most participants had 2

1619 or more comorbidities (n = 398), however 73.6% reported good or excellent health

1620 (n=446). Over 50% of men (n = 377) reported good or very good appetite, and 14%

1621 reported issues affecting their access to food (n = 85). Thirty-nine percent of

1622 participants had 21 or more natural teeth (n = 238), and 14% had no natural teeth (n =

1623 88). Yet only 14% of men wore full dentures (n = 84). Over two-thirds of men brushed

1624 less than twice per day (n = 418), and 16% saw their dentist less than twice a year (n =

1625 99).

1626 119

Study Participants Baseline data collection n = 1705 1627 Did not complete 2nd wave data collection: n = 339 Deceased: n = 99 Unable to contact/moved/residential care: n = 52 Health problems/too old: n = 115 Other reasons: n = 73

2nd wave data collection n = 1366 Did not complete 3rd wave data collection: n = 751 Deceased: n = 382 Unable to contact/moved/residential care: n = 46 Health problems/too old: n = 186 Withdrawn: n = 46 Other reasons: n = 91

3rd wave data collection n = 954 Did not complete 4th wave data collection: n = 924 Deceased: n = 669 Unable to contact/moved: n = 31 Health problems/too old: n = 93 Withdrawn = 56 Other reasons: n = 75

4th wave data collection n = 781 (735 + 46 SCQ only)

Did not complete 4th wave Dietary Assessment: n = 63 SCQ Only: n = 46 Unable/NESB: n = 14 Refused/Other: n = 3

4th wave Dietary Assessment n = 718

4th wave Oral Health n = 614

Excluded due to dietary misreporting n=1

Dietary and Oral Health assessment final sample n = 608

Figure 3.1: Flow chart of sample size at baseline, 2nd wave, 3rd wave, and 4th wave of data collection, and reason for non-reporting at each follow-up. 120

Study Participants

Table 3.1 Demographic, lifestyle, and socio-economic characteristics of the sample population (n=608) Characteristic Nutrition/Oral health sample: n (%) Age (years) 78 – 79 89 (14.6) 80 – 84 285 (46.9) 85 – 89 172 (28.3) ≥ 90 62 (10.2) Mean (±SD) 83.9 (±4.08) Marital Status Married/De Facto 439 (72.4) Widowed 113 (18.7) Divorced/Separated 21 (3.5) Never Married/Other 33 (5.4) Living Arrangements Live Alone 138 (22.8) Lives with Others 468 (77.2) Birth Country Australia/New Zealand 321 (52.8) Italy/Greece 146 (24.0) Other 141 (23.2) Body Mass Index (BMI) ≤ 23.0 (kg/m2) 62 (10.3) 23.0 – <30.0 (kg/m2) 360 (60.0) ≥ 30.0 (kg/m2) 176 (29.7) Mean (±SD) 28.5 (± 13.4) Smoking Non-smoker 242 (39.9) Ex-smoker 346 (57.1) Current Smoker 18 (3.0) Housing Owns Home Outright 513 (84.9) Source of incomea Age Pension Only 247 (40.8) Age Pension + Other 136 (22.4) Other 223 (36.8) Occupational History Clerks 42 (7) Labourer 48 (8) Manager 80 (13) Paraprofessionals 21 (3) Plant and machine operator 47 (8) Professional 130 (21) Salesperson/personal service 23 (4) Tradesperson 154 (25) Inadequately stated/unknown 60 (10) Level of Education

121

Study Participants

Bachelor degree or higher 92 (15.3) Trade/Apprenticeship 144 (23.9) Certificate/Diploma 130 (21.6) High School or Below 236 (39.2) Alcohol Consumption Life-long abstainer 51 (8.4) Ex-drinker 94 (15.6) Safe Drinker (1 – 21 drinks/week) 418 (69.2) Unsafe Drinker (≥ 21 drinks/week) 41 (6.8) Meal preparation Needs help 44 (7.3) Grocery Shopping Needs help 29 (4.8) MOW Yes 27 (4.5) PASE ≤ 74 212 (35.0) Mean (±SD) 106.4 (± 63.6)

SD, Standard Deviation. PASE, Physical Activity Scale for the Elderly. MOW, Meals On Wheels. a. Superannuation or private income, own business/farm/partnership, wage or salary, repatriation pension, veterans’ pension, or other. 1628

1629 When compared to census data of Australian males within a similar age bracket (75

1630 years and older), CHAMP men had comparable demographic statistics, 21% of

1631 Australian males (over 75 years) lived alone, while approximately 23% of CHAMP

1632 men reported living alone (179). Furthermore 53% of Australian males (aged 75 years

1633 and older) were born in Australia, and comparatively 53% of CHAMP men were

1634 Australian born (179). Finally 36% of males, aged 75 years and older, in the census

1635 were non-smokers, while 40% of CHAMP men were non-smokers (180).

1636

1637 However compared to males within the study area (Burwood, Canada Bay and

1638 Strathfield) in the 2016 census our CHAMP men were older, with 38% of CHAMP

1639 men were aged 85 years and older, while only 29% of males in the study area were aged

1640 85 years and older (181). CHAMP men aged 78 – 79 years of age made up 15% of the

122

Study Participants

Table 3.2 Health status characteristics of the sample population (n=608) Health Status Measure Nutrition/Oral health sample: n (%) Comorbidities: Diabetes 134 (22.2) Thyroid Issues 35 (5.8) Osteoporosis 86 (14.2) Paget’s Disease 10 (1.7) Stroke 55 (9.1) Parkinson’s Disease 22 (3.6) Kidney Stone 65 (10.7) Dementia 31 (5.1) Depression 41 (6.7) Epilepsy 6 (1.0) Hypertension 336 (55.5) Heart Attack 124 (20.5) Angina 72 (11.9) Congestive Heart Disease 39 (6.4) Claudication 58 (9.6) Chronic Obstructive Lung Disease 82 (13.5) Liver disease 10 (1.7) Chronic Kidney Disease 39 (6.5) Osteoarthritis or Gout 229 (37.7) Cancer 36 (5.9) Comorbidity ≥ 2 398 (65.6) ≤ 1 209 (34.3) Cognitive Decline <26 111 (21.0) Mean score (±SD) 27.2 (±3.1) GDS Score >5 108 (18.0) Self-Rated Health Good/Excellent 446 (73.6) Fair/Poor/Very Poor 160 (26.4)

GDS, Geriatric Depression Score. SD, Standard Deviation. 1641

1642 study sample compared to 22% of males in the study area (181). The percentage of

1643 males aged between 80 – 84 years were similar in the CHAMP study (47%) and the

1644 census area (41%) (181).

1645

1646 Energy and nutrient intakes from the last National Nutrition Survey by the Australian

1647 Health Survey were comparable to our sample of CHAMP participants, despite the

123

Study Participants

1648 difference in methodologies (182). Furthermore, the percentage of males over the age

1649 of 75 with less than 21 natural teeth was similar in the NSAOH (56%), compared to

1650 CHAMP (61%) (32, 43). However, our sample population (15%) had lower edentulous

1651 rates compared to the NSAOH (31%) (32, 43).

1652

Table 3.3 Food access characteristics of the sample population (n=608) Food Access Factors Nutrition/Oral health sample: n (%) Special food requirements Yes 63 (10) Changed diet due to Chewing problems 19 (3) Swallowing problems 18 (13) Nausea 4 (1) Heart Burn 36 (6) Appetite Very Poor 6 (1) Poor 36 (6) Average 188 (31) Good 259 (43) Very Good 118 (19) Issues affecting food access Difficulty getting to/from shops 11 (2) Difficulty carrying groceries 38 (6) Difficulty with cost of groceries 36 (6)

1653

1654 3.2 Respondents versus non-respondents

1655 Of the 735 men who completed the main CHAMP assessment 718 (91% of the 4th wave

1656 sample) completed the dietary assessment and 614 completed the oral health assessment

1657 (79% of the 4th wave sample). The main reason for not completing the dietary

1658 assessment was cognitive decline (59%).

1659

1660 Participants who completed both the dietary assessment and oral health examination

1661 (n= 608) were younger, less likely to be underweight, more likely to be living alone,

124

Study Participants

Table 3.4 Oral health characteristics of the sample population (n=608) Oral Health Characteristic Nutrition/Oral health sample: n (%) Self-Rated Oral Health Good/Very Good/Excellent 426 (70.3) Fair/Poor/Don’t Know 180 (29.7) Mouth dryness Yes 73 (12) Dentist visits Less than once every two years 99 (16) Brushes teeth Less than twice a day 410 (67) Numbers of Natural Teeth ≥21 238 (39) 11 – 20 179 (29) 1 – 10 103 (17) 0 88 (14) Mean 15.59 (±7.9) Dentures Full Dentures 84 (14) Partial Denture 267 (44) No Dentures 257 (42)

1662

1663 more physically active (as per PASE), and more likely to rate their health as ‘Good’ or

1664 ‘Excellent’ than those who did not complete either the oral health examination or

1665 dietary assessment (n= 173) (Table 3.5).

1666

1667 Baseline data was used to compare characteristics of living CHAMP men who did not

1668 participate in any assessments or examinations in the 4th wave of data collection (n=

1669 202) and those who completed both the dietary assessment and oral health examination

1670 (n= 608) (Table 3.6). Participants who completed both components of the 4th wave of

1671 CHAMP were younger, had higher activity levels (as per PASE), less likely to have

1672 the Aged Pension as their only source of income, more likely to be Australian born and

1673 have post-school qualifications, and more likely to rate their health as ‘Good’ or

1674 ‘Excellent’.

125

Study Participants

1675

Table 3.5 CHAMP Nutrition assessment and oral health examination respondents (n=608) vs non-respondents (n=173) Characteristic Nutrition/Oral Health assessment P-Value Respondents Non-Respondents n=608 n=173 Age (years) 75 – 79, % (n) 15 (89) 8 (14) 0.01* 80 – 84, % (n) 47 (285) 43 (74) 85 – 89, % (n) 28 (172) 32 (56) ≥90, % (n) 10 (62) 17 (29) Mean, (range) 83.9 (78 – 99) 85.0 (79 – 100) 0.002* Body Mass Index (kg/m2) Underweight (<23.0 kg/m2) 10 (62) 6 (7) 0.03* Normal weight (≥23.0 - <30.0 60 (360) 73 (80) kg/m2) Overweight/Obese (≥30.0 29 (176) 20 (23) kg/m2) Mean, (range) 27.9 (16 – 46) 27.5 (19 – 41) 0.42 Marital Status Married/De Facto, % (n) 72 (439) 76 (124) 0.15 Widowed, % (n) 19 (113) 16 (26) Divorced/Separated, % (n) 3 (21) 6 (10) Never Married, % (n) 5 (33) 2 (4) Living Arrangements Live alone, % (n) 23 (138) 14 (23) 0.01* Other, % (n) 77 (468) 86 (141) Incomea Aged Pension, % (n) 41 (247) 49 (81) 0.11 Aged Pension + Other, % (n) 22 (136) 17 (28) Other, % (n) 37 (223) 34 (55) Country of Birth, (781) Australian/NZ, % (n) 53 (321) 46 (79) 0.16 Italy/Greece, % (n) 24 (146) 31 (53) Other, % (n) 23 (141) 24 (41) Smoking Smoker, % (n) 3 (18) 2 (4) 0.69 Ex-smoker, % (n) 57 (346) 54 (88) Non-smoker, % (n) 40 (242) 44 (71) SRH Good/Excellent, % (n) 74 (446) 66 (107) 0.04* Fair/Poor/Very Poor, % (n) 26 (160) 34 (56) Post school qualifications Yes, % (n) 61 (368) 57 (98) 0.39 No, % (n) 39 (236) 43 (73) Multi-Morbidity,

126

Study Participants

<2, % (n) 34 (204) 28 (46) 0.17 ≥2, % (n) 66 (403) 72 (94) PASE Mean, (range) 106.4 (0 – 405) 91.7 (0 – 204) 0.02*

PASE, Physical Activity Scale a. Superannuation or private income, own business/farm/partnership, wage or salary, repatriation pension, veterans pension, or other. *P<0.05 1676

1677 Overall, participants that completed both the dietary assessment and oral health

1678 examination were younger, more active and reported better health than those who did

1679 not complete those assessments but participated in the 4th wave of data collection. Those

1680 who did not participate at all in the 4th wave of data collection at all were older, less

1681 active, had a lower income, less likely to be Australian or New Zealand born, lower

1682 level of education and reported poorer overall health. While the CHAMP participants

1683 had similar nutritional intakes, countries of birth, smoking and living status to the

1684 census population, our sample of CHAMP men who completed both the dietary

1685 assessment and oral health examination were older and had lower rates of edentulism.

127

Study Participants

Table 3.6 CHAMP Nutrition assessment and oral health examination respondents (n=608) vs 4th Wave non-respondents (n=202) Characteristic Nutrition/Oral Health assessment P-Value Respondents 4th wave Non- n=608 Respondents n=202 Age (years), 70 – 74, % (n) 55 (333) 46 (93) 0.0002* 75 – 79, % (n) 33 (198) 29 (58) 80 – 84, % (n) 11 (64) 19 (39) ≥85, % (n) 2 (13) 6 (13) Mean, (range) 74.6 (70 – 89) 76.2 (70 – 88) <0.0001* Body Mass Index (kg/m2) Underweight (<23.0 kg/m2) 9 (52) 7 (14) <0.75 Normal weight (≥23.0 - <30.0 62 (374) 62 (125) kg/m2) Overweight/Obese (≥30.0 30 (179) 31 (62) kg/m2) Mean, (range) 28.1 (17 – 43) 28.5 (20 – 42) 0.182 Marital Status, Married/De Factor, % (n) 81 (493) 79 (159) 0.37 Widowed, % (n) 10 (62) 11 (23) Divorced/Separated, % (n) 3 (21) 6 (12) Never Married, % (n) 5 (32) 4 (8) Living Arrangements, Live alone, % (n) 16 (92) 20 (39) 0.15 Other, % (n) 85 (514) 81 (161) Incomea, Aged Pension, % (n) 34 (205) 45 (89) 0.02* Aged Pension + Other, % (n) 17 (102) 13 (25) Other, % (n) 49 (300) 43 (85) Country of Birth, Australian/NZ, % (n) 53 (321) 35 (71) <0.0001* Italy/Greece, % (n) 24 (146) 31 (62) Other, % (n) 23 (141) 34 (69) Smoking Smoker, % (n) 3 (34) 5 (10) 0.907 Ex-smoker, % (n) 57 (329) 56 (110) Non-smoker, % (n) 40 (241) 39 (76) SRH Good/Excellent, % (n) 78 (472) 68 (134) 0.0052* Fair/Poor/Very Poor, % (n) 22 (134) 32 (63) Post school qualifications Yes, % (n) 61 (368) 45 (90) 0.0001* No, % (n) 39 (236) 56 (109) Multi-Morbidity,

128

Study Participants

<2, % (n) 37 (225) 34 (68) 0.44 ≥2, % (n) 63 (380) 66 (181) PASE Mean, (range) 140 (0 – 379) 131 (8 – 312) 0.04*

PASE, Physical Activity Scale a. Superannuation or private income, own business/farm/partnership, wage or salary, repatriation pension, veterans pension, or other. *P<0.05 1686

129

1687

1688

1689

1690

1691

1692

1693

1694

1695 CHAPTER 4. ASSOCIATIONS BETWEEN THE COMPOSITION OF

1696 FUNCTIONAL TOOTH UNITS AND NUTRIENT INTAKE IN OLDER MEN:

1697 THE CONCORD HEALTH AND AGEING IN MEN PROJECT

1698 (As submitted to the journal Public Health Nutrition, 28.10.2020, under peer review)

1699 Authors: Kate Milledge, Robert G Cumming, Frederick A.C. Wright, Vasi Naganathan,

1700 Fiona M Blyth, David G Le Couteur , Louise M Waite, David J Handelsman, Vasant

1701 Hirani.

1702

1703

1704

1705

1706

1707

130

Composition of FTUs and nutrition in older men

1708 4.1 Abstract

1709 Objective: Inadequate nutrient intakes have been linked with poor dentition in older

1710 adults. The aim of this study was to investigate the associations between composition

1711 of Functional Tooth Units (FTUs) and nutrient intakes in older men.

1712 Design: A cross-sectional study with a standardized validated diet history assessment

1713 and comprehensive oral health assessments. FTUs were categorised by dentition type;

1714 (i) Group A (Natural FTUs Only) (ii) Group B (Natural and Replaced FTUs) and (iii)

1715 Group C (No Natural FTUs). Attainment of Nutrient Reference Values (NRVs) for 16

1716 micronutrients was incorporated into a Micronutrient Risk variable, dichotomised

1717 'good' (≥12) or 'poor' (≤11), and for 7 macronutrients into a Macronutrient Risk

1718 variable, dichotomised 'good' (≥5) or 'poor' (≤4).

1719 Setting: Subjects selected from the local Sydney geographical areas.

1720 Participants: Community dwelling older men (n=608).

1721 Results: 32% (n=197) of participants were categorized as Group A, 27% (n=167) as

1722 Group B and 40% (n=244) as Group C. In adjusted logistic regression analysis being

1723 in Group C, compared to Group A, was associated with intakes below NRV

1724 recommendations for fibre (OR:2.30, 95%CI 1.30 - 4.05), and magnesium (OR:1.75,

1725 95%CI 1.03 – 2.99). Adjusted analysis also showed that men in Group C, compared to

1726 Group A, were more likely to have poor intake of macronutrients (OR:2.00, 95%CI

1727 1.01 – 3.94).

1728 Conclusions: Our study shows statistically significant associations between

1729 composition of FTUs and poor macronutrient intakes. Maintaining natural pairs of

1730 occluding FTUs may be important for attaining adequate nutrient intakes in older men.

1731

1732

131

Composition of FTUs and nutrition in older men

1733 4.2 Introduction

1734 Poor nutrition is a common problem among older adults with up to 40% of older people

1735 living in the Australian community estimated to be malnourished or at risk of

1736 malnutrition (24). Malnutrition risk and nutritional inadequacy in older adults are

1737 associated with a variety of factors including country of birth, socioeconomic status,

1738 health status, and oral health (28, 59, 183-185).

1739

1740 Oral health problems, such as loss of natural teeth, result in compromised dentition

1741 (186). This can lead to older adults avoiding foods that are harder, stringier and more

1742 difficult to chew, instead opting for softer and nutritionally poorer food choices (30,

1743 65). It has also been shown that tooth loss is associated with poor consumption of foods

1744 like meat, nuts, dairy products, fruit and vegetables and suboptimal intakes of a range

1745 of micronutrients (29, 52, 59, 65).

1746

1747 Prosthetic teeth are regularly used to replace missing teeth; however, there is evidence

1748 that prostheses, especially those that are poor fitting, are not functionally equivalent to

1749 natural teeth (52, 187). Compared with intact natural teeth, people wearing partial or

1750 full prostheses have poorer consumption of fruit and vegetables, higher risk of

1751 malnutrition, and are less likely to meet recommended nutrient intakes (52, 99, 188).

1752 Ervin et al. showed that, among older men with incomplete dentition (1-20 teeth), those

1753 with a mixture of natural and replaced teeth had lower intakes of vitamin C than those

1754 with only natural teeth (81).

1755

1756 More recently, research has focused on the association between dietary intakes and

1757 posterior Functional Tooth Units (FTUs) in adults aged 60 years and older (79, 84, 185).

132

Composition of FTUs and nutrition in older men

1758 Due to their location and function, the loss of occluding pairs of molars and premolars

1759 is closely related to declines in masticatory ability (30, 189). In particular, low numbers

1760 of, or no FTUs, have been associated with poor intakes of energy, protein, carbohydrate,

1761 fibre, calcium, iron, vitamin C, vitamin A, riboflavin, zinc and folate (79, 84, 185, 189).

1762 Sahyoun et al. found those with full dentures had significantly lower Healthy Eating

1763 Index scores than those with five or more posterior pairs of teeth (63). Another study

1764 found that older female adults with normal mini-nutritional assessment (MNA) status

1765 had higher numbers of functional tooth units (defined as posterior occluding pairs of

1766 teeth) of natural tooth against natural tooth compared with participants who were

1767 underweight (190).

1768

1769 While there has been a substantial body of research looking at the association between

1770 numbers of FTUs and diet (63, 79, 185, 189, 190), research into the association between

1771 the composition of teeth that make up FTUs, independent of FTU numbers, and dietary

1772 intake of nutrients is limited. Therefore, the aim of this study was to examine the

1773 associations between composition of FTUs and nutrient intakes in community-dwelling

1774 older Australian men.

1775

1776

1777 4.3 Methods

1778 Study population

1779 The Concord Health and Ageing in Men Project (CHAMP) is an ongoing longitudinal

1780 study, established in 2005, to investigate the health of men aged 70 years and older

1781 (144). Recruitment of subjects for the CHAMP study is described in detail elsewhere

1782 (144). Briefly, the subjects were selected from the NSW electoral roll for the

133

Composition of FTUs and nutrition in older men

1783 geographical areas of Burwood, Canada Bay and Strathfield in Sydney (144). The only

1784 exclusion criterion was living in an aged care facility at time of recruitment (144).

1785 Eligible men were sent a letter and, if they had a listed telephone number, were

1786 telephoned about one week later. Of the 2,815 eligible men with whom contact was

1787 made, 1,511 participated in the study (54%). An additional 194 eligible men living in

1788 the study area heard about the study from friends or the local media and were recruited

1789 after contacting the study investigators prior to being identified through the electoral

1790 roll, yielding a total of 1,705 subjects. Participants completed a self-administered

1791 questionnaire and attended a clinic at Concord Hospital that included an interview and

1792 clinical assessment at baseline, 2nd wave (2-year) and 3rd wave (5-year) of data

1793 collection. Collection of nutritional data, via a home visit was added at the 3rd wave.

1794 For the fourth wave of data collection (8-year follow up) men were seen predominantly

1795 in their homes. In addition to the self –completed questionnaire and some of the clinic

1796 assessments collected in previous waves, an oral health questionnaire and examination

1797 was conducted along with a diet history interview. The 4th wave of data collection

1798 occurred between August 2014 and July 2016.

1799

1800 Data collection

1801 For this study the 4th wave of CHAMP data collection was used. Data collection

1802 involved two home visits. The first, which collected general health and dietary

1803 information, was conducted by one of three trained dietitians. The second visit, which

1804 included the oral health assessment, was conducted by one of two trained oral health

1805 therapists using a standardized clinical protocol. A self-completed questionnaire

1806 (SCQ), collecting sociodemographic, economic and health information, was sent to the

1807 participant’s home prior to the first visit. Of the original 1,705 participants, 781

134

Composition of FTUs and nutrition in older men

1808 participated in the 4th wave of data collection. The main reasons for nonparticipation

1809 were death (72.4%) or illness/age (10.1%). Forty-six participants completed the self-

1810 administered questionnaire only, 735 completed the general health assessment, 718

1811 completed the dietary assessment and 614 participants completed the dental

1812 examination. The men who participated in the oral health component were significantly

1813 younger and less likely to live alone than those who did not complete the oral health

1814 assessment. However, they did not differ significantly in income, marital status, post

1815 school qualifications, country of birth, multi-morbidity, and smoking status (data not

1816 shown).

1817

1818 Measurements

1819 Oral health data collection

1820 Participants were asked by interviewers about perceptions of pain, chewing ability and

1821 dental care. During the oral health examination individual teeth were categorized as

1822 ‘present permanent tooth’, ‘implant’, ‘missing and replaced’, ‘missing and not

1823 replaced’, ‘root fragment decayed’ & ‘root fragment not decayed’. FTUs were defined

1824 as opposing molars and premolars that were natural teeth or artificial (prosthetic teeth

1825 on implanted-supported dentures, fixed bridge pontics and/or removable dentures) (43,

1826 178). FTUs were counted according to the Total number of FTUs (defined as natural

1827 and prosthetic replacement molars and premolars), and the number of Natural FTUs,

1828 (defined as opposing natural molar and premolars only) (43, 178). In total there was a

1829 possible maximum score of 12 FTUs (43, 178). The four occluding pairs of molars (not

1830 including third molars), were given a score of two per pair, and the four occluding pairs

1831 of pre-molars, were given a score of one per pair (43, 178). Assessments also recorded

1832 whether the participant had partial or full maxillary and mandibular dentures, and if the

135

Composition of FTUs and nutrition in older men

1833 dentures were likely to be defective – that is, non-retentive, not in occlusion, unstable

1834 or had any large defects.

1835

1836 Dietary assessment

1837 Diet histories were administered using a standardized and validated interview method

1838 (169, 170). A structured questionnaire with open-ended questions, adapted from the

1839 Sydney South West Area Health Service outpatient diet history form, was the tool used

1840 by interviewers to ask participants about their usual dietary intake during the last three

1841 months (169). Food quantities were established by food models, photographs and

1842 household measures, such as measuring spoons (169, 171). A checklist was included to

1843 corroborate commonly consumed foods items which may have been forgotten.

1844 Relatives, carers and/or family members of CHAMP men were encouraged to be

1845 present in the interview, to aid in participants’ memory recall (169, 172). Validity of

1846 this method was established in a previous study in a sub-group of 56 CHAMP men,

1847 which compared the diet history to a 4 day weighed food record (169). We used the

1848 interquartile range to identify potential outliers of energy intake (173). Individual diet

1849 histories of potential outliers were examined and only one outlier was identified as

1850 having an unrealistic intake of food and excluded from the data set (173).

1851

1852 Data handling

1853 Dietary records were converted to nutrient intakes using FoodWorks 7 Professional for

1854 Windows (Xyris Software (Australia) Pty Ltd), which uses the Australian Food,

1855 Supplement and Nutrient Database 2007 (AUSNUT 2007) (28). This database has a

1856 maximum of 37 nutrient values available for each of 4425 foods (174). Vitamin D

1857 values from AUSNUT 2007 need to be interpreted with caution due to the small set of

136

Composition of FTUs and nutrition in older men

1858 analyses from which the values were obtained and the assumption that were made

1859 (175). A coding manual developed during the nutrition collection at the 3rd wave of

1860 CHAMP data collection was updated and utilized at the 4th wave to define and

1861 standardize 1,650 food items to ensure consistent coding of diet histories.

1862

1863 Dietary intake of nutrients

1864 Participants’ median daily dietary intakes of energy, carbohydrates, sugar, protein, total

1865 fats, polyunsaturated fatty acids (PUFA), dietary fibre, alcohol, sodium, potassium,

1866 iodine, iron, phosphorus, calcium, magnesium, zinc, dietary folate equivalents, thiamin,

1867 niacin, riboflavin and vitamins A, C, D & E were compared to the respective NRV

1868 recommendations for males aged 71 years and older (176). Vitamin B6 and Vitamin B12

1869 were not analysed as these values are not available in AUSNUT 2007. Only sodium

1870 available naturally in foods and added during processing food products was included in

1871 the analysis. Percentages of energy from carbohydrates, protein and fat were compared

1872 to the Acceptable Macronutrient Distribution Range (AMDR) and protein intake per

1873 kilogram of body weight was calculated (176). Daily energy intakes were also

1874 compared to participants’ Estimated Energy Requirements (EER) calculated using

1875 Basal Metabolic Rate (BMR) (with a Physical Activity Level of 1.6 for light activity).

1876

1877 Attainment of the NRV recommendations for total energy and six macronutrients

1878 (protein (g/kg of body weight), total fat (AMDR), saturated fat (AMDR), carbohydrate

1879 (AMDR), long chain omega 3 fatty acids, and fibre) were summed for each participant

1880 (28). A dichotomized ‘Macronutrient’ risk variable was created, where meeting

1881 requirements for five or more nutrients was classed as ‘good’, and meeting

1882 requirements for four or fewer nutrients was classed as ‘poor’ (28). Attainment of the

137

Composition of FTUs and nutrition in older men

1883 NRV recommendations for 16 micronutrients (sodium, potassium, iodine, phosphorus,

1884 calcium, magnesium, zinc, iron, dietary folate equivalents, thiamin, niacin, riboflavin

1885 and vitamins A, C, D & E) were also summed for each participant and a dichotomized

1886 ‘Micronutrient’ risk variable was created (28, 84). Meeting the requirements for 12 or

1887 more nutrients was classed as ‘good’, and meeting requirements for 11 or fewer

1888 nutrients was classed as ‘poor’ (28, 84).

1889

1890 Composition of teeth and denture quality

1891 Composition of teeth was categorized as natural only dentition, mixed dentition, and

1892 prosthetic only dentition. Numbers of natural teeth were grouped, (21 or more teeth, 11

1893 – 20 teeth, 1 – 10 teeth and edentulous – no natural teeth). Denture quality was

1894 dichotomized as ‘good’ or ‘poor’. Dentures that were unstable, non-occlusive, non-

1895 retentive, presented with large defects, or any combination of the four, were classified

1896 as ‘poor’ quality. Difficulty chewing hard foods was dichotomized as ‘Yes’ or ‘No’.

1897

1898 FTUs composition and numbers

1899 In addition to ‘Natural FTUs’ and ‘Total FTUs’, a separate ‘Replaced FTUs’ variable

1900 was created, defined as the number of FTUs where one or both teeth that compose the

1901 unit was prosthetic. Using these measures, participants were grouped according to the

1902 composition of their FTUs. Group A had only ‘Natural FTUs’, Group B had a mixture

1903 of ‘Natural FTUs’ and ‘Replaced FTUs’ and Group C had only ‘Replaced FTUs’. As

1904 there was only a very small number without any FTUs (n=28), these men were

1905 combined with participants in Group C. Participants were also grouped according to

1906 the number of FTUs (irrespective of type of FTUs): ‘12 FTUs’, ‘7-11 FTUs’, ‘1-6

138

Composition of FTUs and nutrition in older men

1907 FTUs’, and ‘No FTUs’. Again the ‘No FTUs’ group was combined with the ‘1-6 FTUs’

1908 group.

1909

1910 Other Measurements

1911 Sociodemographic and economic measures, smoking, physical activity, and health

1912 status were assessed by the self-completed questionnaire. Alcohol consumption and

1913 anthropometric measures were assessed during the first home visit.

1914

1915 Sociodemographic and economic measures

1916 Men were asked their country of birth which enabled grouping into the categories of

1917 Australia/New Zealand, Greece/Italy, and Other. Income was grouped into categories

1918 of ‘Age Pension Only’, ‘Age Pension and Other’ or ‘Other’ (superannuation or private

1919 income, own business/farm/partnership, wage or salary, repatriation pension, veteran’s

1920 pension, other, or any possible combination of these options). Living arrangements

1921 were categorized as ‘Living alone’ or ‘Living with others’, marital status was

1922 dichotomized as ‘Married/Partner De facto’ or ‘Not Married’, and post school

1923 qualifications were dichotomized as ‘Yes’ or ‘No’. Men were also asked about any

1924 limitations in access to food and food services, including Meals on Wheels (MoW).

1925

1926 Lifestyle factors

1927 Smoking status was categorized into never smoker, ex-smoker or current smoker.

1928 Participants were categorized into ‘current non-drinkers’, ‘lifelong abstainers’ and ‘ex-

1929 drinkers’. For those who consumed at least 12 drinks in the past year, the frequency and

1930 quantity of alcohol consumption was assessed, enabling categorization of drinkers as

1931 either ‘safe drinkers’ (1–21 drinks per week) or ‘harmful drinkers’ (>21 drinks per

139

Composition of FTUs and nutrition in older men

1932 week) (168). Physical activity was measured using the Physical Activity Scale for the

1933 Elderly (PASE), a validated tool that scores the level of physical activity in individuals

1934 aged 65 years or older (147).

1935

1936 Anthropometric measurements

1937 Height and weight were measured using standardised digital scales and portable

1938 stadiometer and BMI was calculated as kg/m2 and categorised as ‘underweight’ (less

1939 than 23), ‘normal weight’ (23 – 29.9), and ‘overweight/obese’ (30.0 or over) (166, 167).

1940

1941 Health status

1942 Participants reported on medical conditions through the self-completed questionnaire.

1943 They were asked whether a doctor or a health care provider had told them that they had

1944 any of the following diseases: diabetes, thyroid dysfunction, osteoporosis, Paget’s

1945 disease, stroke, Parkinson’s disease, epilepsy, hypertension, heart attack, angina,

1946 congestive heart failure, intermittent claudication, chronic obstructive lung disease,

1947 liver disease, cancer (excluding non- melanoma skin cancers), osteoarthritis and gout.

1948 For the purposes of this study, comorbidity burden was defined as the presence of two

1949 or more of these conditions. Data on self-rated general health (SRH) were obtained and

1950 dichotomized into excellent/good versus fair/poor/very poor. Self-rated oral health

1951 (SROH) was also measured and dichotomized into excellent/very good/good versus

1952 fair/poor/don’t know.

1953

1954

1955

1956

140

Composition of FTUs and nutrition in older men

1957 Ethics approval and informed consent

1958 All participants gave written informed consent. The study was approved by the Sydney

1959 South West Area Health Service Human Research Ethics Committee, Concord

1960 Repatriation General Hospital, Sydney, Australia (HREC/14/CRGH/17 CH62/6/2014-

1961 013).

1962

1963 Statistical analysis

1964 All statistical analyses and calculations were completed using SAS On Demand for

1965 Academics (SAS Institute Inc.). Statistical analysis of distributions revealed that none

1966 of the nutrients analyzed were normally distributed (Shapiro Wilk). Subjects’ energy

1967 and nutrients intakes are reported as medians (5th (P5) and 95th (P95) percentiles) for

1968 numerical values, and percentages for categorical values. A p-value less than 0.05 was

1969 considered statistically significant, and the null hypothesis was rejected.

1970

1971 Logistic regression models were used to examine the unadjusted associations between

1972 the dichotomous macronutrient and micronutrient risk variables and socio-

1973 demographic, economic, health and lifestyle factors. Associations between the nutrient

1974 risk variables and the two FTUs variables (FTUs composition and FTUs number) were

1975 then further analysed via univariate and multivariate logistic regression, with a referent

1976 category of ‘Natural only’ for FTUs composition and ‘FTUs 12’ for FTUs number). All

1977 logistic regression models controlled for age and energy intake (energy was excluded

1978 as a confounder if it was an outcome in the model). Other potential confounders,

1979 including BMI, birth country, income, smoking, PASE, comorbidity, alcohol intake,

1980 self-rated health and oral health, and post school qualifications, included in multivariate

1981 model analyses if P≤0.25 in univariate analyses. Backwards-stepwise elimination was

141

Composition of FTUs and nutrition in older men

1982 used to fit the final adjusted models. When the FTUs composition or FTUs numbers

1983 were the exposure variable, FTUs numbers and FTUs composition were controlled for

1984 respectively. The Hosmer-Lemeshow post estimation test was utilised to assess the

1985 goodness of fit of the final adjusted model.

1986

1987

1988 4.4 Results

1989 Participants’ characteristics

1990 A total of 608 men completed both the dietary and oral health assessment. Mean age of

1991 these participants was 83.9 ± 4.1 years (age range 78 to 100) with 38% over the age of

1992 85 (Table 4.1). The majority of men were married or in de facto relationships (72%),

1993 did not live alone (77%), had an alternative income to the age pension (59%), and were

1994 born in Australia (53%) (Table 4.1). Mean BMI was 27.9 ± 4.2 kg/cm2 and 29% were

1995 classified as overweight/obese (BMI ≥ 30.0). Nearly all the men did not currently

1996 smoke (97%) and alcohol consumption was predominantly at a safe level (69%) (Table

1997 4.1). Oral examination revealed 14% were completely edentulous, 28% of men had a

1998 complete set of FTUs. There was a similar proportion of men in the three ‘Number of

1999 FTU’ groups and in terms of FTU composition 32% were classed as FTUs Group A

2000 (Natural Only) (Table 4.1). Furthermore 5% of participants (n=33) had one or more

2001 implants.

2002

2003 Individual nutrient intake and adequacy

2004 The men’s median daily intake was 8767 kJ (P5 = 5529 kJ, P95 = 12432 kJ). The

2005 majority of men in each of the three FTUs composition categories did not meet their

2006

142

Composition of FTUs and nutrition in older men

Table 4.1 Characteristics and dentate status of the study population (n=608)

Characteristics n (%)/ Mean (±SD) Socio-demographic and economic factors Age (years) 75 – 79 89 (15) 80 – 84 285 (47) 85 – 89 172 (28) ≥90 62 (10) Mean 83.9 (±4.1) Marital Status Married/De Facto 439 (72) Other 167 (28) Living Arrangements Live alone 138 (23) Other 468 (77) Source of income Age Pension Only 247 (41) Age Pension + Other 136 (22) Othera 223 (37) House and Ownership Outright owner 513 (85) Other 91 (15) Post-school qualification Qualifications 368 (61) No qualifications 236 (39) Country of Birth Australia/New Zealand 321 (53) Italy/Greece 146 (24) Other 141 (23)

Health and Lifestyle Factors Body Mass Index (kg/m2) Underweight (<23.0 kg/m2) 62 (10) Normal weight (≥23.0 - <30.0 kg/m2) 360 (60) Overweight/Obese (≥30.0 kg/m2) 176 (29) Mean 27.9 (±4.2) Alcohol Consumption Safe drinker (1 – 21 drinks) 418 (69) Unsafe drinker (>21 drinks) 41 (7) Ex-drinker 94 (16) Lifelong non-drinker 51 (8)

Smoking Current Smoker 18 (3) Ex-smoker 346 (57) Non-smoker 242 (40)

143

Composition of FTUs and nutrition in older men

PASE2 <80 212 (35) ≥80 394 (65) Mean 106.4 (±63.6) Multimorbidity ≥ 2 398 (66) Self-Rated Health Good/Excellent 446 (74) Fair/Poor/Very Poor 160 (26)

Other Factors Able to shop for groceries? Yes 577 (95) No 29 (5) Able to prepare meals? Yes 559 (93) No 44 (7) MOW? Yes 27 (4) No 579 (96) Oral Health Factors Self-Rated Oral Health Good/Very Good/Excellent 426 (70) Fair/Poor/Don’t Know 180 (30) Numbers of Natural Teeth ≥21 238 (39) 11 – 20 179 (29) 1 – 10 103 (17) 0 88 (14) Composition of Teeth Natural 255 (42) Mixed 265 (44) Replaced 88 (14)

Number of FTUs <7 231 (38) 7 – 11 208 (34) 12 169 (28) Composition of FTUs Group A 197 (32) Group B 167 (27) Group C 244 (40)

PASE, Physical Activity Scale for the Elderly. MOW, Meals On Wheels. FTUs, Functional Tooth Units. a. Superannuation or private income, own business/farm/partnership, wage or salary, repatriation pension, veterans pension, or other. $. Group A: only ‘Natural FTUs’, Group C: only ‘Replaced FTUs’, Group B: mixture of ‘Natural FTUs’ and ‘Replaced FTUs’. 2007 144

Composition of FTUs and nutrition in older men

2008 energy NRV requirements (Table 4.2). Mean and median percentage contribution of

2009 total and saturated fat was above the NRV recommendations for all FTUs compositions,

2010 while the median percentage contribution of carbohydrate intake and median intakes of

2011 fibre were below the NRV across all categories (Table 4.2). For each FTUs composition

2012 category, median intakes for the majority of micronutrients met NRVs, except for

2013 Vitamin D, Vitamin E, Calcium, Potassium and Magnesium (Table 4.2). Furthermore,

2014 the majority of men in all FTUs composition categories did not meet their NRVs for

2015 these five micronutrients (Table 4.2).

2016

2017 Although univariate analysis showed no statistically significant differences,

2018 multivariate analysis showed that participants with <7 FTUs were significantly more

2019 likely to have inadequate intakes of fibre than those with a full 12 FTUs. Top food

2020 sources of fibre were bananas, pears and peas.

2021

2022 Univariate analysis revealed that men in FTUs Group C (No Natural FTUs) were

2023 significantly more likely to have inadequate intakes of magnesium and fibre, and men

2024 in FTUs Group B (mixture of Natural and Replaced Only) were significantly more

2025 likely to meet required intakes of protein (g/kg of body weight) compared to men in

2026 FTUs Group A (Natural only) (Table 4.2). After adjusting for confounders FTUs Group

2027 C remained significantly associated with inadequate intakes of magnesium and fibre,

2028 and FTUs Group B remained significantly associated with meeting required intakes of

2029 protein (g/kg of body weight). Top food sources of magnesium were whole cow’s milk,

2030 bananas and instant coffee powder. Top food sources of protein were beef, whole cow’s

2031 milk and chicken.

2032

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Composition of FTUs and nutrition in older men

2033 Overall dietary intake and FTUs

2034 Eighty-seven percent of men (n=523) had poor macronutrient intakes, based on meeting

2035 the NRV recommendations of four or fewer macronutrients out of a possible seven. A

2036 total of 66% (n=403) of participants had poor micronutrient intakes, based on meeting

2037 the NRV recommendations of 11 or fewer micronutrients out of a possible 16. In

2038 univariate analyses, FTUs composition, and numbers of natural teeth were significantly

2039 associated with micronutrient intake, while only FTUs composition was significantly

2040 associated with macronutrient intake (Table 4.3). Denture quality and the self-reported

2041 ability to chew hard foods were not significantly associated in univariate analyses with

2042 either poor micronutrient or macronutrient intakes (Table 4.3).

2043

2044 After multivariate adjustment, FTUs Group C (No Natural FTUs) was no longer

2045 significantly associated with poor micronutrient intake, meeting 11 or fewer

2046 micronutrient recommendations, although the association continued was close to

2047 statistical significance. However multivariate analysis showed FTUs Group C was

2048 significantly associated with poor macronutrient intake, meeting 4 or fewer

2049 macronutrient recommendation, compared to FTUs Group A (Natural Only) (Table

2050 4.4). Numbers of FTUs was not significantly associated with poor intake of either

2051 micronutrients or macronutrients after adjusting for confounders (Table 4.4). A higher

2052 number of natural teeth remained statistically significantly associated with meeting

2053 micronutrient risk intake in multivariate analysis (data not shown).

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Composition of FTUs and nutrition in older men

Table 4.2 Median daily intake (and 5th/95th percentile) of energy and nutrients, percentage and number of participants not meeting the recommended intake for each nutrient by FTUs compositiona FTUs: Group A FTUs: Group B FTUs: Group C Not meeting Not meeting Not meeting NRV NRV NRV Recommended Intake (male, ≥ Variables 70 years old) Median (P5/P95) % n Median (P5/P95) % n Median (P5/P95) % n Energy and Macronutrients Total energy (kJ/d) – EER - 8767.0 69 137 8538.0 76 124 8753.1 68 166 (5529.1/12431.8) (5557.7/12778.1) (5890.4/12267.1) Protein (g/kg per d) - EAR 0.86 1.2 (0.7/2.0) 17 33 1.2 (0.8/1.9) 8 13b 1.2 (0.7/2.0) 13 32 Protein (g/d) - 90.4 (60.9/137.9) - - 92.2 (61.0/136.1) - - 91.1 (59.3/140.3) - - Protein (%E/d) - AMDR 15 – 25 18.2 (13.9/25.5) 19 38 17.7 (13.4/25.9) 20 34 18.1 (12.4/24.4) 21 52 - 205.18 - - 189.0 - - 203.1 - - Carbohydrate (g/d) (113.2/307.1) (114.7/324.87) (123.7/314.2) Carbohydrate (%E/d) - AMDR 45 – 65 38.1 (26.8/48.7) 88 173 37.0c (23.6/48.9) 84 140 38.0 (26.5/49.6) 84 205 Total fat (g/d) - 83.0 (42.8/138.7) - - 84.3 (44.5/151.9) - - 88.2 (47.1/138.9) - - Total fat (%E/d) – AMDR 20 – 35 36.2c (25.0/46.8) 60 118 37.3c (24.8/50.7) 60 100 37.3 (23.4/50.3) 67 164 Saturated fat (g/d) - 29.0 (14.6/49.5) - - 29.2 (14.0/63.0) - - 30.9 (16.1/56.5) - - Saturated fat (%E/d) – AMDR <10 12.5 (7.5/19.8) 80 158 12.9 (7.5/19.9) 74 123 13.0 (7.9/19.9) 83 203 Dietary fibre (g/d) – AI 30 26.3 (13.5/43.4) 68 134 25.4 (14.1/41.2) 71 119 23.9 (13.7/41.5) 77 187b Vitamins Thiamin (mg/d) – EAR 1 1.5 (0.7/3.4) 15 29 1.5 (0.8/3.2) 10 16 1.5 (0.6/3.2) 16 39 Riboflavin (mg/d) – EAR 1.3 2.1 (1.0/4.4) 9 18 2.1 (1.1/4.2) 9 15 2.1 (1.0/4.1) 14 35 Niacin Equivalent (mg/d) – EAR 12 47.3 (29.8/74.4) 0 0 47.1 (29.5/75.5) 0 0 46.1 (29.1/75.7) 0 0 Dietary Folate Equivalent (ug/d) – 320 374.9 30 60 362.0 39 65 362.4 38 92 EAR (193.2/752.3) (201.3/737.3) (185.8/676.8) Vitamin A (ug/d) – EARd 625 938.1 20 39 924.0 20 34 947.9 18 43 (399.9/2068.0) (450.3/1904.5) (354.3/1947.0)

147

Composition of FTUs and nutrition in older men

Vitamin C (mg/d) – EAR 30 114.9 (37.4/254.9) 3 5 109.9 (38.8/243.8) 3 5 105.2 (40.9/248.9) 2 6

Vitamin De (u/d) – AI 15 3.8 (1.5/7.8) 99 295 3.6 (1.6/8.9) 99 166 4.0 (1.5/7.9) 100 243 Vitamin E (mg/d) – AI 10 9.9 (4.7/20.4) 51 100 10.1 (5.2/19.5) 48 80 9.7 (4.2/20.1) 53 129 Minerals Calcium (mg/day) – EAR 1100 769.3 85 168 788.7 84 141 760.0 86 210 (439.7/1362.4) (404.1/1448.7) (378.7/1336.8) Phosphorus (mg/day) – EAR 580 1510.5 0 0 1462.0 0 0 1434.0 1 2 (993.1/2205.3) (933.7/2213.1) (898.9/2179.0) Iron (mg/day) – EAR 6 12.5 (7.3/20.3) 3 5 12.0 (7.8/21.4) 2 3 12.0 (7.3/20.4) 2 4 Magnesium (mg/day) – EAR 350 350.0 (212.8/5497) 50 98 342.8 52 87 315.9 63 153b (224.3/553.4) (201.8/536.6) Zinc (mg/day) – EAR 12 12.1 (7.0/19.8) 46 90 12.1 (7.5/20.9) 47 79 12.1 (7.3/18.9) 48 118 Potassium (mg/day) – AI 3800 3302.6 71 140 3257.4 70 117 3176.0 73 177 (2092.2/5176.6) (2022.4/5203.9) (1966.9/5040.0) Iodine (ug/day) – AI 100 110.9 (54.6/233.2) 39 77 105.4 (56.7/231.3) 41 68 111.9 (51.9/208.1) 40 98

Sodium (mg/day) – UL 2300 2109.3 38 74 2082.8 34 56 2065.3 36 87 (1173.5/3389.9) (1287.9/3659.6) (1152.6/3553.5)

NRV, Nutrient Reference Values. EER, Estimated Energy Requirements. EAR, Estimated Average Requirement. %E, percentage of energy contributed. AMDR, Accepted Macronutrient Distribution Range. AI, Adequate Intake. ADG, Adequate Dietary Guidelines. UL, Upper Level. a. Group A: only ‘Natural FTUs’, Group C: only ‘Replaced FTUs’, Group B: mixture of ‘Natural FTUs’ and ‘Replaced FTUs’. b. Statistically significant, p-value <0.05, (reference category: FTUs Natural Contacts Only). c. Mean used (Shapiro Wilk’s test satisfied). d. Retinol Equivalents e. Vitamin D data should be interpreted with caution 2054

148

Composition of FTUs and nutrition in older men

2055 4.5 Discussion

2056 In this epidemiological study, we found that among community-dwelling men aged 78

2057 years and over living in Australia, those with no Natural FTUs (FTUs Group C) were

2058 more likely to have poor overall macronutrient than those who had only Natural FTUs.

2059 Multivariate analysis showed no significant association between no Natural FTUs and

2060 overall micronutrient intake, although it was close to statistical significance. There were

2061 also no significant associations between FTUs numbers and overall intakes of either

2062 macronutrients or micronutrients. However, men with no Natural FTUs or those with

2063 <7 FTUs were less likely to meet recommendations for fibre intake.

2064

2065 Our results differ from those in a study of a group of Japanese older adults, aged 65 to

2066 85, that compared intake of individual nutrients in participants who had retained at least

2067 one occluding pair of natural molars and those who had not (191). This study found

2068 significant differences between the two groups in individual intake of micronutrients

2069 and fibre, but not in the intake of macronutrients, possibly because they assessed intake

2070 of macronutrients individually, not the overall risk of meeting or not meeting all

2071 macronutrients (191). Furthermore they did not examine the association of FTUs

2072 composition and nutrient intake independently of FTUs numbers (191). One

2073 explanation for inadequate consumption of macronutrients in men with FTUs

2074 composed with no Natural FTUs (FTUs Group C) is difficulty with chewing. Chewing

2075 capacity with prosthetic teeth is not as effective as with natural teeth, which may lead

2076 to avoidance of foods considered difficult to chew, including crunchy and hard foods

2077 such as fruit and vegetables (30, 98). It is also possible that the link between no Natural

2078 FTUs and poor consumption of macronutrients and micronutrients may be due to

2079 overall poor denture quality, which can impact negatively on chewing ability (97, 99).

2080 149

Composition of FTUs and nutrition in older men

Table 4.3 Univariate analysis of oral health variables and micronutrient and macronutrient intakes Micronutrient Intake Macronutrient Intake Meeting Not Meeting Crude OR Meeting Not Meeting Crude OR Variables n % n % ORa (95%CI) n % n % ORb (95%CI) Self-Rated Oral Health Good/Very Good/Excellent 151 35 275 65 1.00 55 13 369 87 1.00 Fair/Poor/Don’t Know 54 30 126 70 1.28 (0.88 – 1.87) 26 15 153 85 0.88 (0.53 – 1.45) Difficulty Chewing Hard Foods No 179 34 347 66 1.00 69 13 453 87 1.00 Yes 26 32 56 68 1.11 (0.68 – 1.83) 12 15 70 85 0.89 (0.46 – 1.72) Denture Quality Good 83 33 172 67 1.00 31 12 220 88 1.00 Poor 28 30 66 70 1.14 (0.68 – 1.90) 9 10 85 90 1.33 (0.61 – 2.91) Numbers of Natural Teeth ≥21 98 41 140 59 1.00 40 17 195 83 1.00 11 – 20 53 30 126 70 1.66 (1.10 – 2.51)c 22 12 157 88 1.46 (0.84 – 2.57) 1 – 10 32 31 71 69 1.55 (0.95 – 2.54) 10 10 93 90 1.91 (0.91 – 3.98) 0 22 25 66 75 2.10 (1.22 – 3.63)c 9 10 78 90 1.78 (0.82 – 3.84) Composition of Teeth Natural 93 36 162 64 1.00 41 16 214 84 1.00 Mixed 90 34 175 66 1.12 (0.78 – 1.60) 31 12 231 88 1.43 (0.86 – 2.36) Replaced 22 25 66 75 1.72 (1.00 – 2.97) 9 10 78 90 1.66 (0.77 – 3.57) Number of FTUs 12 52 31 117 69 1.00 19 11 148 89 1.00 7 – 11 84 40 124 60 0.66 (0.43 – 1.01) 29 14 177 86 0.78 (0.42 – 1.45) <7 69 30 162 70 1.04 (0.68 – 1.61) 33 14 198 86 0.77 (0.42 – 1.41) Compositiond of FTUs

150

Composition of FTUs and nutrition in older men

Group A 74 38 123 62 1.00 31 16 166 84 1.00 Group B 62 37 105 63 1.02 (0.67 – 1.56) 27 16 137 84 0.95 (0.54 – 1.66) Group C 69 28 175 72 1.53 (1.02 – 2.28)c 23 9 220 91 1.79 (1.00 – 3.18)c

OR, Odds Ratio. FTUs, Functional Tooth Units. a. OR of meeting 11 or fewer recommended micronutrient intakes b. OR of meeting 4 or fewer recommended macronutrient intakes c. Statistically significant, p-value <0.05 d. Group A: only ‘Natural FTUs’, Group C: only ‘Replaced FTUs’, Group B: mixture of ‘Natural FTUs’ and ‘Replaced FTUs’. 2081

2082 Sahyoun et al. found that those who had ‘self-perceived’ poor denture quality had lower intake of fruits and vegetables, lower dietary quality

2083 scores and less variety in their diets (99). However, in our study we did not find any association between the objective measurement of poor denture

2084 quality and inadequate dietary intake of nutrients, which agrees with a previous report by Shinkai et al. (187). Shinkai et al. measured denture

2085 quality by three technical criteria, retention, stability, and tooth wear on posterior artificial teeth, and categorized denture quality as good, medium

2086 and poor (187). Their study found that energy, protein, vitamin A, vitamin C, folate, iron and dietary fibre intakes were not significantly different

2087 across the three categories of denture quality (187).

2088

2089 Studies have also shown that people with prosthetic teeth have higher intakes of total fat, saturated fat and the percentage of energy from fat,

2090 compared to those with natural teeth (86, 192). Moynihan et al. found that those who had had their shortened dental arch replaced with partial

2091 dentures had a higher percentage of energy contributed from fat (192). Another study showed that edentate older adults had significantly higher

151

Composition of FTUs and nutrition in older men

2092 fat, saturated fat and percentage of energy from fat than dentate adults (86). Higher

2093 intakes of fat and saturated fats in those with prosthetic teeth have been shown to be

2094 due to poorer masticatory ability (30, 65, 186).

2095

2096 Our study did not find a relationship between having no Natural FTUs and overall

2097 micronutrient intake. Previous studies on rehabilitation with prostheses have shown

2098 participants with dentures do not meet recommendations for fruit and vegetable intake,

2099 even if their perception of chewing ability increased (192). Other studies examining the

2100 association between dentition and nutrient intakes have shown that denture wearers had

2101 poorer intakes of dietary fibre, fruit and vegetables, as well as nutrients associated with

2102 consumption of fruits and vegetables, such as carotenes and vitamin C (52). De Marchi

2103 et al. found that edentulous participants (no natural teeth) and those who had at least

2104 one denture were at high risk of not meeting adequate vegetable and fruit intakes (80).

2105

2106 Interestingly, in our study, the number of FTUs was not associated with poor

2107 macronutrient and micronutrient intakes. Previous studies have found an association

2108 between low FTUs numbers and intake of individual nutrients (79, 84, 185, 189). Our

2109 study defined FTUs as opposing pairs of molars and premolars and categorized them

2110 into three ordinal levels: ‘12 FTUs’, ‘7-11 FTUs’, and ‘0-6 FTUs’ regardless of their

2111 composition. Other studies used different methods of defining and categorizing the

2112 numbers of FTUs. Iwasaki et al. used the number of FTUs and perceived denture fit as

2113 a measure of oral health status (84). They also formed a composite nutrient deficiencies

2114 variable, composed of macronutrients and micronutrients, where participants who were

2115 below the recommended intake of nine or more nutrients were classified as nutritionally

2116 at risk (84). The study also reported no association between oral health status and risk

152

Composition of FTUs and nutrition in older men

2117 of nutrient deficiencies after adjusting for confounders (84). One study used a definition

2118 of occlusion much closer to our study, where they defined one FTU as a ‘single

2119 posterior occluding pair of teeth’ (POPs) made up of natural or pontics of fixed bridges

2120 (185). They found that participants with no POPs were more likely to have inadequate

2121 intakes of calcium, iron and phosphorus, compared to participants with one or more

2122 POPs (185). Kwok et al. defined FTUs as one opposing pair of natural or denture teeth,

2123 with a possible maximum total of 16 pairs of FTUs (189). Their study found that five

2124 or fewer FTUs was associated with lower intakes of fibre, but no other individual

2125 macronutrient or micronutrients (189).

2126

2127 The differences in results between studies are likely due to the differences in definition

2128 or categorisation of FTUs, or the differences in measuring nutrient outcomes. While

2129 most studies defined the absence of natural FTUs as no FTUs present at all or

2130 replacement by full dentures, our study defined natural FTUs absence as all FTUs

2131 having one or both teeth replaced by prosthesis. This definition allowed for better

2132 determination of the impact that replacing FTUs with prosthesis has on nutrient intake

2133 in older adults, independent of their number. Our study did find that the total number

2134 of natural teeth was related to micronutrient intake, even after adjusting for

2135 confounders. Participants with no natural teeth were more likely to have poor overall

2136 intake of micronutrients compared to those with 21 or more natural teeth. This is

2137 consistent with previous research on numbers of natural teeth and diet (29, 52, 84).

2138

2139 One of the strengths of our study was that we used a validated diet history method

2140 administered by trained dietitians to collect dietary and subsequently nutritional

2141 information (169). This particular method was not burdensome for participants, or

153

Composition of FTUs and nutrition in older men

2142 subject to poor short term memory recall and was not limited in the responses or

2143 information that could be provided (193). However, all measures of nutrient intakes

2144 are only estimates, and the results for vitamin D in particular (see Methods) should be

2145 interpreted with caution (175). The oral health assessments were conducted by

2146 calibrated professionals, providing objective clinical measures on numbers of teeth,

2147 FTUs, presence of dentures and denture quality. This is a similar standard to those of

2148 other epidemiological studies on oral health.

2149

2150 There are some limitations to our study. Firstly, difficulty in chewing hard foods was

2151 assessed using a self-completed questionnaire and participants’ self-report of perceived

2152 chewing difficulty of hard foods may be different from their actual chewing ability.

2153 Secondly our study had a cross-sectional design, therefore causal relationships cannot

2154 be established. It is possible that inadequate nutrition leads to tooth loss, rather than

2155 poor oral health leading to inadequate nutrition (194). Thirdly the generalizability of

2156 our results to other populations, such as community dwelling older women or

2157 institutionalized populations, is not clear. Finally, prosthetic tooth replacement was not

2158 differentiated from replaceable or fixed prosthetics, like implants. Previous literature

2159 has shown that implant treatment has a positive impact on mastication and bite force,

2160 and therefore is likely to have limited impact on dietary intakes (195). However, the

2161 percentage of participants with implants was very small in our study, the majority of

2162 these participants had no natural FTUs (Group C), and the implants were not necessarily

2163 replacing pre-molars, and molars.

2164

2165 In conclusion, this study suggests that maintaining posterior natural teeth in occlusion

2166 is needed for overall optimal dietary intake of macronutrients, but not micronutrients.

154

Composition of FTUs and nutrition in older men

2167 This study also suggests that older people who have no natural posterior teeth in

2168 occlusion may be at risk of nutritional deficiencies. This suggests that dental health care

2169 providers should consider collaborating with dietitians to provide nutritional care and

2170 that dietitians should consider oral health as a risk factor when assessing nutrition in

2171 older adults. This was a cross-sectional study and so the direction of observed

2172 relationships is unclear; prospective investigation into the impacts of FTUs composition

2173 on nutrition need to be done. Additionally, the impact of the type of prosthetic

2174 replacement for FTUs on dietary intake of nutrients should be investigated.

2175

Table 4.4 Multivariate logistic regression model of FTUs composition and FTUs number, and micronutrient (11 or fewer) and macronutrient (4 or fewer) risk variables Micronutrient Risk Variable Macronutrient Risk Variable Adjusted Adjusted Variables ORab (95%CI) ORcd (95%CI) Compositionef Group A 1.00 1.00 Group B 1.00 (0.60 – 1.69) 1.04 (0.57 – 1.91) Group C 1.73 (1.00 – 3.00) 2.00 (1.01 – 3.94)g

Number of FTUsh 12 1.00 1.00 7 – 11 0.84 (0.47 – 1.48) 0.98 (0.48 – 2.01) 0 - 6 1.46 (0.82 – 2.62) 0.97 (0.47 – 1.98)

FTUs, Functional Tooth Units. OR, Odds Ratio. a. OR of meeting 11 or fewer recommended micronutrient intakes. b. Adjusted for FTU numbers, age, energy, BMI, comorbidity and post school education. c. OR of meeting 4 or fewer recommended macronutrient intakes, adjusted for FTU composition, age, BMI, PASE, birth country, living status and alcohol intake. d. adjusted for FTU composition, age, BMI, PASE, birth country, living status and alcohol intake. e. Group A: only ‘Natural FTUs’, Group C: only ‘Replaced FTUs’, Group B: mixture of ‘Natural FTUs’ and ‘Replaced FTUs’. f. Adjusted for FTU numbers g. Statistically significant, p-value <0.05 h. Adjusted for FTU composition 2176

155

2177

2178

2179

2180

2181

2182

2183

2184

2185

2186

2187 CHAPTER 5: ASSOCIATIONS BETWEEN NUTRIENT INTAKE AND

2188 PERIODONTITIS IN OLDER MEN: THE CONCORD HEALTH AND AGEING IN

2189 MEN PROJECT

2190 (As submitted to the Journal of Clinical Periodontology,)Authors: Kate Milledge,

2191 Frederick A C Wright, Joerg Eberhard, Robert G Cumming, Vasi Naganathan, Fiona M

2192 Blyth, David G Le Couteur, Louise M Waite, David J Handelsman, Vasant Hirani.

2193

2194

2195

2196

2197

2198

2199

2200

156

Nutrient intake and periodontitis in older men

2201 5.1 Abstract

2202 Objective: More than half of adults aged 65 years and older have moderate to severe

2203 periodontitis and in this age group there is variability in quality of dietary intake. The

2204 aim of this study was to examine the association between nutrient intake and

2205 periodontitis in older men.

2206 Design: Cross-sectional analysis of 294 men (mean age: 84 years) who completed a

2207 standardised validated dietary assessment and comprehensive oral health examination

2208 in the Concord Health and Ageing Men Project (CHAMP). Severe periodontitis was

2209 based on the classifications of the Center for Disease Control and Prevention (CDC)

2210 and American Academy of Periodontology (AAP): Severe periodontitis ≥2

2211 interproximal sites with a Clinical Attachment Loss (CAL) of ≥6mm, and ≥1 site with

2212 a Probing Depth (PD) of ≥5mm, moderate periodontitis as ≥2 interproximal sites with

2213 a CAL of ≥5mm, or ≥2 interproximal sites with a PD of ≥5mm, and mild periodontitis

2214 as ≥2 interproximal sites with a CAL of ≥3mm, and ≥2 interproximal site with a PD of

2215 ≥4mm. Total Periodontitis was defined as the presence of severe, moderate, or mild

2216 periodontitis. Attainment of Nutrient Reference Values (NRVs) for energy intake and

2217 six other nutrients were incorporated into a ‘key nutrients’ variable, dichotomized as

2218 'good' (meeting recommendations for ≥5 key nutrients) or 'poor' (meeting

2219 recommendations for ≤4 key nutrients).

2220 Results: The prevalence of total periodontitis was 89.5% (n=263). In adjusted analysis,

2221 poor intakes of key nutrients was associated with the presence of total periodontitis OR:

2222 2.36 (95% CI:1.05 – 5.27).

2223 Conclusion: These results indicate that there is an association between periodontitis

2224 and nutrition in older men and is consistent with the hypothesis that diet has a role in

2225 periodontitis, although the direction of causality remains to be established.

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Nutrient intake and periodontitis in older men

2226 5.2 Introduction

2227 Periodontitis is a chronic oral inflammatory condition, characterized by the loss of

2228 connective tissues and bone support and is associated with other chronic diseases,

2229 including cardiovascular disease, type II diabetes and metabolic syndrome (39-41, 196,

2230 197). Prevalence of periodontitis is higher in older age groups, and is an important cause

2231 of tooth loss that influences chewing capacity (32, 38, 71, 198, 199). Periodontitis

2232 impacts men more than women, possibly due to hormonal differences in immune

2233 responses and higher levels of inflammatory cytokines in men than in women (32, 38,

2234 198, 199).

2235

2236 Due to the inflammatory nature of periodontal disease, it is reported that diet, and

2237 dietary nutrients, influence the prevalence and progression of periodontal disease (72,

2238 111). Consumption of fruit, and other food groups high in fibre, are inversely related to

2239 the progression of periodontal disease in men aged 65 years older (111) and high

2240 vegetable intakes are associated with lower prevalence of periodontal disease in

2241 participants aged 70 years and older (72). Adults with low intakes of vitamin C have an

2242 increased risk of periodontal disease (200), whereas high intakes of anti-oxidants

2243 (vitamin C, vitamin E, alpha-carotene and beta-carotene) slow the progression of

2244 periodontal disease among older Japanese adults (107).

2245

2246 Some studies suggest that higher intakes of polyunsaturated fatty acids (PUFAs) and

2247 omega 3 fatty acids are associated with lower prevalence of periodontal disease (106,

2248 201). Eberhard et al. showed that the local application of PUFAs have a beneficial

2249 effect on the inflammatory response in the oral cavity (202). One study found a

2250 relationship between a high ratio omega 6 intake to omega 3 intake and a greater

158

Nutrient intake and periodontitis in older men

2251 number of periodontal disease events (104). In contrast, higher intake of saturated fatty

2252 acids (SFAs) is associated with a pro-inflammatory effects, which increases the

2253 progression of periodontal disease (105).

2254

2255 Considering the relationship between nutrients and food groups with periodontal health,

2256 it is important to look at overall diet quality with periodontitis. Furthermore, no study

2257 has examined the relationship between nutrition and periodontal health in older

2258 community dwelling Australian men. Therefore, the aim of this study was to investigate

2259 the relationship between individual macronutrients and micronutrients, as well as

2260 overall quality of dietary intake with the presence and severity of periodontitis.

2261

2262

2263 5.3 Methods

2264 Study population

2265 The Concord Health and Ageing in Men Project (CHAMP) is an ongoing

2266 longitudinal study, established in 2005. The main aim is to investigate the health

2267 of men aged 70 years and older. Recruitment of subjects for the CHAMP study

2268 is described in detail elsewhere (144). Briefly, the subjects were selected from

2269 the NSW electoral roll from the geographical locations of Burwood, Canada

2270 Bay and Strathfield in Sydney, Australia. The only exclusion criterion was

2271 living in an aged care facility at time of recruitment (144). Eligible men were

2272 sent a letter and, if they had a listed telephone number, were telephoned about

2273 one week later. Of the 2,815 eligible men with whom contact was made, 1,511

2274 participated in the study (54%). An additional 194 eligible men living in the

2275 study area heard about the study from friends or the local media and were

159

Nutrient intake and periodontitis in older men

2276 recruited after contacting the study investigators prior to being identified

2277 through the electoral roll. In total 1,705 subjects were recruited for baseline.

2278 Participants completed a self-administered questionnaire and attended a clinic

2279 at Concord Hospital that included an interview and clinical assessment at

2280 baseline, 2 year (2nd wave) and 5 year (3rd wave) follow ups. Collection of

2281 nutritional data, via a home visit was added at the 3rd wave of data collection.

2282 For the fourth wave of data collection (8 year follow up) in addition to most of

2283 the self –completed questionnaire and clinic assessments collected in previous

2284 waves, an oral health questionnaire and examination was conducted along with

2285 the diet history interview. For this wave men were seen predominantly in their

2286 homes.

2287

2288 Data collection

2289 The fourth wave CHAMP follow up involved two home visits. The first, which

2290 collected clinical health and dietary information was by one of three trained dietitians.

2291 The second visit, was for an oral health assessment, which was conducted by one of

2292 two trained oral health therapists using a standardized clinical protocol. A self-

2293 completed questionnaire (SCQ), collecting sociodemographic, economic and health

2294 information, was sent to the participant’s home prior to the first visit. Of the original

2295 1,705 participant 781were able to participate in the fourth wave of follow up (Fig. 5.1).

2296 The main reasons for non-participation were death (72.4%) or illness/age (10.1%).

2297 Forty-six participants completed the self-administered questionnaire only, 735

2298 completed the clinical assessment, 718 completed the dietary assessment, and 614

2299 participants underwent the oral health assessment, of whom 296 had a full periodontal

2300 assessment. Edentulous participants (n=90) were excluded from the periodontal

160

Nutrient intake and periodontitis in older men

2301 assessment, however large number of men (n=228) were excluded from the full

2302 periodontal assessment because of contra-indicated medical conditions (Fig. 5.1) (32).

2303 There were 294 men who had full oral health assessment including full periodontal

2304 assessment and a complete dietary assessment (Fig. 5.1). Men who completed the full

2305 periodontal assessment and the dietary assessment, were compared to men who

2306 completed the dietary assessment but not the periodontal assessment (n=225) (Table

2307 5.1). Excluded men had higher number of comorbidities, poorer levels of physical

2308 activity, and were less likely to visit the dentist at least every 2 years. Included and

2309 excluded respondents for the full periodontal assessment did not differ significantly in

2310 income, marital status, post school qualifications, country of birth, smoking status and

2311 body mass index (BMI) (Table 5.1).

2312

2313 Measurements

2314 Oral health data collection

2315 During the oral health assessment participants were asked by interviewers about

2316 perceptions of pain, chewing ability and dental care, before undergoing a dental

2317 examination. The examination individual teeth were categorized as according to

2318 National Survey of Adult Oral Health (NSAOH) criteria (32). Details of the oral health

2319 measurements, criteria and outcomes of the CHAMP men have been published

2320 elsewhere (43). Prior to the periodontal examination, men were screened using a

2321 clinical protocol about cardiac health (43). Participants were excluded from a full

2322 periodontal assessment if they answered ‘yes’ to one or more of the 12 clinical protocol

2323 questions on cardiac health (32, 43). Periodontal examination was conducted with a

2324 standardised intra-oral mirror and light source (Intra-oral light. Mirrorlite IN-

2325 7003.Mydent International: Hauppauge, N.Y.), using a Hu Friedy PCP 2 periodontal

161

Nutrient intake and periodontitis in older men

2326 probe (HuFriedy Manufacturing Co, Chicago, IL), with 2 mm markings (43).

2327 Periodontal measurements included recession, and Probing Depth (PD). Measurements

2328 were taken at three sites: mesio-buccal, mid-buccal, and distal buccal for each natural

2329 tooth present, except third and second molars.

2330

2331 Dietary intake

2332 Typical dietary intake over the previous 3 months was assessed by a research dietitian

2333 using a standardized and validated diet history questionnaire (169, 170). A structured

2334 questionnaire with open-ended questions, adapted from Sydney South West Area

2335 Health Service outpatient’s diet history form, was the tool used by interviewers to ask

2336 participants about their usual dietary intake (169). Food quantities were established by

2337 food models, photographs and household measures, such as measuring spoons cups

2338 (169, 171). A checklist was included to corroborate commonly consumed foods items

2339 that may have been forgotten. Diet history collection occurred across a two-year period,

2340 accounting for any seasonal variation in the diet. Relatives, carers and/or family

2341 members of CHAMP men were encouraged to be present in the interview, to aid in

2342 participants memory recall (169, 172). Validity of this method was established in a

2343 study using a 4 day weighed food record in a sub-group of 56 CHAMP men (169). We

2344 used the interquartile range to identify potential outliers of energy intake (173).

2345 Individual diet histories containing potential outliers were examined, and only one was

2346 identified as having an unrealistic intake of food and excluded from the data set (173).

2347

2348 Data handling

2349 Dietary records were converted to nutrient intakes using FoodWorks 7 Professional for

2350 Windows (Xyris Software (Australia) Pty Ltd), which uses the Australian Food,

162

Nutrient intake and periodontitis in older men

2351 Supplement and Nutrient Database 2007 (AUSNUT 2007) (28). This database has a

2352 maximum of 37 nutrient values available for 4425 foods (174). Vitamin D values from

2353 AUSNUT 2007 need to be interpreted with caution due to the small set of analyses from

2354 which the values have been obtained and the assumption that were made (203). A

2355 coding manual was developed during the nutrition collection at the 3rd wave follow up

2356 to define 869 food items. This manual was updated at the 4th wave to define and

2357 standardize 1,650 food items to ensure consistent entry of diet histories.

2358

2359 Dietary intake of nutrients

2360 Participants’ median daily dietary intakes for energy, carbohydrates, sugar, protein,

2361 total fats, polyunsaturated fatty acids (PUFA), including linoleic, linolenic acid, and

2362 long chain n mono-unsaturated fatty acids (MUFA), dietary fibre, alcohol, sodium,

2363 potassium, iodine, iron, phosphorus, calcium, magnesium, zinc, dietary folate

2364 equivalents, thiamin, niacin, riboflavin and vitamins A, C, D & E were compared to the

2365 respective Nutrient Reference Values (NRV) recommendations for males aged >70

2366 years and older (176). Vitamin B6 and vitamin B12 were not analysed as these values

2367 are not available in AUSNUT 2007. For sodium, only that which is available naturally

2368 in foods or added during processing food products was included in the analysis.

2369 Percentage of energy from carbohydrates, protein and fats were compared to the

2370 Acceptable Macronutrient Distribution Range (AMDR) and protein intake per kilogram

2371 of body weight was calculated (176). Daily energy intakes were compared to

2372 participants Estimated Energy Requirements (EER) calculated using BMR (with a

2373 physical activity level of 1.6 for light activity).

2374

163

Nutrient intake and periodontitis in older men

2375 Attainment of the NRV for total energy and six other nutrients (protein, calcium, iron,

2376 zinc, riboflavin, and vitamin D) were counted for each participant. These nutrients are

2377 highlighted as ‘key nutrients’ for older adults (11). A dichotomized ‘key nutrient’

2378 variable was created to measure diet quality. Meeting requirements for five or more of

2379 these key nutrients was classified as ‘good’, and meeting requirements for four or fewer

2380 of these key nutrients was classified as ‘poor’ (28).

2381

2382 Periodontitis

2383 The Clinical Attachment Loss (CAL) at each tooth site was calculated by adding

2384 together the clinical measures of recession and PD. The prevalence of severe and total

2385 periodontitis was characterized according to the Centers for Disease Control and

2386 Prevention (CDC) and American Academy of Periodontology (AAP) case definition

2387 (38, 204). ‘Severe periodontitis’ was defined as two or more interproximal sites with a

2388 CAL of 6 mm or greater, and one site with a PD of 5 mm or more (204). ‘Moderate

2389 periodontitis’ was defined as two interproximal sites with a CAL of 5 mm or more, or

2390 2 interproximal sites with a PD of 5 mm or more (204). The original definition of

2391 moderate periodontitis was two interproximal sites with a CAL of 4 mm or more,

2392 however older people have greater recession, which may be non-inflammatory (205).

2393 The CDC/AAP definition of severe periodontitis includes CAL ‘and’ PD for this reason

2394 (204). Therefore, to account for this, without using PD, the CDC/AAP definition of

2395 moderate periodontitis was modified to include a higher margin of 5 mm or more for

2396 CAL, instead of 4 mm. ‘Mild periodontitis’ was defined as two or more interproximal

2397 sites with CAL of 3 mm or more, and two or more interproximal sites with a PD of 4

2398 mm or more (38). ‘Total Periodontitis’ was defined as the presence of severe, moderate,

2399 or mild periodontitis (38).

164

Nutrient intake and periodontitis in older men

2400 Dentition status

2401 Dentition was categorized into four groups according to numbers of natural teeth

2402 present:21 or more teeth; 11 – 20 teeth; 1 – 10 teeth; and edentulous (no natural teeth).

2403

2404 Other measurements

2405 Sociodemographic and economic measures, smoking, physical activity and health

2406 status were assessed by the self-completed questionnaire. Alcohol consumption and

2407 anthropometric measures were assessed during the home visit.

2408

2409 Sociodemographic and economic measures

2410 Participants were asked their country of birth which enabled grouping into the

2411 categories of Australia/New Zealand, Greece/Italy, and Other. Income was grouped

2412 into categories as ‘Age Pension Only’, ‘Age Pension and Other’ or ‘Other’

2413 (superannuation or private income, own business/farm/partnership, wage or salary,

2414 repatriation pension, veterans pension, other, or any possible combination of these

2415 options). Living arrangements were categorized at ‘Living alone’ or ‘Living with

2416 others’, marital status was dichotomized as ‘Married/Partner De factor’ or ‘Not

2417 Married’, and post school qualifications were dichotomized as ‘Yes’ or ‘No’. Men were

2418 also asked about any limitations in access to food and food services, including Meals

2419 On Wheels (MOW).

2420

2421 Lifestyle factors

2422 Smoking status was categorised as never smoked, ex-smoker, and current smoker.

2423 Alcohol was categorized into ‘current drinkers’, ‘lifelong abstainers’ and ‘ex-drinkers’.

165

Nutrient intake and periodontitis in older men

2424 For those who consumed at least 12 drinks in the past year, the frequency and quantity

2425 of alcohol consumption was assessed, enabling categorization of drinkers as either ‘safe

2426 drinkers’ (1–21 drinks per week) or ‘harmful drinkers’ (>21 drinks per week) (168).

2427 Physical activity was measured using the Physical Activity Scale for the Elderly

2428 (PASE) (147).

2429

2430 Anthropometric measurements

2431 Height and weight were measured using standardised digital scales and portable

2432 stadiometer and BMI was calculated as kg/m2 and categorised as ‘underweight’ (less

2433 than 23), ‘normal weight’ (23 – 29.9), and ‘overweight/obese’ (30.0 or over) (166, 167,

2434 206).

2435

2436 Health status

2437 Participants reported on medical conditions through the self-completed questionnaire.

2438 They were asked whether a doctor or a health care provider had told them that they had

2439 any of the following diseases: diabetes, thyroid dysfunction, osteoporosis, Paget’s

2440 disease, stroke, Parkinson’s disease, epilepsy, hypertension, heart attack, angina,

2441 congestive heart failure, intermittent claudication, chronic obstructive lung disease,

2442 liver disease, cancer (excluding non- melanoma skin cancers), osteoarthritis, or gout.

2443 Comorbidity burden was defined as the presence of two or more of these conditions.

2444 Data on self-rated general health (SRH) were obtained and dichotomized into

2445 ‘excellent/good’ versus ‘fair/poor/very poor’. Self-rated oral health (SROH) was also

2446 measured and dichotomized into ‘excellent/very good/good’ versus ‘fair/poor/don’t

2447 know’.

2448

166

Nutrient intake and periodontitis in older men

2449 Ethics approval and informed consent

2450 All participants gave written informed consent. The study was approved by the Concord

2451 Hospital Human Research Ethics Committee (HREC/14/CRGH/17 CH62/6/2014-013).

2452

2453 Statistical analysis

2454 All statistical analyses and calculations were completed using SAS On Demand for

2455 Academics (SAS Institute Inc.). Statistical analysis revealed that none of the nutrients

2456 analyzed were normally distributed (Shapiro Wilk test). Subjects’ energy and nutrients

2457 intakes are reported as medians (5th (P5) and 95th (P95) percentiles) for numerical

2458 values, and percentages for categorical values. A p-value less than 0.05 was considered

2459 statistically significant, and the null hypothesis was rejected.

2460

2461 Logistic regression models were used to examine the unadjusted and adjusted

2462 associations between the dichotomous nutrient variable (referent category = ‘good’

2463 intake), and severe and total periodontitis as the dependent variables of interest. All

2464 logistic regression models were adjusted for age and energy intake, (unless energy was

2465 a component of the outcome). Other potential confounders, including BMI, birth

2466 country, income, smoking, PASE, comorbidity, alcohol intake, self-rated health and

2467 oral health, and post school qualifications, were also screened (P≤0.25). Backwards

2468 stepwise elimination was used to fit the final adjusted models. The Hosmer-Lemeshow

2469 post estimation test was utilised to assess the goodness of fit of the final adjusted model.

2470

2471

2472

2473

167

Nutrient intake and periodontitis in older men

2474

2475 Baseline Participation n = 1705

2476 Did not complete 4th wave of follow-up: n = 924 2477 Deceased: n = 669 Unable to contact/moved: n = 31 2478 Health problems/too old: n = 93 Withdrawn = 56 2479 Other reasons: n = 75 4th wave n = 781 (735 + 46 SCQ

2480 only) Did not complete 4th wave Dietary Assessment: n 2481 = 63 SCQ Only: n = 46 2482 Unable/NESB: n = 14 Refused/Other: n = 3 2483

2484 4th wave Dietary Hx n = 718 Excluded due to dietary misreporting n=1 2485

2486 Did not complete 4th wave Oral Health: n = 339 Deceased: n = 99 2487 Unable to contact/moved/residential care: n = 52 Health problems/too old: n = 115 2488 Other reasons: n = 73

2489 4th wave Oral Health n = 614

2490

2491 Eligible for periodontal examination = 296 2492

2493

2494 Eligible for periodontal examination 2495 and completed Diet Hx = 294

2496

2497 Figure 5.1: Flow chart of 4th wave CHAMP follow up, diet history and

2498 periodontal assessment participation

168

Nutrient intake and periodontitis in older men

2499 5.4 Results

2500 Participants’ characteristics

2501 Sociodemographic, economic, and oral health characteristics of the 294 participants

2502 who completed both the full periodontal assessment and diet history are shown in Table

2503 5.1. Mean age was 83.5 years (± 3.7) and BMI 27.6 kg/m2 (± 4.2). Forty-four percent

2504 of participants were non-smokers, and 72% consumed alcohol at a safe level. Thirty-

2505 seven percent had only the age-pension as their income and 52% were born in Australia

2506 or New Zealand. Almost half of participants had 21 or more natural teeth present (43%),

2507 most participants brushed their teeth more than once a day (63%) and 23% reported

2508 they saw the dentist less frequently than every 2 years. The periodontal examination

2509 revealed most participants had some periodontitis (90%), with 28% of participants

2510 classified as having severe periodontitis. Seventy-two percent of participants had a poor

2511 diet as defined by only meeting recommendations for four or fewer key nutrients.

2512

2513 Individual nutrient intake and adequacy

2514 The median intake of energy was 8801 kJ per day (P5 = 12417 kJ, P95 = 5884 KJ),

2515 with 68% of participants not meeting their energy requirements (Table 5.2). The

2516 percentage contribution to energy from carbohydrate was below recommendations, and

2517 the majority of participants (n=252) were outside the AMDR (45 – 65%). The median

2518 intake of protein per kilogram of body weight was above recommendations and only

2519 11% (n=31) of participants were below the recommended requirements. With respect

2520 to micronutrients, most participants met recommendations for all vitamin intakes,

2521 except for vitamin D, where nearly 100% were below recommendations. Forty-seven

2522 percent (n=147) did not meet vitamin E requirements. Eighty-five percent of

169

Nutrient intake and periodontitis in older men

Table 5.1 Characteristics and periodontitis status of the study population that participated in the periodontal assessment (n=294), compared against characteristics of participants who were excludeda (n=225) Excluded Participants Participantsa Characteristic n (%)/ Mean (±SD) n (%)/ Mean (±SD) Socio-demographic and economic factors Age (years) 75 – 79 43 (15) 48 (17) 80 – 84 143 (49) 96 (43) 85 – 89 86 (29) 60 (27) ≥90 22 (7) 31 (14) Mean 83.5 (±3.7) 84.1 (±4.5)

Marital Status Married/De Facto 220 (75) 159 (71) Other 74 (25) 66 (29) Living Arrangements Live alone 62 (21) 56 (25) Other 232 (79) 169 (75) Source of income Age Pension Only 110 (37) 78 (35) Age Pension + Other 70 (24) 54 (24) Otherb 114 (39) 93 (41) House and Ownership Outright owner 258 (88) 186 (83) Other 36 (12) 38 (17) Post-school qualification Qualifications 178 (61) 143 (64) No qualifications 114 (39) 82 (36) Country of Birth Australia/New Zealand 154 (52) 132 (59) Italy/Greece 71 (24) 44 (20) Other 69 (23) 49 (22)

Health and Lifestyle Factors Body Mass Index (kg/m2) Underweight (<23.0 kg/m2) 35 (12) 20 (9) Normal weight (≥23.0 - <30.0 kg/m2) 174 (60) 135 (61) Overweight/Obese (≥30.0 kg/m2) 82 (28) 65 (30) Mean 27.6 (±4.2) 28.0 (±4.2) Alcohol Consumption Safe drinker (1 – 21 drinks per week) 209 (72) 154 (68) Unsafe drinker (>21 drinks per week) 21 (7) 12 (5) Ex-drinker 41 (14) 38 (17) Lifelong non-drinker 20 (7) 21 (9)

170

Nutrient intake and periodontitis in older men

Smoking Current Smoker 8 (3) 2 (1) Ex-smoker 158 (54) 130 (58) Non-smoker 128 (44) 93 (41) PASE <80 84 (29) 89 (40)* ≥80 210 (71) 136 (60) Mean 115.1 (±64.9) 99.7 (±62.3)* Multimorbidity ≥ 2 165 (56) 174 (77)*

Self-Rated Health Good/Excellent 233 (79) 153 (68) Fair/Poor/Very Poor 61 (21) 72 (32)

Other Factors Able to shop for groceries? Yes 285 (97) 210 (93) No 9 (3) 15 (7) Able to prepare meals? Yes 275 (94) 206 (92) No 18 (6) 18 (8) MOW?3 Yes 11 (4) 12 (5) No 283 (96) 213 (95)

Oral Health Factors Self-Rated Oral Health Good/Very Good/Excellent 208 (71) 160 (71) Fair/Poor/Don’t Know 86 (29) 65 (29) Numbers of Natural Teeth ≥21 126 (43) 112 (50) 11 – 20 106 (36) 73 (32) 1 – 10 62 (21) 40 (18) Tooth brushing > 1 day 185 (63) 125 (56) ≤ 1 day 109 (37) 100 (44) Dentist Visits < every 2 years 68 (23) 36 (18)* Severe Periodontitis Yes 81 (28) - No 213 (72) - Total Periodontitis Yes 263 (89) - No 31 (11) -

PASE, Physical Activity Scale for the Elderly. MOW, Meals On Wheels. a. Participants excluded from the full periodontal assessment

171

Nutrient intake and periodontitis in older men

b. Superannuation or private income, own business/farm/partnership, wage or salary, repatriation pension, veterans pension, or other * P<0.05, Chi-square used to compare proportions, and Wilcoxon-Mann-Whitney test used to compare continuous means. 2523

2524 participants (n=250) did not meet the calcium recommendations, 68% did not meet the

2525 potassium recommendations, and 51% did not meet the magnesium recommendations.

2526

2527 Overall dietary quality, individual nutrients and periodontitis

2528 Table 5.3 shows the unadjusted and adjusted analyses of the association between

2529 nutrient intakes and any periodontitis and severe periodontitis. Seventy-two per cent

2530 (n=211) had poor intake of key nutrients, based on meeting the NRV recommendations

2531 of four or fewer out of possible macronutrients. After adjustment for confounders

2532 participants categorized with poor intake of key nutrients were at higher risk of having

2533 total periodontitis (adjusted OR 2.36 95%CI: 1.05 – 5.27) (Table 5.3). No association

2534 between key nutrients and severe periodontitis was found, even after adjustment for

2535 confounders. Participants who achieved recommended vitamin E levels were at

2536 increased risk of total periodontitis. Not meeting vitamin E intakes was associated with

2537 the reduced prevalence of severe (adjusted OR: 0.51, 95%CI: 0.27 – 0.94) and total

2538 periodontitis (adjusted OR 0.40, 95%CI: 0.16 – 0.97). Top food sources of vitamin E

2539 were olive oil, canola, and sunflower oil. Univariate analysis showed no other

2540 significant associations between nutrient recommendations and total periodontitis.

172

Nutrient intake and periodontitis in older men

Table 5.2 Median daily intake (and 5th/95th percentile) of energy and nutrients, percentage and number of participants not meeting the recommended intake for each nutrient and top food sources Not meeting recommended intake Recommended Intake (male, ≥ 70 years old) Median (P5/P95) % n Top Food sources Energy and Macronutrients Total energy (kJ/d) – EER - 8801.8 68 198 Olive oil, milk, cheese (12417.0/5884.0) Protein (g/kg per d) - EAR 0.86 1.17 (0.7/2.1) 11 31 Protein (g/d) - 92.8 (59.9/137.9) - - Beef, milk, cheese Protein (%E/d) - AMDR 15 – 25 18.0 (13.2/25.9) 22 65 Carbohydrate (g/d) - 199.9 (117.9/307.7) - - Milk, rice, pasta Carbohydrate (%E/d) - AMDR 45 – 65 37.6 (25.8/49.1) 86 252 Total fat (g/d) - 87.7 (44.1/142.4) - - Olive oil, milk, butter Total fat (%E/d) – AMDR 20 – 35 37.1a (24.1/50.1) 64 188 Saturated fat (g/d) - 12.8 (8.0/20.1) - - Milk, butter, olive oil Saturated fat (%E/d) – AMDR <10 12.8 (8.0/20.1) 80 236 Dietary fibre (g/d) – AI 30 25.5 (13.5/41.5) 71 208 Peas, Bananas, Pear Vitamins Thiamin (mg/d) – EAR 1 1.5 (0.7/3.4) 15 44 Weet-Bix, vegemite, Wholemeal bread Riboflavin (mg/d) – EAR 1.3 2.1 (1.2/4.3) 9 27 Milk, vegemite, weet-bix Niacin Equivalent (mg/d) – EAR 12 48.0 (30.1/74.2) 0 0 Milk, weet-bix, Beef Dietary Folate Equivalent (ug/d) – 320 369.1 (201.3/743.7) 34 100 Vegemite, tea, weet-bix EAR Vitamin A (ug/d) – EARb 625 943.6 (408.0/1903.1) 19 57 Carrot, milk, sweet potato

173

Nutrient intake and periodontitis in older men

Vitamin C (mg/d) – EAR 30 107.6 (38.8/254.9) 3 8 Orange, Broccoli, Orange Juice

Vitamin D (u/d) – AIc 15 3.7 (1.5/8.4) 100 293 Ensure, milk, salmon Vitamin E (mg/d) – AI 10 10.3 (4.7/20.4) 47 139 Olive oil, Canola oil, sunflower oil Minerals Calcium (mg/day) – EAR 1100 798.2 (434.0/1408.3) 85 250 Milk, cheese

Phosphorus (mg/day) – EAR 580 1512.4 0 1 Milk, beef, cheese (993.1/2194.1) Iron (mg/day) – EAR 6 12.3 (7.3/20.4) 1 3 Sustagen, weet-bix, beef Magnesium (mg/day) – EAR 350 349.4 (221.7/562.2) 51 149 Milk, banana, coffee Zinc (mg/day) – EAR 12 12.1 (7.4/19.4) 47 137 Beef, milk, weet-bix Potassium (mg/day) – AI 3800 3292.9 68 200 Milk, banana, coffee (2068.3/5157.1) Iodine (ug/day) – AI 100 113.9 (54.6/225.8) 35 104 Milk, porridge, tea

Sodium (mg/day) – UL 2300 2112.4 37 110 Ham, cheese, wholemeal bread (1170.6/3371.9)

174

Nutrient intake and periodontitis in older men

2542 5.5 Discussion

2543 Our study shows an association between dietary intake measured using a key nutrient

2544 intake model and the presence of total periodontitis in community dwelling males, aged

2545 78 years and older. Poor intakes of key nutrients was associated with an increased risk

2546 of total periodontitis, although no relationship was found with severe periodontitis. Not

2547 meeting the recommendations for vitamin E intake was associated with lower

2548 prevalence of severe and total periodontitis even after adjustment for confounders.

2549

2550 Previous studies have shown a relationship between specific nutrients and food groups

2551 and periodontitis in older populations (72, 107, 111, 200). Enonwu et al. suggested that

2552 populations with protein energy malnutrition, and other macro and micronutrient

2553 deficiencies were more susceptible to periodontal disease (207, 208). However, no

2554 studies have reported on associations between intake across a range of key nutrients

2555 and periodontitis in older adults. In our study none of the individual key nutrients had

2556 a significant association with periodontal disease. The finding that the key nutrient

2557 variable, a reflection of total energy intake and six key nutrients, was associated with

2558 any periodontitis suggests that overall quality of the diet may be more important for

2559 periodontal health that type of nutrient. That key nutrient intake was not associated with

2560 severe periodontitis suggests that there are more important factors that diet associated

2561 with more advanced periodontal disease.

2562

2563 Surprisingly, we found that not meeting the recommended intake for Vit E was

2564 associated with decrease odds of periodontitis. In a previous study meeting or

2565 exceeding vitamin E, and other anti-oxidant, recommendations had a protective effect

2566 against periodontal disease (107). That study found that the highest two tertiles of

175

Nutrient intake and periodontitis in older men

2567 vitamin E intake were inversely associated with periodontal disease progression in

2568 older adults (107). Our study’s association between vitamin E and periodontitis may

2569 reflect differences in the quality of the food source that vitamin E comes from. Vitamin

2570 E from lower fat food sources contributes to better periodontal outcomes, whereas

2571 intakes derived from higher fat sources of vitamin E, such as vegetable oil may

2572 contribute to worse outcomes (209). A higher ratio of n-6 poly unsaturated fatty acids

2573 to n-3 polyunsaturated fatty acids has been associated with poorer periodontal outcomes

2574 in older adults (104). As such the anti-oxidant benefits from a higher intake of vitamin

2575 E, to explain the association in other studies, may have been negated by a high n-6

2576 polyunsaturated to n-3 polyunsaturated fatty acid ratio from vitamin E sources in our

2577 study (75, 104, 107).

2578

2579 Consistent with previous studies (108, 197, 210), we found that men not meeting their

2580 calcium requirements were more likely to have periodontitis (p=0.06) but this

2581 association did not reach conventional statistically significance. One study in older

2582 adults showed that higher total calcium intake and calcium from fermented dairy foods

2583 and milk was associated with less periodontal disease (108). Another cross-sectional

2584 study, in adult women also found similar results, where the highest quartile of calcium

2585 intake was associated with lower prevalence of periodontitis compared with the lowest

2586 quartile of calcium intake (197). Furthermore, one study, which used the same

2587 definition of severe periodontitis as our study, identified that older adults who met

2588 calcium recommendations were less likely to have severe periodontitis (210). The

2589 contrast in significant outcomes in our study, compared to others, could be due to low

2590 statistical power from a smaller sample.

2591

176

Nutrient intake and periodontitis in older men

2592 We observed no relationship between protein intakes and periodontitis. Animal studies

2593 indicate that insufficient protein intake could lead to the ‘degeneration’ of the alveolar

2594 bone, periodontum and gingiva (211). More recently an observational study of adults

2595 aged 18 years and older found a high intake of whey protein was associated with low

2596 prevalence of severe periodontitis (210). This study used the same definition for severe

2597 periodontitis as in our study (210). We also did not find a relationship between

2598 periodontitis and meeting recommended intakes for SFA. Iwasaki et al. found that

2599 higher intakes of SFA was associated with periodontal disease and attachment loss in

2600 non-smoking older adults (105). Our study found no relationship between fibre and

2601 periodontitis, in contrast to other studies. A relationship between fibre rich foods and

2602 the progression of periodontal disease factors such as ‘pocket probing depth’ and

2603 ‘alveolar bone loss’ was found in a study on older men (111). Other studies have found

2604 significant associations between fruits and vegetables, food groups typically high in

2605 fibre, with periodontal disease (72, 107, 111).

2606

2607 Our findings suggest no relationship between vitamin C and periodontitis in older aged

2608 men. Past studies that investigated this relationship have found mixed results. In older

2609 Japanese adults those with the highest intakes of vitamin C had the lowest risk of

2610 periodontal disease (107). Another recent cross-sectional study in Korea found that, in

2611 adults aged 60 years and older, there was no association between meeting

2612 recommended dietary intake of vitamin C and presence of periodontal disease (109). In

2613 comparison, the same study found meeting vitamin C recommendations is significantly

2614 associated with a lower risk of periodontal disease in younger age groups (109). The

2615 difference in outcomes between periodontitis with nutrients such as protein, vitamin C

177

Nutrient intake and periodontitis in older men

2616 and fibre, may be due to the small sample size and therefore poor statistical power. It

2617 could also reflect that the overall quality of diet impacts periodontitis.

2618

2619 There are limitations to this study. Firstly as the analysis is cross-sectional the direction

2620 of the association cannot be established. Previous research suggests that diets impacts

2621 periodontitis (72, 104, 107, 108, 210), however some of the results from our study could

2622 be indicative of an association in the opposing direction as it possible that periodontitis

2623 impairs nutritional intake by interfering with mastication (212). The second limitation

2624 is the size of the sample, which means we had limited statistical power to detect

2625 associations. Furthermore, the generalizability of our results to other populations, such

2626 as community dwelling older women or institutionalized populations, is not clear. The

2627 representativeness of our study group to the older men in the population they were

2628 recruited from is diminished by the exclusion criteria for full periodontal assessment.

2629 Another limitation is that diet could change over decades and it is possible that the

2630 current periodontitis disease was impacted by historical rather than recent dietary

2631 intake.

2632

2633 This study only measured three sites on the buccal side of each tooth. The gold standard

2634 is measuring six sites on each tooth, on the buccal and lingual sides (213). As such it is

2635 possible that measuring only three sites per tooth led to an underestimation of the

2636 presence and extent of periodontitis. However this method of measuring periodontitis

2637 has been validated against the gold standard and has been used in past studies (32, 214).

2638 One of the strengths of this study was that we used a validated diet history method

2639 administered by trained dietitians (169). This particular method to collect dietary and

2640 subsequently nutritional information is also not subject to short term memory recall and

178

Nutrient intake and periodontitis in older men

Table 5.3 Associations between intake of key nutrients and dietary intake of macronutrients and micronutrients with the presence of total and severe periodontitis Total Periodontitis Severe Periodontitis Variables Unadjusted OR (95%CI) Adjusted ORa (95%CI) Unadjusted OR (95%CI) Adjusted ORaa (95%CI) Key Nutrient intakebc Good Intake 1.00 1.00 1.00 1.00 Poor Intaked 1.99 (0.93 – 4.28) 2.36 (1.05 – 5.27)e 0.91 (0.52 – 1.60) 0.85 (0.45 – 1.58) Total energy (kJ/d) – EERc Meeting 1.00 1.00 1.00 1.00 Not Meeting 1.59 (0.74 – 3.39) 2.26 (0.98 – 5.22) 0.88 (0.51 – 1.50) 0.92 (0.50 – 1.68)

Macronutrients Protein (%E/d) – AMDR Meeting 1.00 1.00 1.00 1.00 Not Meeting 1.54 (0.57 – 4.18) 1.33 (0.47 – 3.75) 1.01 (0.55 – 1.87) 0.80 (0.40 – 1.63) Carbohydrate (%E/d) – AMDR Meeting 1.00 1.00 1.00 1.00 Not Meeting 0.88 (0.29 – 2.65) 1.21 (0.38 – 3.84) 1.08 (0.52 – 2.27) 0.75 (0.33 – 1.71) Total fat (%E/d) – AMDR Meeting 1.00 1.00 1.00 1.00 Not Meeting 0.83 (0.38 – 1.83) 1.00 (0.43 – 2.30) 0.88 (0.52 – 1.49) 0.83 (0.46 – 1.50) Saturated fat (%E/d) – AMDR Meeting 1.00 1.00 1.00 1.00 Not Meeting 1.21 (0.50 – 2.97) 1.34 (0.52 – 3.48) 0.81 (0.43 – 1.51) 0.99 (0.48 – 2.03) Dietary fibre (g/d) – AI Meeting 1.00 1.00 1.00 1.00 Not Meeting 1.17 (0.53 – 2.61) 1.21 (0.49 – 2.98) 1.06 (0.60 – 1.86) 1.01 (0.51 – 2.02)

179

Nutrient intake and periodontitis in older men

Micronutrients Vitamins Thiamin (mg/d) – EAR Meeting 1.00 1.00 1.00 1.00 Not Meeting 1.72 (0.50 – 5.93) 2.61 (0.65 – 10.23) 0.98 (0.48 – 2.02) 0.54 (0.23 – 1.31) Riboflavin (mg/d) – EAR Meeting 1.00 1.00 1.00 1.00 Not Meeting 0.94 (0.27 – 3.31) 0.95 (0.23 – 3.88) 0.91 (0.37 – 2.25) 0.43 (0.14 – 1.28) Dietary Folate Equivalent (ug/d) – EAR Meeting 1.00 1.00 1.00 1.00 Not Meeting 1.09 (0.49 – 2.42) 1.20 (0.50 – 2.93) 1.04 (0.60 – 1.77) 0.92 (0.48 – 1.76) Vitamin A (ug/d) – EARf Meeting 1.00 1.00 1.00 1.00 Not Meeting 2.41 (0.71 – 0.82) 2.94 (0.78 – 11.0) 0.73 (0.37 – 1.45) 0.70 (0.32 – 1.54) Vitamin C (mg/d) – EAR Meeting 1.00 1.00 1.00 1.00 Not Meeting 0.34 (0.07 – 1.75) 0.30 (0.05 – 1.92) 1.60 (0.37 – 6.86) 1.34 (0.25 – 7.02) Vitamin D (u/d) – AIg Meeting 1.00 1.00 1.00 1.00 Not Meeting <0.001 (<0.001 – >999.9) <0.001 (<0.001 – >999.9) <0.001 (<0.001 – >999.9) <0.001 (<0.001 – >999.9) Vitamin E (mg/d) – AI Meeting 1.00 1.00 1.00 1.00 Not Meeting 0.62 (0.29 – 1.31) 0.40 (0.16 – 0.97)e 0.45 (0.26 – 0.77)e 0.42 (0.20 – 0.84)e Minerals Calcium (mg/day) – EAR Meeting 1.00 1.00 1.00 1.00 Not Meeting 2.19 (0.91 – 5.28) 2.64 (0.97 – 7.22) 1.17 (0.56 – 2.44) 0.91 (0.39 – 2.16)

180

Nutrient intake and periodontitis in older men

Iron (mg/day) – EAR Meeting 1.00 1.00 1.00 1.00 Not Meeting >999.9 (<0.001 – >999.9) >999.9 (<0.001 – >999.9) 1.32 (0.12 – 14.8) 4.26 (0.33 – 54.8) Magnesium (mg/day) – EAR Meeting 1.00 1.00 1.00 1.00 Not Meeting 1.48 (0.70 – 3.15) 1.64 (0.64 – 4.23) 0.76 (0.45 – 1.27) 0.55 (0.27 – 1.11) Zinc (mg/day) – EAR Meeting 1.00 1.00 1.00 1.00 Not Meeting 1.24 (0.58 – 2.62) 1.02 (0.41 – 2.53) 0.95 (0.57 – 1.59) 0.75 (0.38 – 1.46) Potassium (mg/day) – AI Meeting 1.00 1.00 1.00 1.00 Not Meeting 1.39 (0.65 – 3.01) 1.42 (0.59 – 3.42) 0.92 (0.53 – 1.58) 0.98 (0.49 – 1.95) Iodine (ug/day) – AI Meeting 1.00 1.00 1.00 1.00 Not Meeting 1.00 (0.46 – 2.17) 0.98 (0.41 – 2.33) 0.95 (0.56 – 1.63) 0.83 (0.43 – 1.60) Sodium (mg/day) – UL Meeting 1.00 1.00 1.00 1.00 Not Meeting 0.81 (0.38 – 1.72) 0.90 (0.37 – 2.17) 0.84 (0.49 – 1.44) 0.82 (0.43 – 1.60)

OR, Odds Ratio. EER, Estimated Energy Requirements. AMDR, Accepted Macronutrient Distribution Range. NRV, Nutrient Reference Values. EAR, Estimated Average. AI, Adequate Intake. a Adjusted for age, energy, BMI, comorbidity, post school qualifications, tooth brushing and alcohol. aa Adjusted for age, energy, COB, post school qualifications, smoking and alcohol. b Key Nutrients: total energy and six other nutrients, protein, calcium, iron, zinc, riboflavin, and vitamin D c Not adjusted by energy intake d Poor intake: Meeting recommendations for ≤ 4 or less. e Statistically significant finds, p-value <0.05 f Retinol Equivalents g Vitamin D data should be interpreted with caution. 2641

181

Nutrient intake and periodontitis in older men

2642 is not limited in the responses or information that could be provided (193). However

2643 all measures of nutrient intakes are only estimates, and the results for vitamin D in

2644 particular (see Methods) should be interpreted with caution (203). Another strength is

2645 that calibrated oral health assessments were conducted by experienced professionals,

2646 providing objective clinical measures on gingival recession, probing depth of

2647 periodontal pockets, and numbers of natural teeth. This is a similar standard to other

2648 epidemiological studies of oral health (32).

2649 2650 In conclusion this study suggests, for the first time, that not meeting key nutrient

2651 recommendations is associated with periodontitis It is of interest that our study

2652 suggests vitamin E is a potential factor contributing to total and severe periodontitis in

2653 older men. Future research should be conducted to clarify the relationship between

2654 periodontal disease with individual nutrients, and food groups.

182

2655

2656

2657

2658

2659

2660

2661

2662

2663

2664 CHAPTER 6: ASSOCIATIONS BETWEEN NUTRIENT INTAKE AND TOOTH

2665 DECAY IN OLDER MEN: THE CONCORD HEALTH AND AGEING IN MEN

2666 PROJECT

2667 (As submitted to Caries Research, 14.11.2020, under peer review)

2668 Authors: Kate Milledge, Frederick A C Wright, Joerg Eberhard, Robert G Cumming,

2669 Vasi Naganathan, Fiona M Blyth, David G Le Couteur, Louise M Waite, David J

2670 Handelsman, Vasant Hirani.

2671

2672

2673

2674

2675

2676

2677

2678

2679

183

Nutrient intake and tooth decay in older men

2680 6.1 Abstract

2681 Objective: Poor nutrition is a risk factor for dental decay in younger people, but it is

2682 unclear if this is true in older age groups. The aim of this study was to analyze the

2683 associations between dietary intake of nutrients and diet quality and presence of dental

2684 decay in community dwelling older men.

2685

2686 Design: A cross-sectional study with a standardized validated diet history assessment

2687 and comprehensive oral health examination in 520 community dwelling men (mean

2688 age: 84 years) participating in the Concord Health and Ageing in Men Project. Nutrient

2689 Reference Values (NRVs) were used to determine if individual micronutrients and

2690 macronutrients were meeting recommendations. Acceptable Macronutrient

2691 Distribution Ranges (AMDR) were attained for fat and carbohydrate intakes and were

2692 incorporated into variable to determine if the participants were consuming a high fat

2693 and low carbohydrate diet. Presence of coronal decay was defined as ‘≥1 coronal

2694 decayed surface,’ while presence of severe coronal decay was defined as ‘≥3 coronal

2695 decayed surfaces’. Presence of root decay was categorized as ‘≥1 decayed root surface,’

2696 while presence of severe root decay was categorized as ‘≥3 decayed root surfaces’.

2697

2698 Results: Adjusted logistic regression showed not meeting the recommended intakes for

2699 zinc (odds ratio (OR): 2.32 95% confidence interval (CI) 1.15 - 4.67), and thiamin (OR:

2700 1.71, 95% CI 1.71 – 6.48) were associated with presence of severe root decay. Adjusted

2701 analysis also showed that participants who were outside the recommended AMDR for

2702 fat (OR: 0.56, 95% CI 0.35 – 0.91), and those who consumed a high fat and low

2703 carbohydrate diet (OR: 0.61, 95% CI 0.38 – 0.98) were less likely to have coronal tooth

2704 decay.

184

Nutrient intake and tooth decay in older men

2705 Conclusions: Our study shows statistically significant associations between

2706 micronutrients and macronutrients and coronal and root surface decay. Although this

2707 study cannot prescribe causality, diet has an important association with dental decay in

2708 older adults.

2709

2710

2711

2712

2713

2714

2715

2716

2717

2718

2719

2720

2721

2722

2723

2724

2725

2726

2727

2728

2729

185

Nutrient intake and tooth decay in older men

2730 6.2 Introduction

2731 Dental caries is an ongoing global problem across all age groups. However, new and

2732 recurrent caries is increasingly an issue for older adults, as each subsequent generation

2733 continues to have greater retention of teeth (32, 35, 36). Compared to the 1987-88

2734 National Oral Health Study of Australia (NOHSA) edentulism rates for older adults

2735 aged 75 years and older were considerably lower in the 2004-2006 NSAOH (32, 35).

2736 Continued retention of more natural teeth, and risk of caries, will lead to increased

2737 demand for dental care amongst older adults (35, 36).

2738

2739 There are a number of risk factors for dental caries, including access to fluoride, oral

2740 hygiene and dietary factors (69, 75). Studies show that dental decay is strongly linked

2741 to sugar consumption, or foods high in sugar among children and adults (69, 120). The

2742 World Health Organisation (WHO) recommended that to reduce the rates of dental

2743 decay, as well as of obesity, adults and children should reduce their intake of sugar to

2744 contribute to less than 10% of their energy intake (118).

2745

2746 Previous population studies suggest that intakes of sugar contributing to more than 10%

2747 of energy intakes also show a positive linear dose-response relationship with dental

2748 decay (117). Furthermore, earlier cross-sectional studies and literature reviews show

2749 that increased frequency of dental caries is associated with higher intakes of

2750 fermentable carbohydrates, sugar sweetened beverages, phosphorus, high Glycemic

2751 Index (GI) foods, and diet quality (73-75, 215). Other population studies have found an

2752 inverse association between dental caries and intakes of fruit and vegetables, grain and

2753 dairy products, particularly yoghurt (72, 73, 115).

2754

186

Nutrient intake and tooth decay in older men

2755 Research examining the relationship between nutrition and dental caries amongst older

2756 adults however are limited. A longitudinal study found that lower prevalence of dental

2757 caries was associated with increased consumption of ‘milk and milk products’ among

2758 elderly Japanese participants (72). Another study found that adults, aged 48 – 78 years

2759 old with, root caries reported higher consumption of sugar than adults without untreated

2760 root caries (216). The same study found that adults with root caries had more frequent

2761 consumption of fermentable carbohydrates than adults without root caries (216).

2762

2763 Overall, with increasing demand for oral health care due to dental cares among older

2764 adults it is important to examine the association between dietary intake of nutrients with

2765 dental decay, particularly with limited research available in in older adult populations.

2766 Therefore, the aim of this study is to analyze the association between presence of dental

2767 decay and dietary intake of nutrients, as well as overall diet quality, in community

2768 dwelling older men.

2769

2770

2771 6.3 Methods

2772 Study Population

2773 The Concord Health and Ageing in Men Project (CHAMP) is an ongoing longitudinal

2774 study, established in 2005, to investigate the health of men aged 70 years and older

2775 (144). Recruitment of subjects for the CHAMP study is described in detail elsewhere

2776 (144). Briefly, participants were selected from the NSW electoral roll from the

2777 geographical locations of Burwood, Canada Bay and Strathfield in Sydney, and

2778 excluded individuals living in an aged care facility at time of recruitment (144). Eligible

2779 men were sent a letter and were followed up via telephone. Of the 2,815 eligible men

187

Nutrient intake and tooth decay in older men

2780 with whom contact was made, 1,511 (54%) agreed to participate in the study. An

2781 additional 194 eligible men living in the study area heard about the study from friends

2782 or the local media and were recruited after contacting the study investigators prior to

2783 being identified through the electoral roll, yielding a total of 1,705 subjects. Participants

2784 completed a self-administered questionnaire and attended a clinic at Concord Hospital

2785 that included an interview and clinical assessment at 1st wave (baseline), 2nd wave (2

2786 year) and third wave (5 year) follow ups. At the 3rd wave of data collection of nutritional

2787 data was added via a separate home visit. For the fourth wave of data collection (8-year

2788 follow up) men were seen predominantly in their homes. In addition to the self-

2789 completed questionnaire and some sections of the clinic assessments collected in

2790 previous waves, an oral health questionnaire and examination were conducted along

2791 with a diet history interview.

2792

2793 Data collection

2794 The fourth wave CHAMP follow up involved two home visits. The first, which

2795 collected clinical health and dietary information, was conducted by one of three trained

2796 dietitians. The second visit, which included the oral health assessment, was conducted

2797 by one of two trained oral health therapists using a standardized clinical protocol. A

2798 self-completed questionnaire (SCQ), collecting sociodemographic, economic and

2799 health information, was sent to the participant’s home prior to the first visit. Of the

2800 original 1,705 participants, only 781 participated in the fourth wave of data collection.

2801 Main reasons for non-participation were death (72.4%) or illness/age (10.1%). Forty-

2802 six participants completed the self-administered questionnaire only, 735 completed the

2803 clinical assessment, 718 completed the dietary assessment and 614 participants

2804 underwent the oral health examination. Of those who underwent the oral health

188

Nutrient intake and tooth decay in older men

2805 examination, 524 were eligible for assessment of coronal and root decay, while 90 men

2806 were edentate (had no natural teeth). Respondents who completed the oral health

2807 examination were significantly younger and less likely to live alone than those who did

2808 not complete the oral health assessment. Respondents and non-respondents for the oral

2809 health assessment did not differ significantly in income, marital status, post school

2810 qualifications, country of birth, multi-morbidity, smoking status, and body mass index

2811 (BMI) (data not shown).

2812

2813 Measurements

2814 Dietary intake

2815 Diet histories were administered using a standardized and validated interview method

2816 (169, 170). A structured questionnaire with open-ended questions, adapted from

2817 Sydney South West Area Health Service outpatient’s diet history form, was the tool

2818 used by interviewers to ask participants about their usual dietary intake during the last

2819 three months (169). Food quantities were established by food models, photographs and

2820 household measures, such as measuring spoons (171). A checklist was included to

2821 corroborate commonly consumed foods items that may have been forgotten. Relatives,

2822 carers and/or family members of CHAMP men were encouraged to be present in the

2823 interview, to aid in participants memory recall (169, 172). Validity of this method was

2824 established in a previous study in a sub-group of 56 CHAMP men, which compared the

2825 diet history to a 4 day weighed food record (169). The interquartile range was used to

2826 identify potential outliers of energy intake (173). Individual diet histories of potential

2827 outliers were identified and examined. Only one was identified as having an unrealistic

2828 intake of food and excluded from the data set (173).

2829

189

Nutrient intake and tooth decay in older men

2830 Oral health data collection

2831 During the oral health assessment participants were asked by interviewers about

2832 perceptions of pain, chewing ability and dental care, before continuing to a dental

2833 examination by calibrated examiners. During the examination individual teeth were

2834 categorized as ‘present permanent tooth’, ‘implant’, ‘missing and replaced’, ‘missing

2835 and not replaced’, ‘root fragment decayed’ and ‘root fragment not decayed’.

2836 Assessments also recorded whether the participant had partial or full maxillary and

2837 mandibular dentures, and if the dentures were likely to be defective – that is, non-

2838 retentive, not in occlusion, unstable or had any large defects. Decay experiences on both

2839 coronal and root tooth surfaces were recorded.

2840

2841 Data handling

2842 Dietary records were converted to nutrient intakes using FoodWorks 7 Professional for

2843 Windows (Xyris Software (Australia) Pty Ltd), which uses the Australian Food,

2844 Supplement and Nutrient Database 2007 (AUSNUT 2007) (28). This database has a

2845 maximum of 37 nutrient values available for 4425 foods (174). Vitamin D values from

2846 AUSNUT 2007 need to be interpreted with caution due to the small set of analyses from

2847 which the values have been obtained and the assumptions that were made (203). To

2848 ensure consistent entry of diet histories a coding manual developed during the nutrition

2849 collection at the 3rd wave of data collection, which was updated and utilized at the 4th

2850 wave to define and standardize 1,650 food items.

2851

2852 Dietary intake of nutrients

2853 Participant’s median daily dietary intakes for energy, carbohydrates, sugar, protein,

2854 total fats, polyunsaturated fatty acids (PUFA), dietary fibre, alcohol, sodium,

190

Nutrient intake and tooth decay in older men

2855 potassium, iodine, iron, phosphorus, calcium, magnesium, zinc, dietary folate

2856 equivalents, thiamin, niacin, riboflavin and vitamins A, C, D & E were compared to

2857 the respective NRV recommendations for males aged 71 years and older (176). Vitamin

2858 B6 and Vitamin B12 were not available in AUSNUT 2007, and therefore were not

2859 included in the analysis. Furthermore, only sodium available naturally in foods and

2860 added during processing food products was included in the analysis. Percentage of

2861 energy from carbohydrates, protein and fat were compared to the Acceptable

2862 Macronutrient Distribution Range (AMDR) and protein intake per kilogram of body

2863 weight was calculated (176). Daily energy intakes were also compared to participants

2864 Estimated Energy Requirements (EER) calculated using Basal Metabolic Rate (BMR)

2865 (with a Physical Activity Level of 1.6 for light activity).

2866

2867 Attainment of the NRV for total energy and the six macronutrients: protein (g/kg of

2868 body weight), total fat (AMDR), saturated fat (AMDR), carbohydrate (AMDR), long

2869 chain omega 3 fatty acids, and fibre, were counted for each participant and

2870 dichotomized into a ‘Macronutrient’ risk variable, where meeting requirements for five

2871 or more nutrients was classed as ‘good’, and meeting requirements for four or less

2872 nutrients was classed as ‘poor’ (28). Similarly the attainment of the NRV for 16

2873 micronutrients, sodium, potassium, iodine, phosphorus, calcium, magnesium, zinc,

2874 iron, dietary folate equivalents, thiamin, niacin, riboflavin and vitamins A, C, D & E

2875 were counted for each participant and a dichotomized ‘Micronutrient’ risk variable was

2876 created (28, 84). Meeting the requirements for 12 or more nutrients was classed as

2877 ‘good’, and meeting requirements for 11 or less nutrients was classed as ‘poor’ (28, 84).

2878 Finally a variable was created to measure whether participants adhered to a diet with

2879 high contributions of energy intake from fat, and low contributions of energy from

191

Nutrient intake and tooth decay in older men

2880 carbohydrates (176). Participants who had more than 35% of energy intake contribution

2881 from fat, and had less than 45% of their energy intake contributed from carbohydrates,

2882 were classed as consuming a high fat to low carbohydrate diet (176).

2883

2884 Coronal and root decay

2885 Dental decay can occur on both the crown (coronal surfaces) and exposed root surfaces

2886 of teeth. For the ‘presence of coronal decay’, participants were dichotomised into two

2887 categories, those with ‘one or more coronal decayed surfaces’, and those with ‘no

2888 coronal decayed surfaces’. The ‘presence of root decay’ in participants was also

2889 categorized with ‘one or more decayed root surfaces’, or those with ‘no decayed root

2890 surfaces’. The severity of coronal and root decay was also assessed. Participants who

2891 had ‘three or more coronal decayed surfaces’ were categorized as ‘severe coronal

2892 decay’, and participants with ‘fewer than three coronal decayed surfaces’ as ‘no severe

2893 coronal decay’. Similarly participants who had ‘three or more decayed root surfaces’

2894 were categorized with ‘severe root decay’, and participants with ‘fewer than three

2895 decayed root surfaces’ categorized as ‘no severe root decay’.

2896

2897 Dentition and oral hygiene

2898 Dentition was categorized according to the composition of teeth and/or their

2899 replacement (natural only dentition, mixed dentition, and replaced (prosthetic) only

2900 dentition), and numbers of natural teeth were grouped, (21 or more teeth, 11 – 20 teeth,

2901 1 – 10 teeth and edentulous – no natural teeth). Oral hygiene was assessed by self-

2902 reported frequency of how often participants cleaned their teeth. Categories were

2903 dichotomised as those who cleaned their teeth ‘twice or more day’ vs ‘once a day or

2904 less’. Frequency of visits to the dentist was also assessed through the self-reported

192

Nutrient intake and tooth decay in older men

2905 questionnaire. Participants were dichotomised as seeing the dentist ‘at least once every

2906 two years’, or ‘less often than once every two years’.

2907

2908 Other measurements

2909 Sociodemographic and economic measures, smoking, physical activity and health

2910 status were assessed by the self-completed questionnaire. Alcohol consumption and

2911 anthropometric data were collected during the first home visit.

2912

2913 Sociodemographic and economic measures

2914 Country of birth was grouped into the categories; Australia/New Zealand, Greece/Italy,

2915 and Other. Income was grouped into categories of ‘Age Pension Only’, ‘Age Pension

2916 and Other’ or ‘Other’ (superannuation or private income, own

2917 business/farm/partnership, wage or salary, repatriation pension, veteran’s pension,

2918 other, or any possible combination of these options). Living arrangements were

2919 categorized at ‘Living alone’ or ‘Living with others’, marital status was dichotomized

2920 as ‘Married/Partner De factor’ or ‘Not Married’, and post school qualifications were

2921 dichotomized as ‘Yes’ or ‘No’. Men were also asked about any limitations in access to

2922 food and food services, including Meals On Wheels (MOW).

2923

2924 Lifestyle factors

2925 Smoking status (‘never smoker’, ‘ex-smoker’, ‘current smoker’) was assessed, as was

2926 alcohol. Participants were categorized into ‘current non-drinkers’, ‘lifelong abstainers’

2927 and ‘ex-drinkers’. Alcohol consumption in participants were categorized as ‘current

2928 non-drinkers’, ‘lifelong abstainers’ and ‘ex-drinkers’. For those who consumed at least

2929 12 drinks in the past year frequency and quantity of alcohol consumption was assessed.

193

Nutrient intake and tooth decay in older men

2930 Drinkers were then categorised as either ‘safe drinkers’ (1–21 drinks per week) or

2931 ‘harmful drinkers’ (>21 drinks per week) (168). Physical activity was measured using

2932 the Physical Activity Scale for the Elderly (PASE), a validated tool that scores the level

2933 of physical activity in individuals aged 65 years or older (147).

2934

2935 Anthropometric measurements

2936 Height and weight were measured using standardised digital scales and portable

2937 stadiometer and BMI was calculated as kg/m2 and categorised as ‘underweight’ (less

2938 than 23), ‘normal weight’ (23 – 29.9), and ‘overweight/obese’ (30.0 or over) (166, 167).

2939

2940 Health Status

2941 Participants reported on medical conditions through the self-completed questionnaire.

2942 They were asked whether a doctor or a health care provider had told them that they had

2943 any of the following diseases: diabetes, thyroid dysfunction, osteoporosis, Paget’s

2944 disease, stroke, Parkinson’s disease, epilepsy, hypertension, heart attack, angina,

2945 congestive heart failure, intermittent claudication, chronic obstructive lung disease,

2946 liver disease, cancer (excluding non- melanoma skin cancers), osteoarthritis, and gout.

2947 For the purposes of this study, comorbidity burden was defined as the presence of two

2948 or more of these conditions (164). Data on self-rated general health (SRH) were

2949 obtained and dichotomized into ‘excellent/good’ versus ‘fair/poor/very poor’. Self-

2950 rated oral health (SROH) was also measured and dichotomized into ‘excellent/very

2951 good/good’ versus ‘fair/poor/don’t know’.

2952

2953

2954

194

Nutrient intake and tooth decay in older men

2955 Ethics approval and informed consent

2956 All participants gave written informed consent. The study was approved by the Sydney

2957 South West Area Health Service Human Research Ethics Committee, Concord

2958 Repatriation General Hospital, Sydney, Australia (HREC/14/CRGH/17 CH62/6/2014-

2959 013).

2960

2961 Statistical analysis

2962 All statistical analyses and calculations were completed using SAS On Demand for

2963 Academics (SAS Institute Inc.). Statistical analysis of distribution revealed that none

2964 of the nutrients analyzed were normally distributed (Shapiro Wilk). Subjects’ energy

2965 and nutrients intakes are reported as medians (5th (P5) and 95th (P95) percentiles) for

2966 numerical values, and percentages for categorical values. A p-value less than 0.05 was

2967 considered statistically significant, and the null hypothesis was rejected.

2968

2969 Logistic regression models were used to examine the unadjusted and adjusted

2970 associations between the dichotomous nutrient variable (referent category = ‘good’

2971 intake), and the coronal and root decay variables. All logistic regression models were

2972 controlled for age and energy intake, unless energy was a component of the exposure

2973 variable. Other potential confounders, including oral hygiene, dentist visits, BMI, birth

2974 country, income, smoking, PASE, comorbidity, alcohol intake, self-rated health and

2975 oral health, and post school qualifications, were also screened (P≤0.25). Backwards

2976 stepwise elimination was used to fit the final adjusted models. The Hosmer-Lemeshow

2977 post estimation test was utilised to assess the goodness of fit of the final adjusted model.

2978

2979

195

Nutrient intake and tooth decay in older men

2980 6.4 Results

2981 A total of 520 participants completed both the diet history assessment and the dental

2982 decay examination. The demographic characteristics and dental status of participants is

2983 shown in Table 6.1. Mean age was 83.8 ± 4.1 years (age range: 78 – 99 years), and

2984 38.5% of participants were aged 85 years and older. The majority of men were married

2985 or in a de facto relationship (73%, n= 73), had an alternative income to the age pension

2986 (64%, n= 207), did not live alone (77%, n= 401), and were born in Australia (54%, n=

2987 280). Mean BMI was 27.8 ± 4.2 kg/m2), and mean number of natural teeth was 18.2 ±

2988 7.5 teeth. The majority did not currently smoke (98%, n= 510), and had safe levels or

2989 no alcohol consumption (94% n= 484). Coronal decay was present in 20% (n= 103) of

2990 participants and severe coronal decay was present in 6% (n= 30). Furthermore, 23%

2991 (n= 122) had some root decay and 13% (n= 69) had severe root decay.

2992

2993 Analysis of Nutrients and overall dietary intakes

2994 Intake of individual nutrients, and whether they met NRV recommendations are

2995 represented in Table 6.2. Those who were classified as having a high contribution of

2996 energy from fat intake and low contribution of energy from carbohydrate intake were

2997 less likely to have coronal decay (Table 6.3). Meeting 5 or more intake of

2998 macronutrients (macronutrient risk variable) was significantly associated with being

2999 less likely to have coronal decay after adjustment for confounder. Similarly participants

3000 who were not within the recommended percentage of energy intake from fat (AMDR)

3001 were also significantly less likely to have coronal tooth decay, after adjustment for

3002 confounders.

3003

3004

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Nutrient intake and tooth decay in older men

Table 6.1 Characteristics and decay status of the study population Characteristics n (%)/ Mean (±SD) Socio-demographic and economic factors Age (years) 75 – 79 81 (16) 80 – 84 239 (46) 85 – 89 147 (28) ≥90 53 (10) Mean 83.8 (±4.1) Marital Status Married/De Facto 379 (73) Other 141 (27) Living Arrangements Live alone 119 (23) Other 401 (77) Source of income Age Pension Only 189 (36) Age Pension + Other 124 (24) Othera 207 (40) House and Ownership Outright owner 444 (86) Other 75 (15) Post-school qualification Qualifications 322 (62) No qualifications 196 (38) Country of Birth Australia/New Zealand 280 (54) Italy/Greece 115 (22) Other 125 (24)

Health and Lifestyle Factors Body Mass Index (kg/m2) Underweight (<23.0 kg/m2) 55 (11) Normal weight (≥23.0 - <30.0 kg/m2) 310 (61) Overweight/Obese (≥30.0 kg/m2) 147 (29) Mean 27.8 (±4.2) Alcohol Consumption Safe drinker (1 – 21 drinks) 364 (70) Unsafe drinker (>21 drinks) 33 (6) Ex-drinker 79 (15) Lifelong non-drinker 41 (8) Smoking Current Smoker 10 (2) Ex-smoker 289 (56) Non-smoker 221 (43) PASE <80 173 (33)

197

Nutrient intake and tooth decay in older men

≥80 347 (67) Mean 108.4 (±64) Multimorbidity ≥ 2 339 (65) Self-Rated Health Good/Excellent 387 (74) Fair/Poor/Very Poor 133 (26)

Other Factors Able to shop for groceries? Yes 496 (95) No 24 (5) Able to prepare meals? Yes 482 (93) No 36 (7) MOW?3 Yes 23 (4) No 497 (96)

Oral Health Factors Self-Rated Oral Health Good/Very Good/Excellent 369 (71) Fair/Poor/Don’t Know 151 (29) Numbers of Natural Teeth ≥21 238 (46) 11 – 20 179 (34) 1 – 10 103 (20) Teeth brushing > 1 day 310 (60) ≤ 1 day 210 (40) Dentist Visits < every 2 years 105 (20) Coronal Decay ≥1 103 (20) Severe Coronal Decay ≥3 30 (6) Root Decay ≥1 122 (23) Severe Root Decay ≥3 69 (13)

PASE, Physical Activity Scale for the Elderly. MOW, Meals On Wheels. a. Superannuation or private income, own business/farm/partnership, wage or salary, repatriation pension, veterans pension, or other. 3005

3006

198

Nutrient intake and tooth decay in older men

3007 In unadjusted analysis, those who were not within the recommended percentage of

3008 energy intake from carbohydrates (AMDR) were significantly less likely to have root

3009 decay; however, with adjustment for confounders, the association was no longer

3010 statistically significant (p=0.06) (Table 6.4). Not meeting recommendations for fibre

3011 intake was significantly associated with the presence of root decay, even after

3012 adjustment for confounders.

3013

3014 No significant associations between severe coronal decay and diet were observed

3015 (Supplementary Table 6.1). Unadjusted analysis showed that not meeting the

3016 recommended intakes for zinc and thiamin was associated with the presence of severe

3017 root decay (Table 6.5), which remained significantly associated after adjustment for

3018 confounders. Multivariate analysis showed that participants who had overall poor

3019 intake of micronutrients were more likely to have severe decay on the root surfaces of

3020 the teeth (Table 6.5).

3021

3022

3023 6.5 Discussion

3024 This study shows poor intake of macronutrients and a high fat- low carbohydrate diet

3025 is significantly associated with coronal decay. Being outside the AMDR for percentage

3026 of energy from fat was also associated with coronal decay. The study also shows that

3027 those who met their fibre intake recommendations were less likely to have root decay.

3028 Not meeting zinc and thiamin recommendations, and poor overall intake of

3029 micronutrients, was associated with the presence of severe root decay.

3030

199

Nutrient intake and tooth decay in older men

Table 6.2 Median daily intake (and 5th/95th percentile) of energy and nutrients, percentage and number of participants not meeting the recommended intake for each nutrient by presence of Coronal and Root Decay Presence of Coronal Decay (≥1) Presence of Root Decay (≥1) Not meeting Meeting Not meeting Meeting NRV NRV NRV NRV Recommended Intake (male, ≥ 70 years old) Median (P5/P95) % n % n Median (P5/P95) % n % n Energy and Macronutrients Total energy (kJ/d) – EER - 8859.40 18 66 24 36 8636.1 21 79 27 41 (5800.5/12918.7) (5890.4/12264.7) Protein (g/kg per d) - EAR 0.86 1.20 (0.7/2.2) 26 16 35 161 1.18 (0.7/2.2) 31 19 26 120 Protein (g/d) - 89.9 (60.5/137.9) - 87.2 (59.3/134.2) - Protein (%E/d) - AMDR 15 – 25 17.7 (13.1/25.2) 39 39 33 139 17.8a (12.1/24.1) 29 29 27 112 Carbohydrate (g/d) - 211.9 (121.5/328.0) - 207.2a - (117.9/287.3) Carbohydrate (%E/d) - AMDR 45 – 65 38.9a (27.0/49.9) 33 146 42 32 37.6 (26.5/49.8) 25 112 38 29 Total fat (g/d) - 81.2 (46.1/140.3) - 81.3 (47.0/142.9) - Total fat (%E/d) – AMDR 20 – 35 35.7a (24.5/46.3) 32 104 37 74 37.1 (25.0/47.9) 29 92 25 49 Saturated fat (g/d) - 29.5 (12.9/54.9) - 30.1 (14.6/59.4) - Saturated fat (%E/d) – AMDR <10 12.4a (7.2/19.0) 33 133 40 45 12.8 (8.1/19.9) 27 112 26 29 Dietary fibre (g/d) – AI 30 25.5 (12.4/43.0) 35 130 32 48 24.1 (12.4/40.5) 29 109 21 32 Vitamins Thiamin (mg/d) – EAR 1 1.6 (0.8/3.1) 28 19 35 159 1.4 (0.6/3.0) 35 24 26 117 Riboflavin (mg/d) – EAR 1.3 2.1 (1.1/4.0) 31 17 35 161 2.0 (1.1/3.9) 33 18 26 123 Niacin Equivalent (mg/d) – 12 46.6 (34.0/74.4) 0 0 34 178 45.4 (29.1/72.6) 0 0 27 141 EAR

200

Nutrient intake and tooth decay in older men

Dietary Folate Equivalent (ug/d) 320 364.3 (183.8/714.0) 33 60 35 118 364.6 (185.6/707.8) 28 51 27 90 – EAR Vitamin A (ug/d) – EARb 625 976.4 32 34 35 144 1056.3 28 30 27 111 (405.1/2147.6) (417.5/1965.1) Vitamin C (mg/d) – EAR 30 107.6 (40.9/254.9) 23 3 35 175 108.4 (35.9/265.4) 38 5 27 136

Vitamin Dc (u/d) – AI 15 3.9 (1.5/8.6) 34 176 50 2 3.5 (1.5/9.4) 27 138 75 3 Vitamin E (mg/d) – AI 10 10.1 (4.7/19.4) 33 87 35 91 9.7 (4.7/20.4) 27 70 27 71 Minerals Calcium (mg/day) – EAR 1100 788.7 34 149 35 29 751.0 28 122 23 19 (439.7/1346.0) (385.4/1507.1) Phosphorus (mg/day) – EAR 580 1460.9 0 0 34 178 1396.7 100 1 27 140 (989.7/2194.1) (900.7/2175.8) Iron (mg/day) – EAR 6 12.2 (7.6/20.5) 22 2 34 176 11.7 (7.5/20.0) 22 2 27 139 Magnesium (mg/day) – EAR 350 331.9 (231.5/523.9) 34 95 35 83 322.0 (210.8/473.2) 29 81 25 60 Zinc (mg/day) – EAR 12 11.8 (7.4/18.9) 33 80 35 98 11.8 (6.8/18.9) 30 72 25 69 Potassium (mg/day) – AI 3800 3218.8 34 123 36 55 3200.0 27 100 27 41 (2022.4/5203.9) (2022.4/5014.9) Iodine (ug/day) – AI 100 113.1 (48.1/212.7) 33 67 35 111 102.9 (48.4/246.9) 31 63 25 78

Sodium (mg/day) – UL 2300 2088.1 38 71 32 107 2011.7 24 45 29 96 (1374.1/3503.9) (1220.2/3313.4)

201

Nutrient intake and tooth decay in older men

Table 6.3 Multivariate logistic regression model of higher fat, lower carbohydrate diet, macronutrient (4 or fewer) risk variables, energy intake, and individual macronutrients and the presence of Coronal Decay Presence of Coronal Decay (≥1) Unadjusted Adjusted Variables OR (95%CI) ORa (95%CI) Higher fat, lower carbohydrate diet No 1.00 1.00 Yes 0.69 (0.45 – 1.07) 0.56 (0.35 – 0.91)b Macronutrient Risk Variablec Good Intaked 1.00 1.00 Poor Intake 0.59 (0.33 – 1.04) 0.53 (0.29 – 0.98)b Micronutrient Risk Variable Good Intakee 1.00 1.00 Poor Intake 1.12 (0.71 – 1.78) 1.20 (0.68 – 2.11) Total energy (kJ/d) – EERc Meeting 1.00 1.00 Not Meeting 0.69 (0.44 – 1.10) 0.81 (0.49 – 1.34)

Macronutrients Protein (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 1.36 (0.81 – 2.29) 1.25 (0.72 – 2.18) Carbohydrate (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 0.64 (0.37 – 1.13) 0.64 (0.35 – 1.17) Total fat (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 0.76 (0.49 – 1.17) 0.61 (0.38 – 0.98)b Saturated fat (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 0.68 (0.41 – 1.11) 0.62 (0.36 – 1.05) Dietary fibre (g/d) – AI Meeting 1.00 1.00 Not Meeting 0.87 (0.54 – 1.38) 0.93 (0.54 – 1.59)

Micronutrients Vitamins Thiamin (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 0.95 (0.50 – 1.82) 0.85 (0.42 – 1.73)

Riboflavin (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 1.33 (0.68 – 2.57) 1.18 (0.57 – 2.46) Dietary Folate Equivalent (ug/d) – EAR

202

Nutrient intake and tooth decay in older men

Meeting 1.00 1.00 Not Meeting 0.75 (0.47 – 1.20) 0.68 (0.41 – 1.15) Vitamin A (ug/d) – EARf Meeting 1.00 1.00 Not Meeting 1.16 (0.69 – 1.95) 1.11 (0.62 – 2.00) Vitamin C (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 1.22 (0.33 – 4.52) 0.98 (0.25 – 3.90) Vitamin D (u/d) – AIg Meeting 1.00 1.00 Not Meeting 0.74 (0.08 – 7.18) 0.28 (0.12 – 14.21) Vitamin E (mg/d) – AI Meeting 1.00 1.00 Not Meeting 0.93 (0.60 – 1.43) 0.97 (0.58 – 1.63) Minerals Calcium (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 0.95 (0.53 – 1.70) 1.01 (0.52 – 1.99) Iron (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 1.16 (0.24 – 5.67) 1.60 (0.29 – 8.78) Magnesium (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 1.08 (0.70 – 1.66) 1..03 (0.59 – 1.81) Zinc: EAR Meeting 1.00 1.00 Not Meeting 1.37 (0.89 – 2.11) 1.59 (0.92 – 2.73) Potassium (mg/day) – AI Meeting 1.00 1.00 Not Meeting 0.91 (0.57 – 1.45) 0.94 (0.53 – 1.66) Iodine (ug/day) – AI Meeting 1.00 1.00 Not Meeting 1.01 (0.65 – 1.57) 1.02 (0.62 – 1.69) Sodium (mg/day) – UL Meeting 1.00 1.00 Not Meeting 0.95 (0.60 – 1.49) 0.74 (0.43 – 1.27)

OR, Odds Ratio. EER, Estimated Energy Requirements. AMDR, Accepted Macronutrient. AI, Adequate Intake. EAR, Estimated Average Requirement. UL, Upper Level. Distribution Range. AI, Adequate Intake. a. Adjusted for age, energy, BMI, pase, income and SROH. b. Statistically significant, p-value <0.05 c. Not adjusted by energy d. Reference Meeting 5 or more recommended macronutrient intakes e. Reference Meeting 12 or more recommended micronutrient intakes f. Retinol Equivalents g. Vitamin D data should be interpreted with caution 3032

203

Nutrient intake and tooth decay in older men

3033 A high fat low carbohydrate diet was associated with being less likely to have coronal

3034 decay. Previous studies have found that very low carbohydrate diets showed decreased

3035 risk of dental caries (217). The WHO has recommended free sugars, sugars added by

3036 the food manufacturer or naturally present in honey, syrup, and fruit juices, should only

3037 contribute to 5% of energy intakes, while recent American dietary guidelines

3038 recommend restricting sugar and refined carbohydrates (118, 218)

3039

3040 Carbohydrates are subjected to fermentation by micro-organisms, releasing acidic end

3041 products that possibly lower the pH of the mouth and degrade enamel (75). Our study

3042 found no significant relationship between meeting recommended AMDR for

3043 carbohydrates and coronal decay. Interestingly univariate analysis showed a significant

3044 relationship with root decay, however after adjustment for confounders, this

3045 relationship was no longer statistically significant. A significant relationship between

3046 recommended AMDR for fat and the presence of coronal decay was also found.

3047

3048 The majority of participants outside AMDR recommendations were above

3049 recommended percentage for energy intake from fat. In contrast, most participants

3050 outside AMDR for carbohydrates were below the recommended percentage of energy

3051 intake from carbohydrates. Results from past studies on the relationship between decay

3052 and carbohydrates in adults are inconsistent. Burt et al. found a significant relationship

3053 between energy contributed from carbohydrate intake and dental caries in adults, which

3054 became stronger when limited to only sugar intake (74). On the other hand, Marshall et

3055 al. found that total carbohydrate intake was not significantly associated with either

3056 coronal or root caries, in older adults aged 65 years and older (97). Neither study looked

3057 at the percentage of energy contributed by carbohydrates, instead following different

204

Nutrient intake and tooth decay in older men

Table 6.4 Multivariate logistic regression model of higher fat, lower carbohydrate diet, macronutrient (4 or fewer) risk variables, energy intake, and individual macronutrients and the presence of Root Decay Presence of Root Decay (≥1) Unadjusted Adjusted Variables OR (95%CI) ORa (95%CI) Higher fat, lower carbohydrate diet No 1.00 1.00 Yes 1.11 (0.73 – 1.68) 1.07 (0.68 – 1.68) Macronutrient Risk Variableb Good Intakec 1.00 1.00 Poor Intake 1.17 (0.64 – 2.16) 1.19 (0.62 – 2.27) Micronutrient Risk Variable Good Intaked 1.00 1.00 Poor Intake 1.39 (0.90 – 2.17) 1.58 (0.92 – 2.72) Total energy (kJ/d) – EERb Meeting 1.00 1.00 Not Meeting 0.73 (0.47 – 1.13) 0.88 (0.54 – 1.41)

Macronutrients Protein (%E/d) - AMDR Within AMDR 1.00 1.00 Outside AMDR 1.35 (0.82 – 2.21) 1.23 (0.73 – 2.10) Carbohydrate (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 0.53 (0.31 – 0.90)e 0.58 (0.33 – 1.02) Total fat (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 1.24 (0.81 – 1.90) 1.18 (0.75 – 1.87) Saturated fat (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 1.09 (0.66 – 1.79) 1.00 (0.59 – 1.68) Dietary fibre (g/d) – AI Meeting 1.00 1.00 Not Meeting 1.55 (0.96 – 2.51) 1.81 (1.04 – 3.14)e

Micronutrients Vitamins Thiamin (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 1.68 (0.97 – 2.93) 1.63 (0.88 – 3.01)

Riboflavin (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 1.43 (0.77 – 2.67) 1.39 (0.71 – 2.74) Dietary Folate Equivalent (ug/d) – EAR

205

Nutrient intake and tooth decay in older men

Meeting 1.00 1.00 Not Meeting 1.50 (0.69 – 1.61) 0.95 (0.59 – 1.53) Vitamin A (ug/d) – EARf Meeting 1.00 1.00 Not Meeting 0.94 (0.57 – 1.57) 0.93 (0.53 – 1.63) Vitamin C (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 2.08 (0.67 – 6.49) 2.13 (0.62 – 7.33) Vitamin D (u/d) – AIg Meeting 1.00 1.00 Not Meeting 0.10 (0.01 – 0.97)c 0.11 (0.01 – 1.25) Vitamin E (mg/d) – AI Meeting 1.00 1.00 Not Meeting 1.09 (0.73 – 1.64) 1.08 (0.66 – 1.75) Minerals Calcium (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 1.04 (0.60 – 1.81) 1.23 (0.64 – 2.38) Iron (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 0.93 (0.19 – 4.55) 1.25 (0.24 – 6.44) Magnesium (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 1.26 (0.84 – 1.90) 1.28 (0.76 – 2.18) Zinc: EAR Meeting 1.00 1.00 Not Meeting 1.39 (0.93 – 2.09) 1.50 (0.90 – 2.49) Potassium (mg/day) – AI Meeting 1.00 1.00 Not Meeting 1.04 (0.67 – 1.63) 1.03 (0.60 – 1.76) Iodine (ug/day) – AI Meeting 1.00 1.00 Not Meeting 1.18 (0.78 – 1.78) 1.20 (0.75 – 1.92) Sodium (mg/day) – UL Meeting 1.00 1.00 Not Meeting 0.83 (0.54 – 1.28) 0.79 (0.47 – 1.32)

OR, Odds Ratio. EER, Estimated Energy Requirements. AMDR, Accepted Macronutrient. AI, Adequate Intake. EAR, Estimated Average Requirement. UL, Upper Level. a. Adjusted for age, energy, BMI, number of natural teeth and SROH. b. Not adjusted by energy c. Reference Meeting 5 or more recommended macronutrient intakes d. Reference Meeting 12 or more recommended micronutrient intakes e. Statistically significant, p-value <0.05 f. Retinol Equivalents g. Vitamin D data should be interpreted with caution 3058

206

Nutrient intake and tooth decay in older men

3059 national guidelines for carbohydrate intake, potentially accounting for the different

3060 outcome in our study (74, 97, 176).

3061

3062 Few studies have investigated the relationship between fat intake and tooth decay. A

3063 previous study looking at dental caries and nutrition in young children found that being

3064 overweight or obese, and consuming a high fat diet, was associated with dental decay

3065 (219). Hooley et al. found that high fat foods were significantly associated with tooth

3066 decay in older children, theorizing that the foods classified as high fat were also high

3067 in starchy carbohydrates that tended to stick to teeth (219). It is possible that the

3068 CHAMP participants consumed fat from food sources which were not also in high

3069 starch or sugar, which defines a poor diet (219). High energy intakes may also be

3070 associated with diets of poor quality that consist of foods not only high in fat, but also

3071 in sugar and other fermentable carbohydrates (220, 221). However, our study found no

3072 significant overall relationship between meeting recommended energy intakes with

3073 either coronal or root decay.

3074

3075 Participants who met recommended fibre intakes were significantly less likely to have

3076 root decay, however no association was found with severe root decay. This relationship

3077 is consistent with past studies. Coogan et al. found dietary fibre was a predictor of

3078 dental caries among dental students (222). A recent study in adult men investigating

3079 the Dietary Approaches to Stop Hypertension (DASH) diet and found that participants

3080 in the highest quartile of the DASH diet score had 30% less adjusted root caries

3081 increment, (defined as the number of teeth with root caries incidence and root caries

3082 reversals), than participants in the lowest quartile (73). Specifically, vegetables scores

207

Nutrient intake and tooth decay in older men

3083 and total grain scores, food groups high in dietary fibre, were inversely associated with

3084 adjusted root caries increment (115).

3085

3086 Severe root decay in our study was associated with poor intake of micronutrients and

3087 not meeting recommended intakes of zinc or thiamin. Few studies have found a

3088 relationship between micronutrient intake and root decay (97). Marshall et al. found

3089 that root caries was not significantly associated with mean daily intake of nutrients,

3090 however the study did find there was a higher number of root caries in participants with

3091 inadequate intake of zinc (97). It is possible that the concentration and quantity of zinc

3092 in saliva may reduce the susceptibility of teeth to caries (223-225). The relationship

3093 between thiamin and root decay may be explained by thiamin’s potential to prevent the

3094 reproduction of cariogenic micro-organisms, or by deficiency in cocarboxylase (226).

3095

3096 One strength of this study was the use of calibrated oral health professionals providing

3097 objective clinical measures of decay on coronal and root components of teeth. This is a

3098 similar standard to other studies measuring tooth decay. Another strength was the use

3099 of validated measure of diet history and the use of a dietitian to collect dietary habits

3100 and nutritional information (169). This method was not burdensome to participants and

3101 it was not limited by short term memory recall, or the responses and information

3102 provided by participants (193). However all dietary measures are estimates, and vitamin

3103 D results should be interpreted with caution (203).

3104

3105 There are some limitations to this study. Firstly as the study population is only males

3106 aged 78 years and older, the results have limited generalizability to females and younger

3107 populations. Due to the observational nature of this study the direction of causality of

208

Nutrient intake and tooth decay in older men

Table 6.5 Multivariate logistic regression model of higher fat, lower carbohydrate diet, micronutrient (11 or fewer) risk variables, energy intake, and individual micronutrients and the presence of Severe Root Decay Presence of Severe Root Decay (≥3) Unadjusted Adjusted Variables OR (95%CI) ORa (95%CI) Higher fat, lower carbohydrate diet No 1.00 1.00 Yes 1.06 (0.63 – 1.78) 1.09 (0.62 – 1.89) Macronutrient Risk Variableb Good Intakec 1.00 1.00 Poor Intake 1.07 (0.51 – 2.26) 1.10 (0.51 – 2.37) Micronutrient Risk Variable Good Intaked 1.00 1.00 Poor Intake 1.94 (1.08 – 3.52)e 2.24 (1.11 – 4.52)e Total energy (kJ/d) – EERb Meeting 1.00 1.00 Not Meeting 0.83 (0.48 – 1.44) 0.88 (0.49 – 1.58)

Macronutrients Protein (%E/d) - AMDR Within AMDR 1.00 1.00 Outside AMDR 1.45 (0.80 – 2.63) 1.34 (0.70 – 2.57) Carbohydrate (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 0.56 (0.30 – 1.06) 0.66 (0.33 – 1.33) Total fat (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 1.28 (0.75 – 2.19) 1.29 (0.73 – 2.27) Saturated fat (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 0.90 (0.49 – 1.64) 0.88 (0.47 – 1.64) Dietary fibre (g/d) – AI Meeting 1.00 1.00 Not Meeting 1.39 (0.76 – 2.51) 1.39 (0.72 – 2.68)

Micronutrients Vitamins Thiamin (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 2.32 (1.24 – 4.35)e 2.32 (1.15 – 4.67)e Riboflavin (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 1.80 (0.88 – 3.69) 1.91 (0.88 – 4.13) Dietary Folate Equivalent (ug/d) – EAR Meeting 1.00 1.00

209

Nutrient intake and tooth decay in older men

Not Meeting 1.50 (0.90 – 2.51) 1.46 (0.82 – 2.58) Vitamin A (ug/d) – EARf Meeting 1.00 1.00 Not Meeting 1.46 (0.81 – 2.62) 1.43 (0.74 – 2.73) Vitamin C (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 1.19 (0.26 – 5.51) 1.01 (0.21 – 4.85) Vitamin D (u/d) – AIg Meeting 1.00 1.00 Not Meeting 0.15 (0.02 – 1.07) 0.17 (0.02 – 1.38) Vitamin E (mg/d) – AI Meeting 1.00 1.00 Not Meeting 0.97 (0.58 – 1.61) 0.89 (0.49 – 1.63) Minerals Calcium (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 1.31 (0.62 – 2.75) 1.24 (0.55 – 2.84) Iron (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 1.89 (0.39 – 9.30) 1.96 (0.37 – 10.36) Magnesium (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 1.60 (0.95 – 2.71) 1.71 (0.88 – 3.11) Zinc: EAR Meeting 1.00 1.00 Not Meeting 2.46 (1.45 – 4.18)e 3.33 (1.71 – 6.48)e Potassium (mg/day) – AI Meeting 1.00 1.00 Not Meeting 1.21 (0.68 – 2.15) 1.14 (0.58 – 2.23) Iodine (ug/day) – AI Meeting 1.00 1.00 Not Meeting 1.29 (0.77 – 2.14) 1.34 (0.75 – 2.39) Sodium (mg/day) – UL Meeting 1.00 1.00 Not Meeting 0.88 (0.51 – 1.50) 0.84 (0.44 – 1.58)

OR, Odds Ratio. EER, Estimated Energy Requirements. AMDR, Accepted Macronutrient. AI, Adequate Intake. EAR, Estimated Average Requirement. UL, Upper Level. a. Adjusted for age, energy, BMI, meal preparation and SROH. b. Not adjusted by energy c. Reference Meeting 5 or more recommended macronutrient intakes d. Reference Meeting 12 or more recommended micronutrient intakes e. Statistically significant, p-value <0.05 f. Retinol Equivalents g. Vitamin D data should be interpreted with caution 3108

210

Nutrient intake and tooth decay in older men

3109 the association reported cannot to be defined. Secondly, the frequency of dental visits

3110 and oral hygiene were self-reported. Decay is a cause for tooth loss, and as such could

3111 be influencing dietary intake and not reverse causality with diet impacting tooth decay

3112 (71). There is some evidence for this (84, 86, 88). Numerous studies have found that

3113 tooth loss due to tooth decay could lead to a diet with a contribution of energy from

3114 sugar and fat (71, 86, 88).

3115

3116 The database used to analyse food intake was from 2007 and does not calculate the

3117 intake of ‘free sugar’ from discretionary food sources. The database does not calculate

3118 energy from sugar, and as such the association between recommended sugar intakes

3119 and decay could not be explored. Many previous studies have found a connection

3120 between overall and free sugar intakes and tooth decay (35, 75, 117, 120). It is also

3121 worth noting that the relationship between sugar and tooth decay is thought to be dose-

3122 responsive (120). Unfortunately, our nutrient analysis did not provide insight into the

3123 timing and amount of sugar intake.

3124

3125 In conclusion, our study provides new insight into the relationship between nutrition

3126 and dental decay in older adults, although the cross-sectional nature of the study means

3127 the direction of the association is uncertain. Going forward, prospective

3128 epidemiological studies and clinical research into nutrition and tooth decay in older age

3129 groups is needed, particularly focusing on the role of carbohydrates, fat, fibre and

3130 micronutrients.

3131

3132

3133

211

Nutrient intake and tooth decay in older men

Supplementary Table 6.1 Multivariate logistic regression model of higher fat, lower carbohydrate diet, micronutrient (11 or fewer) risk variables, energy intake, and individual micronutrients and the presence of Severe Coronal Decay Presence of Severe Coronal Decay (≥3) Unadjusted Adjusted Variables OR (95%CI) ORa (95%CI) Higher fat, lower carbohydrate diet No 1.00 1.00 Yes 0.66 (0.32 – 1.38) 0.54 (0.24 – 1.20) Macronutrient Risk Variableb Good Intakec 1.00 1.00 Poor Intake 0.63 (0.25 – 1.59) 0.59 (0.22 – 1.59) Micronutrient Risk Variable Good Intaked 1.00 1.00 Poor Intake 1.28 (0.58 – 2.87) 1.23 (0.46 – 3.30) Total energy (kJ/d) – EERb Meeting 1.00 1.00 Not Meeting 0.69 (0.32 – 1.49) 0.85 (0.37 – 1.98)

Macronutrients Protein (%E/d) - AMDR Within AMDR 1.00 1.00 Outside AMDR 1.30 (0.54 – 3.12) 1.10 (0.42 – 2.85) Carbohydrate (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 0.85 (0.31 – 2.29) 0.88 (0.30 – 2.54) Total fat (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 0.80 (0.38 – 1.69) 0.66 (0.30 – 1.46) Saturated fat (%E/d) – AMDR Within AMDR 1.00 1.00 Outside AMDR 0.62 (0.28 – 1.40) 0.58 (0.25 – 1.37) Dietary fibre (g/d) – AI Meeting 1.00 1.00 Not Meeting 1.65 (0.66 – 4.12) 1.80 (0.63 – 5.13)

Micronutrients Vitamins Thiamin (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 1.73 (0.68 – 4.39) 1.30 (0.47 – 3.59) Riboflavin (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 1.80 (0.66 – 4.92) 1.54 (0.50 – 4.74) Dietary Folate Equivalent (ug/d) – EAR Meeting 1.00 1.00

212

Nutrient intake and tooth decay in older men

Not Meeting 0.78 (0.35 – 1.74) 0.57 (0.23 – 1.40) Vitamin A (ug/d) – EARe Meeting 1.00 1.00 Not Meeting 1.74 (0.77 – 3.91) 1.74 (0.68 – 4.42) Vitamin C (mg/d) – EAR Meeting 1.00 1.00 Not Meeting 1.38 (0.17 – 10.93) 0.90 (0.10 – 7.99) Vitamin D (u/d) – AIf Meeting 1.00 1.00 Not Meeting 0.18 (0.02 – 1.77) 0.42 (0.03 – 5.85) Vitamin E (mg/d) – AI Meeting 1.00 1.00 Not Meeting 1.00 (0.48 – 2.09) 0.95 (0.38 – 2.35) Minerals Calcium (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 2.77 (0.64 – 11.86) 3.53 (0.72 – 17.18) Iron (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 2.08 (0.25 – 17.18) 2.26 (0.22 – 23.63) Magnesium (mg/day) – EAR Meeting 1.00 1.00 Not Meeting 1.31 (0.62 – 2.77) 1.11 (0.41 – 2.99) Zinc: EAR Meeting 1.00 1.00 Not Meeting 1.81 (0.85 – 3.84) 2.11 (0.81 – 5.54) Potassium (mg/day) – AI Meeting 1.00 1.00 Not Meeting 1.71 (0.69 – 4.28) 1.89 (0.64 – 5.62) Iodine (ug/day) – AI Meeting 1.00 1.00 Not Meeting 1.57 (0.75 – 3.28) 1.57 (0.68 – 3.64) Sodium (mg/day) – UL Meeting 1.00 1.00 Not Meeting 0.88 (0.41 – 1.93) 0.77 (0.29 – 2.02)

OR, Odds Ratio. EER, Estimated Energy Requirements. AMDR, Accepted Macronutrient. AI, Adequate Intake. EAR, Estimated Average Requirement. UL, Upper Level. a. Adjusted for age, energy, BMI, marital status and SROH. b. Not adjusted by energy c. Reference Meeting 5 or more recommended macronutrient intakes d. Reference Meeting 12 or more recommended micronutrient intakes e. Retinol Equivalents f. Vitamin D data should be interpreted with caution 3134

213

3135

3136

3137

3138

3139

3140

3141

3142

3143

3144

3145

3146 CHAPTER 7: FRAILTY IMPACTS THE RELATIONSHIP BETWEEN DIET AND

3147 ORAL HEALTH IN COMMUNITY DWELLING OLDER MEN

3148

3149

3150

3151

3152

3153

3154

3155

3156

3157

3158

3159

214

Frailty impacts the relationship between diet and oral health in older men

3160 7.1 Introduction

3161 A literature review on frailty, nutrition and oral health was conducted in Chapter 1 of

3162 this thesis. A systematic review that explored the relationship between nutrition and

3163 frailty in older adults found that while there were some inconsistencies between the

3164 studies, overall higher diet quality was associated with decreased risk of frailty (132).

3165 One study that focused on older Chinese adults found that participants with better diet

3166 quality, as measured by the Diet Quality Index-International (DQII), had lower chances

3167 of developing frailty (136).

3168

3169 There have been multiple systematic reviews conducted to explore the relationship

3170 between oral health and frailty (227, 228). One review found that presence of dentures,

3171 numbers of teeth, self-rated oral health and poor use of oral health services were risk

3172 factors that increased the risk of frailty (227). This review also found a relationship

3173 between components of frailty, particularly handgrip strength and weight loss, and oral

3174 health rated quality of life (as measure by the Geriatric Oral Health Assessment Index,

3175 GOHAI), masticatory ability, numbers of teeth and periodontal disease (227). Another

3176 systematic review that focused on only longitudinal studies also found that those

3177 dentures, numbers of teeth, self-rated health and poor use of oral health services were

3178 risk factors that increased the probability of frailty (228). However periodontal

3179 disease’s relationship with frailty was less certain (228).

3180

3181 The aim of Chapter 7 of this thesis is to explore whether different levels of frailty impact

3182 on the relationship between diet quality, overall micronutrient, and macronutrient

3183 intake, and oral health. This would be done by stratifying the population by frailty status

3184 (robust versus pre-frail/frail) and examining the outcomes for heterogeneity.

215

Frailty impacts the relationship between diet and oral health in older men

3185 Methods

3186 Study Population

3187 Chapter 2, 4, 5 and 6 of this thesis detail the recruitment of CHAMP participants at

3188 baseline. Out of the 2815 non-instutionalised males aged 70 years and older, 1,511

3189 (54%) agreed to participate. An additional 194 eligible men in the study area were

3190 recruited after hearing about the study from friends and local media, yielding a total of

3191 1705 subjects.

3192

3193 At the 1st wave (baseline), 2nd wave (2-year) and 3rd wave’s (5-year) of data collection

3194 participants completed a self-completed questionnaire and attended an interview and

3195 clinical at Concord Hospital. At the 3rd wave of data collection of nutritional data was

3196 added via a separate home visit. For the 4th wave of data collection (8-year follow up)

3197 men were seen predominantly in their homes. In addition to the self-completed

3198 questionnaire and some sections of the clinic assessments collected in previous waves,

3199 an oral health questionnaire and examination were conducted along with a diet history

3200 interview.

3201

3202 Data collection

3203 Details on data collection and participant characteristics are provided in Chapters 2, 3,

3204 4, 5 and 6. Of the original 1,705 participants, 781 participated in the 4th wave of data

3205 collection. The main reasons for non-participation was death (72.4%) or illness/age

3206 (10.1%). Out of the 781 participants, 718 completed the dietary assessment and 614

3207 participants completed the dental examination. A total of 596 of those who completed

3208 the dental examination had frailty information available and completed the dietary

3209 assessment.

216

Frailty impacts the relationship between diet and oral health in older men

3210 Edentulous participants (n=90) were excluded from the examination for coronal and

3211 root decay, and periodontitis. Of the 520 who had their teeth examined for coronal and

3212 root decay, 511 had complete information regarding their frailty status, and also

3213 participated in the dietary assessment. Only 296 men were eligible for a full periodontal

3214 assessment, as a large number of participants were excluded (n=228) because of contra-

3215 indicated medical conditions. Of the 296 who had the full periodontal examination, 292

3216 participants had information available on their frailty status, and participated in the

3217 dietary assessment.

3218

3219 In comparison to men who did not complete the oral health assessment, those who did

3220 the oral health component (n=614) were significantly younger and less likely to live

3221 alone. However, they did not differ significantly in income, marital status, post school

3222 qualifications, country of birth, multi-morbidity, and smoking status. Participants who

3223 were excluded from the full periodontal assessment had higher number of

3224 comorbidities, poorer levels of physical activity, and were less likely to visit the dentist

3225 at least every 2 years (Chapter 5, Table 5.1).

3226

3227 Measurements

3228 Collection of oral health and dietary data has been documented in Chapter 2, 4, 5 and

3229 6.

3230

3231 Oral health data collection

3232 Briefly, FTUs were defined as opposing molars and premolars that were natural teeth

3233 or artificial (prosthetic teeth on implanted-supported dentures, fixed bridge pontics

3234 and/or removable dentures) (43, 178). In total there was a possible maximum score of

217

Frailty impacts the relationship between diet and oral health in older men

3235 12 FTUs (43, 178). The four occluding pairs of molars (not including third molars),

3236 were given a score of two per pair, and the four occluding pairs of pre-molars, were

3237 given a score of one per pair (43, 143, 178). Periodontal measurements, recession and

3238 Probing Depth (PD), were taken at three sites: mesio-buccal, mid-buccal, and distal

3239 buccal for each natural tooth present, except third and second molars. Decay

3240 experiences on both coronal and root tooth surfaces were recorded on all teeth,

3241 including third and second molars.

3242

3243 Dietary intake

3244 Diet histories were administered using a standardized and validated interview method

3245 (169, 170). A structured questionnaire with open-ended questions, adapted from the

3246 Sydney South West Area Health Service outpatient diet history form, was the tool used

3247 by interviewers to ask participants about their usual dietary intake during the last three

3248 months (169). Food quantities were established by food models, photographs and

3249 household measures, such as measuring spoons (169, 171). A checklist was included to

3250 corroborate commonly consumed foods items which may have been forgotten.

3251 Relatives, carers and/or family members of CHAMP men were encouraged to be

3252 present in the interview, to aid in participants’ memory recall (169, 172). Validity of

3253 this method was established in a previous study in a sub-group of 56 CHAMP men,

3254 which compared the diet history to a 4 day weighed food record (169). We used the

3255 interquartile range to identify potential outliers of energy intake (173). Individual diet

3256 histories of potential outliers were examined and only one was identified as having an

3257 unrealistic intake of food and excluded from the data set (173).

3258

3259

218

Frailty impacts the relationship between diet and oral health in older men

3260 Data handling

3261 Entry of dietary records into FoodWorks 7 Professional for Windows (Xyris Software

3262 (Australia) Pty Ltd), based on the Australian Food, Supplement and Nutrient Database

3263 2007 (AUSNUT 2007) is described in Chapters 2, 4, 5 and 6.

3264

3265 Dietary intake of nutrients

3266 Participants’ median daily dietary intakes of energy, carbohydrates, sugar, protein, total

3267 fats, polyunsaturated fatty acids (PUFA), dietary fibre, alcohol, sodium, potassium,

3268 iodine, iron, phosphorus, calcium, magnesium, zinc, dietary folate equivalents, thiamin,

3269 niacin, riboflavin and vitamins A, C, D & E were compared to the respective Nutrient

3270 Reference Values (NRV) for males aged 71 years and older (176). Vitamin B6 and

3271 Percentages of energy from carbohydrates, protein and fat were compared to the

3272 Acceptable Macronutrient Distribution Range (AMDR) and protein intake per kilogram

3273 of body weight was calculated (176). Daily energy intakes were also compared to

3274 participants’ Estimated Energy Requirements (EER) calculated using Basal Metabolic

3275 Rate (BMR) (with a Physical Activity Level of 1.6 for light activity). Vitamin B6 and

3276 Vitamin B12 were not available in AUSNUT 2007, and therefore were not included in

3277 the analysis. Furthermore, only sodium available naturally in foods and added during

3278 processing food products was included in the analysis.

3279

3280 Attainment of the NRV for total energy and six other nutrients (protein, calcium, iron,

3281 zinc, riboflavin, and vitamin D) were counted for each participant. These nutrients are

3282 highlighted as ‘key nutrients’ for older adults (11). A dichotomized ‘key nutrient’

3283 variable was created, where meeting requirements for five or more of these key

219

Frailty impacts the relationship between diet and oral health in older men

3284 nutrients was classed as ‘good’, and meeting requirements for four or fewer of these

3285 key nutrients was classed as ‘poor’ (28).

3286

3287 Similarly attainment of the NRV recommendations for total energy and six

3288 macronutrients (protein (g/kg of body weight), total fat (AMDR), saturated fat

3289 (AMDR), carbohydrate (AMDR), long chain omega 3 fatty acids, and fibre) were

3290 summed for each participant and a dichotomized ‘Macronutrient’ risk variable was

3291 created (28). Meeting requirements for five or more nutrients was classed as ‘good’,

3292 and meeting requirements for four or fewer nutrients was classed as ‘poor’ (28).

3293 Attainment of the NRV recommendations for 16 micronutrients (sodium, potassium,

3294 iodine, phosphorus, calcium, magnesium, zinc, iron, dietary folate equivalents, thiamin,

3295 niacin, riboflavin and vitamins A, C, D & E) were also summed for each participant

3296 and a dichotomized ‘Micronutrient’ risk variable was created (28, 84). Meeting the

3297 requirements for 12 or more nutrients was classed as ‘good’, and meeting requirements

3298 for 11 or fewer nutrients was classed as ‘poor’ (28, 84).

3299

3300 FTUs composition and numbers

3301 In addition to ‘Natural FTUs’ and ‘Total FTUs’, a separate ‘Replaced FTUs’ variable

3302 was created, defined as the number of FTUs where one or both teeth that compose the

3303 unit was prosthetic. Using these measures, participants were grouped according to the

3304 composition of their FTUs. Group A had only ‘Natural FTUs’, Group C had only

3305 ‘Replaced FTUs’, and Group B had a mixture of ‘Natural FTUs’ and ‘Replaced

3306 FTUs’. As there was only a very small number without any FTUs (n=28), these men

3307 were combined with participants in Group C. Participants were also grouped

220

Frailty impacts the relationship between diet and oral health in older men

3308 according to the number of FTUs: ‘12 FTUs,’, ‘7-11 FTUs’, ‘1-6 FTUs’, and ‘No

3309 FTUs’. Again the ‘No FTUs’ group was combined with the ‘1-6 FTUs’ group.

3310

3311 Periodontitis

3312 The Clinical Attachment Loss (CAL) at each tooth site was calculated by adding

3313 together the clinical measures of recession and PD. The prevalence of severe and total

3314 periodontitis was characterized according the Centre of Disease Control (CDC) and

3315 American Academy of Periodontology (AAP) case definition (38, 204). ‘Severe

3316 periodontitis’ was defined as two or more interproximal sites with a CAL of 6 mm or

3317 greater, ‘and’ one site with a PD of 5 mm or more (204). ‘Moderate periodontitis’ was

3318 defined as two interproximal sites with a CAL of 5 mm or more, ‘or’ 2 interproximal

3319 sites with a PD of 5 mm or more (204). The original definition of moderate periodontitis

3320 was two interproximal sites with a CAL of 4 mm or more, however older populations

3321 have greater recession, which may be non-inflammatory (205). The CDC/AAP

3322 definition of severe periodontitis includes CAL ‘and’ PD for this reason (204).

3323 Therefore, to account for this, without using PD, the CDC/AAP definition of moderate

3324 periodontitis was modified to include a higher margin of 5 mm or more for CAL,

3325 instead of 4 mm. ‘Mild periodontitis’ was defined as two or more interproximal sites

3326 with CAL of 3 mm or more, ‘and’ two or more interproximal sites with a PD of 4 mm

3327 or more (38). ‘Total Periodontitis’ (TPD) was defined as the presence of severe,

3328 moderate, or mild periodontitis (38).

3329

3330 Tooth decay

3331 The crown (coronal surface) and exposed root surfaces of teeth were assessed, as decay

3332 can occur on both sections. In relation to coronal surfaces participants were

221

Frailty impacts the relationship between diet and oral health in older men

3333 dichotomised into two categories, those with ‘one or more coronal decayed surfaces’,

3334 and those with ‘no coronal decayed surfaces’. Participants was also categorized with

3335 ‘one or more decayed root surfaces’, or those with ‘no root decayed surfaces’. The

3336 severity of coronal and root decay was also assessed. Participants who had ‘three or

3337 more coronal decayed surfaces’ experiences were categorized with ‘severe coronal

3338 decay’, and participants with ‘less than three coronal decayed surfaces’ were

3339 categorised as ‘no severe coronal decay’. Similarly, participants who had ‘three or more

3340 root decayed surfaces’ were categorized with ‘severe root decay’, and participants with

3341 ‘less than three root decayed surfaces’ as ‘no severe root decay’.

3342

3343 Frailty

3344 Frailty was defined according to an adapted version of Fried’s Frailty criteria, as

3345 determined in the Cardiovascular Health Study (CHS) (121). Fried used five phenotype

3346 criteria including weight loss, weakness, exhaustion, slowness and low activity.

3347 Weakness and slowness were measured by the same criteria as in the CHS. Weakness

3348 was defined as the lowest quintile for grip strength in the study, adjusted by BMI. Grip

3349 strength was measured twice in the right and left hands using the JAMAR

3350 dynamometer. The greatest mean value was compared against the CHS criteria for

3351 weakness. Slowness was measured by walking speed on a 6 metre course, administered

3352 twice. The mean value of the two trials was used, and frailty was defined as the lowest

3353 quintile of the CHS study for walking speed, adjusted for height.

3354

3355 Weight-loss exhaustion and low activity were adapted for the CHAMP study. Weight

3356 loss was defined as current weight of 15% or more lower than the participants self-

3357 reported heaviest weight, or weight at 25 years old. Exhaustion was defined according

222

Frailty impacts the relationship between diet and oral health in older men

3358 to the self-reported answer to the Medical Outcomes Survey Short Form (SF12) ‘How

3359 much of the time during the past 4 weeks did you have a lot of energy?’. Responses ‘a

3360 little’ or ‘none of the time’ were classed as frail. Physical activity was measured using

3361 the Physical Activity Scale for the Elderly (PASE), a method that scores the level of

3362 physical activity in individuals aged 65 years or older (147). A cut off score of <73 was

3363 used to determine frailty.

3364

3365 Subjects were grouped into three categories according to how many of the five criteria

3366 they meet. Participants who met none of the criteria were classed as ‘robust’,

3367 participants who met 1 or 2 criteria were classed as ‘pre-frail’, and participants who

3368 met 3 or more criteria were classed as ‘Frail’. Due to low numbers of participants that

3369 were classed as ‘prefrail’ or ‘frail’, these were further grouped together into a ‘Non –

3370 Robust’.

3371

3372 Other measurements

3373 Sociodemographic and economic measures, smoking, physical activity and health

3374 status were collected by the self-completed questionnaire. Alcohol consumption and

3375 anthropometric measures were collected at the first home visit.

3376

3377 Sociodemographic and economic measures

3378 Country of birth was grouped into the categories; Australia/New Zealand, Greece/Italy,

3379 and Other. Income was grouped into categories of ‘Age Pension Only’, ‘Age Pension

3380 and Other’ or ‘Other’ (superannuation or private income, own

3381 business/farm/partnership, wage or salary, repatriation pension, veteran’s pension,

3382 other, or any possible combination of these options). Living arrangements were

223

Frailty impacts the relationship between diet and oral health in older men

3383 categorized at ‘Living alone’ or ‘Living with others’, marital status was dichotomized

3384 as ‘Married/Partner De factor’ or ‘Not Married’, and post school qualifications were

3385 dichotomized as ‘Yes’ or ‘No’. Men were also asked about any limitations in access to

3386 food and food services, including Meals on Wheels (MOW).

3387

3388 Lifestyle factors

3389 Smoking status (‘never smoker’, ‘ex-smoker’ or ‘current smoker’) was assessed, as was

3390 alcohol. Participants were categorized into ‘current non-drinkers’, ‘lifelong abstainers’

3391 and ‘ex-drinkers’. For those who consumed at least 12 drinks in the past year, the

3392 frequency and quantity of alcohol consumption was assessed, enabling categorization

3393 of drinkers as either ‘safe drinkers’ (1–21 drinks per week) or ‘harmful drinkers’ (>21

3394 drinks per week) (168).

3395

3396 Anthropometric measurements

3397 Height and weight were measured using standardised digital scales and portable

3398 stadiometer and BMI was calculated as kg/m2 and categorised as ‘underweight’ (less

3399 than 23), ‘normal weight’ (23 – 29.9), and ‘overweight/obese’ (30.0 or over) (166, 167).

3400

3401 Health Status

3402 Participants reported on medical conditions through the self-completed questionnaire.

3403 They were asked whether a doctor or a health care provider had told them that they had

3404 any of the following diseases: diabetes, thyroid dysfunction, osteoporosis, Paget’s

3405 disease, stroke, Parkinson’s disease, epilepsy, hypertension, heart attack, angina,

3406 congestive heart failure, intermittent claudication, chronic obstructive lung disease,

3407 liver disease, cancer (excluding non- melanoma skin cancers), osteoarthritis, and gout.

224

Frailty impacts the relationship between diet and oral health in older men

3408 For the purposes of this study, comorbidity burden was defined as the presence of two

3409 or more of these conditions. Data on self-rated general health (SRH) were obtained and

3410 dichotomized into ‘excellent/good’ versus ‘fair/poor/very poor’. Self-rated oral health

3411 (SROH) was also measured and dichotomized into ‘excellent/very good/good’ versus

3412 ‘fair/poor/don’t know’.

3413

3414 Oral hygiene and dentist visits

3415 Participants were dichotomised as those who cleaned their teeth ‘twice or more day’ vs

3416 ‘once a day or less’. Frequency of visits to the dentist was also assessed. Participants

3417 were dichotomised as seeing the dentist ‘at least once every two years’, or ‘less often

3418 than once every two years’.

3419

3420 Ethics approval and informed consent

3421 All participants gave written informed consent. The study was approved by the Sydney

3422 South West Area Health Service Human Research Ethics Committee, Concord

3423 Repatriation General Hospital, Sydney, Australia (HREC/14/CRGH/17 CH62/6/2014-

3424 013).

3425

3426 Statistical analysis

3427 All statistical analyses and calculations were completed using SAS On Demand for

3428 Academics (SAS Institute Inc.). A p-value less than 0.05 was considered statistically

3429 significant, and the null hypothesis was rejected.. The population data set was stratified

3430 by those classed as ‘Robust’ and participants classed as ‘Non-Robust’ (frail and pre-

3431 frail). Logistic regression models were applied to the separate strata, and statistical

3432 interactions were assessed using the Breslow Day test for homogeneity.

225

Frailty impacts the relationship between diet and oral health in older men

3433 Logistic regression models were used to examine the unadjusted associations between

3434 the dichotomous macronutrient and micronutrient risk variables and socio-

3435 demographic, economic, health and lifestyle factors. Associations between the two

3436 FTUs variables (FTUs composition and FTUs number) and the nutrient risk variables

3437 were then further analysed via univariate and multivariate logistic regression, with a

3438 referent category of ‘Natural only’ for FTUs composition and ‘FTUs 12’ for FTUs

3439 number. Logistic regression models were also used to examine the unadjusted and

3440 adjusted associations between the dichotomous nutrient risk variables (referent

3441 category = ‘good’ intake), and severe and total periodontitis, as well as the unadjusted

3442 and adjusted associations between the dichotomous nutrient risk variables (referent

3443 category = ‘good’ intake), and the coronal and root decay variables.

3444

3445 All logistic regression models were controlled for age and energy intake unless energy

3446 was a component of the exposure variable. Other potential confounders, including oral

3447 hygiene, dentist visits, BMI, birth country, income, smoking, PASE, comorbidity,

3448 alcohol intake, self-rated health and oral health, and post school qualifications, were

3449 also screened using a p-value of ≤0.25 to determine if confounders would be included

3450 in the model. Backwards stepwise elimination was used to fit the final adjusted models.

3451 The Hosmer-Lemeshow post estimation test was utilised to assess the goodness of fit

3452 of the final adjusted model.

3453

3454

3455 7.3 Results

3456 Overall 596 participants had available information for analysis, 24.5% (n=146) of

3457 whom were classified as ‘robust’, and the other 75.5% (n=450) were classified as ‘non-

226

Frailty impacts the relationship between diet and oral health in older men

3458 robust’ (pre-frail/frail) (Table 7.1). Of the participants classed as non-robust, 74.7%

3459 were pre-frail (n=336), and 25.3% were frail (n=114).

3460

3461 FTUs characteristics

3462 Mean age of robust participants was 82.1 ± 2.9 years, and mean age of non-robust

3463 participants was 84.4 ± 4.2 years. Twelve percent (n=56) of non-robust participants and

3464 2% (n=3) of robust participants were aged 90 years and older. Compared to robust

3465 participants, non-robust participants were significantly older, less likely to be married,

3466 own their house outright and be physically active, and more likely to have two or more

3467 comorbidities, and rate their health as fair, poor or very poor.

3468

3469 More than a third of robust (37.0%, n=54) and non-robust (38.4%, n=173) participants

3470 had <7 FTUs. Non-robust participants were significantly more likely to have No

3471 Natural FTUs (43.5%, n=196), compared to robust participants (29.5%, n=43).

3472

3473 Tooth Decay characteristics

3474 Overall 511 participants had available information for analysis, 26.2% (n=134) of

3475 whom were classified as ‘robust’, and the other 73.8% (n=311) were classified as ‘non-

3476 robust’ (Table 7.2). Of the participants classed as non-robust, 75.1% were pre-frail

3477 (n=283), and 24.9% were frail (n=94). Mean age of robust participants was 82.1 ± 2.9

3478 years, and mean age of non-robust participants was 84.3 ± 4.2 years. Twelve percent

3479 (n=47) of non-robust participants and 2% (n=3) of robust participants were aged 90

3480 years and older. Compared to robust participants, non-robust participants were older,

3481 less likely to be married, own their own home and be physically active, and more likely

3482 to have two or more comorbidities, and describe their health as fair, poor and very poor.

227

Frailty impacts the relationship between diet and oral health in older men

Table 7.1 Characteristics and dentate status of the study population stratified by robust vs non-robusta, (n=596). Main Robust Non-Robust n (%)/ Mean n (%)/ Mean n (%)/ Mean Characteristic (±SD) (±SD) (±SD) Socio-demographic and economic factors Age (years) 75 – 79 88 (15) 28 (19) 60 (13)* 80 – 84 281 (47) 87 (60) 194 (43) 85 – 89 168 (28) 28 (19) 140 (31) ≥90 59 (10) 3 (2) 56 (12) Mean 83.1 (±4.0) 82.1 (±2.9) 84.4 (±4.2)* Marital Status Married/De Facto 434 (73) 118 (81) 316 (70)* Other 162 (27) 28 (19) 134 (30) Living Arrangements Live alone 134 (22) 27 (18) 107 (24) Other 462 (88) 119 (82) 343 (76) Source of income Age Pension Only 241 (40) 46 (32) 195 (43)* Age Pension + Other 135 (23) 37 (25) 98 (22) Otherb 220 (37) 63 (43) 157 (35) House and Ownership Outright owner 506 (85) 133 (91) 373 (83)* Other 88 (15) 13 (9) 75 (17) Post-school qualification Qualifications 361 (61) 98 (68) 263 (59) No qualifications 231 (39) 47 (32) 184 (41) Country of Birth Australia/New Zealand 315 (53) 84 (58) 231 (51) Italy/Greece 143 (24) 29 (20) 114 (25) Other 138 (23) 33 (23) 105 (23)

Health and Lifestyle Factors Body Mass Index (kg/m2) Underweight (<23.0 kg/m2) 61 (10) 11 (8) 50 (11) Normal weight (≥23.0 - <30.0 360 (61) 94 (64) 266 (59) kg/m2) Overweight/Obese (≥30.0 kg/m2) 174 (29) 41 (28) 133 (30) Mean 27.9 (±4.2) 28.1 (±4.0) 27.8 (±4.3) Alcohol Consumption Safe drinker (1 – 21 drinks) 413 (70) 108 (74) 305 (68) Unsafe drinker (>21 drinks) 40 (7) 11 (8) 29 (6) Ex-drinker 88 (15) 17 (12) 71 (16) Lifelong non-drinker 51 (9) 10 (7) 41 (9)

228

Frailty impacts the relationship between diet and oral health in older men

Smoking Current Smoker 17 (3) 2 (1) 15 (3) Ex-smoker 341 (57) 77 (52) 264 (59) Non-smoker 238 (40) 67 (46) 171 (38) PASE2 <80 205 (34) 5 (3) 200 (44)* ≥80 391 (66) 141 (97) 250 (56) Mean 107 (±63.3) 143 (±43.5) 95.7 (64.3)* Multimorbidity ≥ 2 394 (66) 83 (57) 311 (69)* Self-Rated Health Good/Excellent 442 (74) 126 (86) 316 (70)* Fair/Poor/Very Poor 154 (76) 20 (14) 134 (30)

Other Factors Able to shop for groceries? Yes 570 (96) 146 (100) 424 (94)* No 26 (4) 0 (0) 26 (6) Able to prepare meals? Yes 551 (93) 145 (99) 406 (91)* No 42 (7) 1 (1) 41 (9) MOW? Yes 26 (4) 2 (1) 24 (5)* No 570 (96) 144 (99) 426 (95)

Oral Health Factors Self-Rated Oral Health Good/Very Good/Excellent 422 (71) 104 (71) 318 (71) Fair/Poor/Don’t Know 174 (29) 42 (29) 132 (29) Number of FTUs <7 227 (38) 54 (37) 173 (38) 7 – 11 203 (34) 58 (40) 145 (32) 12 166 (28) 34 (23) 132 (29) Composition of FTUs Group A 196 (33) 51 (35) 145 (32)* Group B 161 (27) 52 (36) 109 (24) Group C 239 (40) 43 (29) 196 (44)

SD, Standard Deviation. PASE, Physical Activity Scale for the Elderly. MOW, Meals On Wheels. FTUs, Functional Tooth Units. a. Frail and pre-frail population, as per CHS frailty definition(121) b. Superannuation or private income, own business/farm/partnership, wage or salary, repatriation pension, veterans pension, or other. * p<0.05, nonrobust vs robust participants. 3483

3484

229

Frailty impacts the relationship between diet and oral health in older men

3485 Sixteen percent (n=21) of robust and 21% (n=80) of non-robust participants had coronal

3486 decay, while 3% (n=4) of robust and 7% (n=21) of non-robust participants had severe

3487 coronal decay. Eighteen percent (n=24) of robust and 25% (n=93) of non-robust

3488 participants had root decay, while 12% (n=16) of robust and 14% (n=52) of non-robust

3489 participants had severe root decay.

3490

3491 Periodontitis characteristics

3492 Overall, 292 participants had available information for analysis, 27.7% (n=81) of whom

3493 were classified as ‘robust’, and the other 72.3% (n=211) were classified as ‘non-robust’

3494 (Table 7.3). Of the participants classed as non-robust, 80.1% were pre-frail (n=169),

3495 and 19.9% were frail (n=42). Mean age of robust participants was 82.0 ± 2.8 years, and

3496 mean age of non-robust participants was 84.1 ± 3.9 years. Compared to robust

3497 participants, non-robust participants were older, less physically active, more likely to

3498 have two or more comorbidities, and more likely to describe their health as fair, poor

3499 and very poor.

3500

3501 Nine percent (n=20) of non-robust participants and 2% (n=2) of robust participants

3502 were aged 90 years and older. Ninety percent (n=190) of non-robust participants, and

3503 robust participants, experienced some form of periodontitis. Comparatively 29%

3504 (n=61) of non-robust participants, and 23% (n=19) of robust participants, were classed

3505 as having severe periodontitis.

3506

3507

230

Frailty impacts the relationship between diet and oral health in older men

Table 7.2 Characteristics and decay status of the study population included in the tooth decay examination stratified by robust and non-robusta population, (n=511) Main Robust Non-Robust n (%)/ Mean n (%)/ Mean n (%)/ Mean Characteristic (±SD) (±SD) (±SD) Socio-demographic and economic factors Age (years) 75 – 79 81 (16) 27 (20) 54 (14)* 80 – 84 236 (46) 79 (59) 157 (42) 85 – 89 144 (28) 25 (19) 119 (32) ≥90 50 (10) 3 (2) 47 (12) Mean 83.7 (±4.02) 82.1 (±2.9) 84.3 (±4.2)* Marital Status Married/De Facto 374 (73) 107 (80) 267 (71)* Other 137 (27) 27 (27) 110 (29) Living Arrangements Live alone 116 (23) 26 (19) 90 (24) Other 395 (77) 108 (81) 287 (76) Source of income Age Pension Only 184 (36) 38 (28) 146 (39) Age Pension + Other 123 (24) 35 (26) 88 (23) Otherb 204 (40) 61 (46) 143 (38) House and Ownership Outright owner 438 (86) 122 (91) 316 (84)* Other 72 (14) 12 (9) 60 (16) Post-school qualification Qualifications 317 (62) 92 (69) 225 (60) No qualifications 192 (38) 41 (31) 151 (40) Country of Birth Australia/New Zealand 276 (54) 79 (59) 197 (52) Italy/Greece 113 (22) 24 (18) 89 (24) Other 122 (24) 31 (23) 91 (24)

Health and Lifestyle Factors Body Mass Index (kg/m2) Underweight (<23.0 kg/m2) 54 (11) 11 (8) 43 (11) Normal weight (≥23.0 - <30.0 310 (61) 88 (66) 222 (59) kg/m2) Overweight/Obese (≥30.0 kg/m2) 146 (29) 35 (26) 111 (30) Mean 27.8 (±4.2) 27.9 (±3.9) 27.8 (±4.3) Alcohol Consumption Safe drinker (1 – 21 drinks) 360 (71) 100 (75) 260 (70) Unsafe drinker (>21 drinks) 33 (7) 9 (7) 24 (6)

231

Frailty impacts the relationship between diet and oral health in older men

Ex-drinker 74 (15) 15 (12) 59 (16) Lifelong non-drinker 41 (8) 10 (7) 31 (8) Smoking Current Smoker 10 (2) 2 (1) 8 (2) Ex-smoker 284 (56) 68 (51) 216 (57) Non-smoker 217 (42) 64 (48) 153 (41) PASE <80 166 (32) 5 (4) 161 (43)* ≥80 345 (68) 129 (96) 216 (57) Mean 109.7 (±63.8) 142.9 (±44.8) 97.9 (±65.4)* Multimorbidity ≥ 2 331 (65) 74 (55) 257 (68)* Self-Rated Health Good/Excellent 383 (75) 115 (86) 268 (71)* Fair/Poor/Very Poor 128 (25) 19 (14) 109 (29)

Other Factors Able to shop for groceries? Yes 490 (96) 134 (100) 356 (94)* No 21 (4) 0 (0) 21 (6) Able to prepare meals? Yes 475 (93) 133 (99) 342 (91)* No 34 (7) 1 (1) 33 (9) MOW? Yes 23 (4) 2 (1) 21 (6) No 488 (96) 132 (99) 356 (94)

Oral Health Factors Self-Rated Oral Health Good/Very Good/Excellent 365 (71) 98 (73) 267 (71) Fair/Poor/Don’t Know 146 (29) 36 (27) 110 (29) Coronal Decay ≥1 101 (20) 21 (16) 80 (21) Severe Coronal Decay ≥3 30 (6) 4 (3) 26 (7) Root Decay ≥1 117 (23) 24 (18) 93 (25) Severe Root Decay ≥3 68 (13) 16 (12) 52 (14)

SD, Standard Deviation. PASE, Physical Activity Scale for the Elderly. MOW, Meals On Wheels. a. Frail and pre-frail population, as per CHS frailty definition(121) b. Superannuation or private income, own business/farm/partnership, wage or salary, repatriation pension, veterans pension, or other. * p<0.05, nonrobust vs robust participants. 3508

3509

232

Frailty impacts the relationship between diet and oral health in older men

3510 FTUs and overall nutrient intake

3511 No significant associations were found between composition and numbers of FTUS

3512 with poor intake of micronutrients in the robust population (Table 7.4). In the non-

3513 robust population univariate analysis found an association between composition of

3514 FTUs and poor micronutrient intake (Table 7.4). Multivariate analysis showed that

3515 FTUs Group C (No Natural FTUs) was significantly associated with poor micronutrient

3516 intake, (meeting 11 or fewer micronutrient recommendations), compared to Group A

3517 (Natural Only FTUs) (adjusted Odds Ratio (OR) 2.11, 95% Confidence Interval (CI):

3518 1.08 – 4.13). No association was found between numbers of FTUs and poor

3519 micronutrient intake in the non-robust population. No evidence of a statistical

3520 interaction was found between frailty (robust vs non-robust) specific OR for the

3521 association between composition of FTUs (p=0.11) or numbers of FTUs (p=0.71) and

3522 overall micronutrient intakes.

3523

3524 No significant associations were found between composition and numbers of FTUS

3525 with poor intake of macronutrients in the robust population (Table 7.5). In the non-

3526 robust population univariate analysis found an association between composition of

3527 FTUs and poor macronutrient intake (Table 7.5). However, the association between

3528 composition for FTUs and poor macronutrient intake no longer remained significant

3529 after adjustment for confounders (adjusted OR 1.92, 95%CI: 0.86 – 4.30). No

3530 association between numbers of FTUs and poor macronutrient intake was found (Table

3531 7.5). No evidence of a statistical interaction was found between frailty specific OR for

3532 the association between composition of FTUs (p=0.66) or numbers of FTUs (p=0.43)

3533 and overall macronutrient intakes.

3534

233

Frailty impacts the relationship between diet and oral health in older men

Table 7.3 Characteristics and periodontitis status of the study population included in the periodontal examination stratified by robust and non-robusta population, (n=292) Main Robust Non-Robust n (%)/ Mean n (%)/ Mean n (%)/ Mean Characteristic (±SD) (±SD) (±SD) Socio-demographic and economic factors Age (years) 75 – 79 43 (15) 15 (19) 28 (13)* 80 – 84 143 (49) 50 (62) 92 (44) 85 – 89 86 (29) 14 (17) 71 (34) ≥90 22 (7) 2 (2) 20 (9) Mean 83.5 (±3.7) 82.0 (±2.8) 84.1 (±3.9)* Marital Status Married/De Facto 74 (25) 65 (80) 16 (20) Other 220 (75) 153 (73) 58 (27) Living Arrangements Live alone 62 (21) 15 (19) 47 (22) Other 232 (79) 66 (81) 164 (78) Source of income Age Pension Only 110 (37) 23 (28) 87 (41) Age Pension + Other 70 (24) 22 (27) 47 (22) Otherb 114 (39) 36 (44) 77 (36) House and Ownership Outright owner 258 (88) 71 (88) 185 (88) Other 36 (12) 10 (12) 26 (12) Post-school qualification Qualifications 178 (61) 55 (69) 123 (59) No qualifications 114 (39) 25 (31) 87 (41) Country of Birth Australia/New Zealand 154 (52) 48 (59) 106 (50) Italy/Greece 71 (24) 15 (19) 55 (26) Other 69 (23) 18 (22) 50 (24)

Health and Lifestyle Factors Body Mass Index (kg/m2) Underweight (<23.0 kg/m2) 35 (12) 10 (12) 25 (12) Normal weight (≥23.0 - <30.0 174 (60) 52 (64) 122 (58) kg/m2) Overweight/Obese (≥30.0 kg/m2) 82 (28) 19 (23) 63 (30) Mean 27.6 (±4.2) 27.6 (±4.1) 27.6 (±4.3) Alcohol Consumption Safe drinker (1 – 21 drinks) 209 (72) 63 (78) 146 (70) Unsafe drinker (>21 drinks) 21 (7) 6 (7) 15 (7)

234

Frailty impacts the relationship between diet and oral health in older men

Ex-drinker 41 (14) 7 (9) 32 (15) Lifelong non-drinker 20 (7) 5 (6) 15 (7) Smoking Current Smoker 8 (3) 1 (1) 7 (3) Ex-smoker 158 (54) 39 (48) 118 (56) Non-smoker 128 (44) 41 (51) 86 (41) PASE2 <80 84 (29) 3 (4) 80 (38)* ≥80 210 (71) 78 (96) 131 (62) Mean 115 (±64.9) 137.5 (±41.9) 107.2 (±69.9)* Multimorbidity ≥ 2 165 (56) 35 (43) 128 (61)* Self-Rated Health Good/Excellent 233 (79) 72 (89) 160 (76)* Fair/Poor/Very Poor 61 (21) 9 (11) 51 (24)

Other Factors Able to shop for groceries? Yes 285 (97) 81 (100) 203 (96) No 8 (3) 0 (0) 8 (4) Able to prepare meals? Yes 275 (94) 80 (99) 193 (92)* No 18 (6) 1 (1) 17 (8) MOW? Yes 11 (4) 1 (1) 10 (5) No 283 (96) 80 (99) 201 (95)

Oral Health Factors Self-Rated Oral Health Good/Very Good/Excellent 208 (71) 69 (76) 145 (69) Fair/Poor/Don’t Know 86 (29) 19 (23) 66 (31) Total Periodontitis ≥1 264 (90) 72 (89) 190 (90) Severe Periodontitis ≥3 81 (28) 19 (23) 61 (29)

235

Frailty impacts the relationship between diet and oral health in older men

Table 7.4 Multivariate logistic regression model of FTUs composition and FTU number, and micronutrient (11 or fewer) risk variable, stratified by robust and non-robust (prefrail and frail) population Robust Non-Robusta Micronutrient Risk Variable Micronutrient Risk Variable Micronutrient Risk Micronutrient Risk Variable Variable Unadjusted Adjusted Unadjusted Adjusted Variables OR (95%CI) ORbd (95%CI) OR (95%CI) ORcd (95%CI) Compositionef Group A 1.00 1.00 1.00 1.00 Group B 0.64 (0.29 – 1.41) 1.83 (0.71 – 4.68) 1.26 (0.74 – 2.12) 1.26 (0.66 – 2.41) Group C 0.68 (0.30 – 1.56) 1.17 (0.41 – 3.33) 1.83 (1.15 – 2.92)g 2.11 (1.08 – 4.13)g

Number of FTUsh 12 1.00 1.00 1.00 1.00 7 – 11 0.61 (0.26 – 1.44) 1.26 (0.43 –3.68) 0.70 (0.42 – 1.16) 0.93 (0.46 – 1.85) 0 - 6 1.29 (0.53 – 3.12) 0.56 (0.19 – 1.72) 1.01 (0.61 – 1.68) 1.68 (0.83 – 3.43)

CI, Confidence Intervals. OR, Odds Ratio. FTUs, Functional Tooth Units. a. Frail and pre-frail population, as per CHS frailty definition(121) b. Adjusted by age, energy, COB, marital status, and living status. c. Adjusted by age, energy, bmi, post school qualifications. d. OR of meeting 11 or fewer recommended micronutrient intakes e. Adjusted for FTU numbers f. Group A: only ‘Natural FTUs’, Group C: only ‘Replaced FTUs’, Group B: mixture of ‘Natural FTUs’ and ‘Replaced FTUs’. g. Statistically significant, p-value <0.05 h. Adjusted for FTU composition 3536

236

Frailty impacts the relationship between diet and oral health in older men

3537 No significant association between numbers of FTUs or composition of FTUs with poor

3538 intake of key nutrients was found in either robust or non-robust men (Table 7.6). No

3539 evidence of a statistical interaction was found between frailty specific OR for the

3540 association between composition of FTUs (p=0.60) or numbers of FTUs (p=0.59) and

3541 intake of key nutrients.

3542

3543 Tooth decay and overall nutrient intake

3544 In the robust population no relationships with intake of micronutrients, macronutrients

3545 and key nutrients, were found for coronal (Table 7.7) or root decay (Table 7.8), or

3546 severe coronal (Table 7.9) or severe root decay (Table 7.10) in the robust population.

3547 Furthermore, in the non-robust population no relationship was found between intake of

3548 micronutrients, macronutrients and key nutrients and root decay (Table 7.8) or severe

3549 coronal decay (Table 7.9). There was also no evidence of a statistical interaction was

3550 found between frailty specific OR for the association between overall micronutrient

3551 intake (p=0.76), macronutrient intake (p=0.07), and intake of key nutrients (p=0.79)

3552 and root decay. Nor was there evidence of a statistical interaction between frailty

3553 specific OR for the association between overall micronutrient intake (p=0.60),

3554 macronutrient intake (p=0.92), and intake of key nutrients (p=0.51) and severe coronal

3555 decay.

3556

3557 In the non-robust population, poor intake of macronutrients was significantly associated

3558 with being less likely to have coronal decay (Table 7.7) even after adjustment for

3559 confounders (adjusted OR 0.48, 95%CI: 0.24 – 0.96). No association was found

3560 between poor intake of micronutrients or key nutrients with the presence of coronal

3561 decay in the non-robust population (Table 7.7). No evidence of a statistical interaction

237

Frailty impacts the relationship between diet and oral health in older men

3562 was found between frailty specific OR for the association between overall micronutrient

3563 intake (p=0.78), macronutrient intake (p=0.33), intake of key nutrients (p=0.79) and

3564 coronal decay.

3565

3566 While no association was found between poor intake of macronutrients or key nutrients

3567 with the presence of severe root decay, univariate analysis in the non-robust population

3568 showed poor intake of micronutrients was significantly associated with being more

3569 likely to have severe root decay (Table 7.10). However, with the adjustment of

3570 confounders, the association was no longer statistically significant (Table 7.10). No

3571 evidence of a statistical interaction was found between frailty specific OR for the

3572 association between overall micronutrient intake (p=0.40), macronutrient intake

3573 (p=0.17), poor intake of key nutrients (p=0.15) and severe root decay.

3574

3575 Periodontitis and overall nutrient intake

3576 In the non-robust population poor intake of key nutrients was significantly associated

3577 with total periodontitis (Table 7.11) even after adjustment for confounders (adjusted

3578 OR 4.07, 95%CI: 1.47 – 11.2). No association was found between poor intake of

3579 micronutrients or macronutrients with total periodontitis in the robust non-robust

3580 population, and no association was found between poor intake key nutrients with total

3581 periodontitis in the robust population (Table 7.11). Furthermore, in robust and non-

3582 robust populations no significant associations were found between intake of key

3583 nutrients, poor intake of micronutrients and macronutrients with severe periodontitis

3584 (Table 7.12). There was no evidence of a statistical interaction found between frailty

3585 specific OR for the association between overall intake of micronutrients (p=0.45),

3586 macronutrients (p=0.25), key nutrients (p=0.19) and total periodontitis. Nor was there

238

Frailty impacts the relationship between diet and oral health in older men

3587 evidence of a statistical interaction found between frailty specific OR for the association

3588 between overall intake of micronutrients (p=0.18), macronutrients (p=0.21), key

3589 nutrients (p=0.44) and severe periodontitis.

3590

3591

3592 7.4 Discussion

3593 The findings of our study show that overall, no associations were evident between oral

3594 health factors and nutrient intake in CHAMP participants classed as robust. An

3595 association between diet with dentition, decay and periodontal outcomes was observed

3596 among non-robust participants. Poor intake of key nutrients was associated with total

3597 periodontitis in adjusted analysis and poor intake of macronutrients was associated with

3598 being less likely to have coronal decay.

3599

3600 Non-robust participants with no Natural FTUs had a higher risk of poor intakes of

3601 micronutrients than non-robust participants categorised with only Natural FTUs. This

3602 significant association was not found in the robust population, where the stratified OR

3603 for the robust population differed from the non-robust population. No evidence of a

3604 statistical interaction was found. The relationship between no Natural FTUs and overall

3605 poor intake of micronutrients was not found in the main CHAMP sample.

3606

3607 The frailty model proposed by Castrejón-Pérez et al. suggests that frailty (defined by

3608 Fried’s phenotype) leads to disability, dependence and long term care, all of which may

3609 have a negative impact on utilisation of oral health services (124). Limited use of oral

3610 health services contributes to loss of natural teeth, which the results of our study show

3611 is associated with poorer intake of micronutrients in older adults (81, 84, 85, 124).

239

Frailty impacts the relationship between diet and oral health in older men

Table 7.5 Multivariate logistic regression model of FTUs composition and FTU number, and macronutrient (4 or fewer) risk variable, stratified by robust and non-robust (prefrail and frail) population Robust Non-Robusta Macronutrient Risk Variable Macronutrient Risk Variable Macronutrient Risk Macronutrient Risk Variable Variable Unadjusted Adjusted Unadjusted Adjusted Variables OR (95%CI) ORbd (95%CI) OR (95%CI) ORcd (95%CI) Compositionef Group A 1.00 1.00 1.00 1.00 Group B 0.90 (0.33 – 2.43) 0.94 (0.32 – 2.75) 0.97 (0.49 – 1.93) 1.06 (0.51 – 2.23) Group C 1.32 (0.43 – 4.06) 1.60 (0.45 – 5.70) 2.01 (1.02 – 3.99)g 1.92 (0.86 – 4.30)

Number of FTUsh 12 1.00 1.00 1.00 1.00 7 – 11 1.25 (0.43 – 3.65) 2.36 (0.67 – 8.27) 0.66 (0.31 – 1.43) 0.99 (0.40 – 2.46) 0 - 6 1.49 (0.49 – 4.57) 2.22 (0.61 – 8.16) 0.62 (0.30 – 1.29) 0.83 (0.35 – 1.99)

CI, Confidence Intervals. OR, Odds Ratio. FTUs, Functional Tooth Units. a. Frail and pre-frail population, as per CHS frailty definition(121) b. Adjusted by age, energy, comorbidity, marital status, and SROH. c. Adjusted by age, energy, bmi, living status, housing, and alcohol. d. OR of meeting 4 or fewer recommended macronutrient intakes e. Adjusted for FTU numbers f. Group A: only ‘Natural FTUs’, Group C: only ‘Replaced FTUs’, Group B: mixture of ‘Natural FTUs’ and ‘Replaced FTUs’. g. Statistically significant, p-value <0.05 h. Adjusted for FTU composition

240

Frailty impacts the relationship between diet and oral health in older men

Table 7.6 Multivariate logistic regression model of FTUs composition and FTU number, and key nutrient intake, stratified by robust and non-robust (prefrail and frail) population Robust Non-Robusta Key Nutrients Risk Variable Key Nutrients Risk Variable Key Nutrients Risk Key Nutrients Risk Variable Variable Unadjusted Adjusted Unadjusted Adjusted Variables OR (95%CI) ORbdc (95%CI) OR (95%CI) ORcd (95%CI) Compositionef Group A 1.00 1.00 1.00 1.00 Group B 0.94 (0.41 – 2.15) 0.94 (0.38 – 2.38) 1.51 (0.83 – 2.73) 1.70 (0.91 – 3.19) Group C 0.77 (0.33 – 1.82) 0.66 (0.25 – 1.78) 1.18 (0.72 – 1.91) 1.19 (0.65 – 2.17)

Number of FTUsg 12 1.00 1.00 1.00 1.00 7 – 11 0.68 (0.28 – 1.65) 0.77 (0.28 – 2.13) 0.83 (0.48 – 1.44) 0.91 (0.48 – 1.72) 0 - 6 1.37 (0.53 – 3.50) 1.38 (0.48 – 4.01) 1.02 (0.60 – 1.74) 1.05 (0.55 – 2.00)

241

Frailty impacts the relationship between diet and oral health in older men

3613 A robust older adult may not follow the same pathway, and as such may not have the

3614 same outcome between dentition and micronutrient intake as an older adult who is pre-

3615 frail or frail. Several studies have found no association between individual components

3616 of Fried’s frailty phenotype and occluding pairs of teeth (227, 229, 230). Moriya et al.

3617 found no association between patterns of occluding teeth with hand grip strength (229).

3618 A study on community-dwelling older adults found that participants with higher

3619 number of FTUs were at lower risk of weight loss over a one year period, however this

3620 did not reach statistical significance (230). The same study did find being edentulous

3621 was a risk factor for weight loss in older adults over a 1 year period (230). Another

3622 study in adults aged 60 years and older found that participants with 21 or more teeth

3623 were significantly less likely to be frail, as per Fried’s criteria, compared to edentulous

3624 participants (138). The presence of dentures was also found to be risk factor for frailty

3625 status (138).

3626

3627 Poor intake of micronutrients may also negatively affect frailty status, which could lead

3628 to tooth loss, through the Castrejón-Pérez et al. pathway described (124). The

3629 relationship between micronutrient intakes and frailty status has also been found in

3630 older adults (132). A study in elderly Japanese women found higher intakes of

3631 micronutrients, including folate, vitamin C and vitamin B6 were associated with lower

3632 prevalence of frailty (135, 231). Vitamin D and vitamin B12 deficiency are thought to

3633 contribute to frailty and frailty component of older adults through bone health and

3634 muscular strength pathways (232). The cross-sectional nature of our study means the

3635 causal relationship between no natural FTUs and overall intake of micronutrients

3636 cannot be described, however frailty status appears to possibly play a modifying effect

242

Frailty impacts the relationship between diet and oral health in older men

Table 7.7 Multivariate logistic regression model of the micronutrient risk variable (11 or fewer), macronutrient risk variable (4 or fewer), and intake of key nutrients, with the presence of coronal decay, stratified by robust and non-robust (prefrail and frail) populations Robust Non-Robusta Coronal Decay (≥1) Coronal Decay (≥1) Unadjusted Adjusted Unadjusted Adjusted OR (95%CI) OR (95%CI)b OR (95%CI) OR (95%CI)c Micronutrient Good Intaked 1.00 1.00 1.00 1.00 Poor Intake 1.24 (0.48 – 3.24) 1.95 (0.57 – 6.60) 1.07 (0.63 – 1.82) 1.12 (0.58 – 2.17) Macronutriente Good Intakef 1.00 1.00 1.00 1.00 Poor Intake 0.91 (0.28 – 3.01) 0.79 (0.21 – 3.00) 0.47 (0.24 – 0.90)g 0.48 (0.24 – 0.96)g Key nutriente Good Intakef 1.00 1.00 1.00 1.00 Poor Intake 0.82 (0.31 – 2.16) 0.45 (0.15 – 1.40) 0.96 (0.54 – 1.70) 1.16 (0.62 – 2.15) CI, Confidence Intervals. OR, Odds Ratio. a. Frail and pre-frail population, as per CHS frailty definition(121) b. Adjusted for age, energy, BMI, comorbidity, income and post school qualifications. c. Adjusted for age, energy, BMI, PASE, income and SROH. d. Reference Meeting 12 or more recommended micronutrient intakes e. Not adjusted by energy f. Reference Meeting 5 or more recommended macronutrient/key nutrient intakes g. Statistically significant, p-value <0.05

243

Frailty impacts the relationship between diet and oral health in older men

Table 7.8 Multivariate logistic regression model of the micronutrient risk variable (11 or fewer), macronutrient risk variable (4 or fewer), and intake of key nutrients, with the presence of root decay, stratified by robust and non-robust (prefrail and frail) populations Robust Non-Robusta Root Decay (≥1) Root Decay (≥1) Unadjusted Adjusted Unadjusted Adjusted OR (95%CI) OR (95%CI)b OR (95%CI) OR (95%CI)c Micronutrient Good Intaked 1.00 1.00 1.00 1.00 Poor Intake 1.29 (0.52 – 3.20) 1.61 (0.56 – 4.64) 1.52 (0.90 – 2.56) 1.70 (0.89 – 3.27) Macronutriente Good Intakef 1.00 1.00 1.00 1.00 Poor Intake 6.08 (0.78 – 47.4) 6.58 (0.83 – 52.4) 0.84 (0.42 – 1.66) 0.88 (0.42 – 1.84) Key nutriente Good Intakef 1.00 1.00 1.00 1.00 Poor Intake 0.85 (0.34 – 2.11) 0.88 (0.34 – 2.27) 0.98 (0.57 – 1.68) 1.03 (0.57 – 1.87) OR, Odds Ratio. a. Frail and pre-frail population, as per CHS frailty definition(121) b. Adjusted for age, energy, BMI, numbers of natural teeth, SROH and brushing habits. c. Adjusted for age, energy, BMI, birth country, housing and SROH. d. Reference Meeting 12 or more recommended micronutrient intakes e. Not adjusted by energy f. Reference Meeting 5 or more recommended macronutrient/key nutrient intakes

3637

244

Frailty impacts the relationship between diet and oral health in older men

3638 in this association, although there was no evidence of statistical interaction indicating

3639 heterogeneity (124).

3640

3641 Our study also found a relationship between no natural FTUs and overall macronutrient

3642 intake in non-robust participants, but not in robust participants. After adjustment for

3643 confounders this was no longer significant, unlike the significant relationship

3644 established in the main CHAMP sample (Chapter 4). Theoretically the relationship

3645 between dentition and macronutrients in pre-frail and frail older adults would take a

3646 similar pathway, as described by Castrejón-Pérez et al., to the relationship between

3647 dentition and micronutrients in pre-frail and frail older adults (124). After all inadequate

3648 intake of macronutrients, like micronutrients, are associated with frailty status (132).

3649 Deficiency in energy and protein intakes have been significantly linked to poor frailty

3650 status and outcomes (232). Kobayashi et al. also found that higher intakes of total

3651 protein in elderly Japanese women was associated with lower prevalence of frailty

3652 (135). Distribution of protein intake across daily meals was associated with increased

3653 prevalence of frailty (233). Frail participants had lower percentage of protein

3654 consumed in the morning, and a higher percentage of protein consumed at midday,

3655 compared to non-frail participants (233). Interestingly this study found no association

3656 between overall protein intake and frailty (233).

3657

3658 Meeting the recommended intake of four or fewer macronutrients was associated with

3659 being less likely to have coronal decay, even after adjustment for confounders. Meeting

3660 the recommended intakes of eleven or fewer micronutrients was associated with being

3661 more likely to have severe root decay, although this association was no longer

3662 significant after adjustment for confounders. Again, these relationships were only

245

Frailty impacts the relationship between diet and oral health in older men

3663 found in the non-robust (frail or pre-frail) population, and there was no evidence of a

3664 statistically significant interaction indicating heterogeneity between ORs. However,

3665 these results were found in the non-stratified population, even after adjustment for

3666 confounders (Chapter 6). The stratified OR of the association between overall

3667 macronutrient intake and coronal decay for the robust population differed from the non-

3668 robust population OR of the association between overall macronutrient intake and

3669 coronal decay. The ORs of the relationship between overall micronutrient intake and

3670 severe root decay did not appear to differ greatly between the stratified populations, nor

3671 did they differ from the OR in the non-stratified population (Chapter 6). As such frailty

3672 status likely confounds the relationship between overall micronutrient intake and severe

3673 root decay in older adults but may act more as an effect modifier between overall

3674 macronutrient intake and coronal decay.

3675

3676 Our study also found that participants who were frail or pre-frail were more likely to

3677 experience coronal decay (143). This relationship between tooth decay and frailty has

3678 not been found in previous studies, possibly due to social-psychological factors and

3679 minimal intervention by dental professionals, as per supporting research on frail older

3680 adults (138, 143). This is supported in the modelled pathways on oral health and frailty

3681 proposed by Castrejon-Perez et al., where physiological and psychological frailty leads

3682 to disability and dependence, impacting use of oral health services (124).

3683

3684 We were surprised to find that poor intake of macronutrients was associated with lower

3685 risk of coronal decay in non-robust older men, as well as the overall CHAMP

3686 population. As recommendations for percentage of energy from carbohydrates and fat

3687 are measured as a range, poor intakes could reflect being either above or below this

246

Frailty impacts the relationship between diet and oral health in older men

3688 range. As discussed in Chapter 6, the majority of participants outside AMDR

3689 recommendations for fat were above the recommended range, and the majority of

3690 participants outside AMDR for carbohydrates were below the recommended range.

3691 Lower percentage of energy from carbohydrates has been previously linked to lower

3692 prevalence of decay outcomes in adults (74). Frailty is also associated with the

3693 increased prevalence or risk of malnutrition (123, 129). The key nutritional intervention

3694 is food-based fortification and supplements resulting in higher intakes of energy,

3695 typically through higher amounts of carbohydrates (234, 235). This could lead to

3696 greater prevalence of coronal decay (74). Alternatively CHAMP participants could be

3697 consuming fatty foods that are also high in carbohydrates that stick to the teeth (219).

3698

3699 Frail older adults experiencing social-psychological and structural barriers impacting

3700 use of oral health services, who are consuming higher carbohydrate diets, may have

3701 higher prevalence of coronal decay compared to frail adults not consuming a higher

3702 carbohydrate diet (124). For robust older adults the pathways between frailty and tooth

3703 decay do not apply, and the relationship between poor intake of macronutrients and the

3704 presence of coronal decay is not impacted (124).

3705

3706 Our study found that meeting the recommended intake of four or fewer key nutrients

3707 was associated with presence of total periodontitis in the non-robust population. This

3708 was not reflected in the robust population, where the OR was substantially different to

3709 the OR from the non-robust population. Furthermore, in Chapter 5, meeting

3710 recommended intakes of four or fewer key nutrients was associated with the presence

3711 of total periodontitis in the non-stratified CHAMP population, although the OR was

3712 smaller.

247

Frailty impacts the relationship between diet and oral health in older men

Table 7.9 Multivariate logistic regression model of the micronutrient risk variable (11 or fewer), macronutrient risk variable (4 or fewer), and intake of key nutrients, with the presence of severe coronal decay, stratified by robust and non-robust (prefrail and frail) populations Robust Non-Robusta Severe Coronal Decay (≥3) Severe Coronal Decay (≥3) Unadjusted Adjusted Unadjusted Adjusted OR (95%CI) OR (95%CI)b OR (95%CI) OR (95%CI)c Micronutrient Good Intaked 1.00 1.00 1.00 1.00 Poor Intake 0.73 (0.10 – 5.37) 10.10 (0.37 – 274.8) 1.32 (0.54 – 3.24) 0.97 (0.31 – 2.99) Macronutriente Good Intakef 1.00 1.00 1.00 1.00 Poor Intake 0.64 (0.06 – 6.48) 0.65 (0.06 – 6.91) 0.57 (0.20 – 1.60) 0.60 (0.20 – 1.77) Key nutriente Good Intakef 1.00 1.00 1.00 1.00 Poor Intake 0.51 (0.07 – 3.74) 0.64 (0.08 – 5.11) 1.08 (0.42 – 2.78) 1.37 (0.50 – 3.80) CI, Confidence Intervals. OR, Odds Ratio. a. Frail and pre-frail population, as per CHS frailty definition(121) b. Adjusted for age, energy, BMI and SRH c. Adjusted for age, energy, BMI, PASE and SROH. d. Reference Meeting 12 or more recommended micronutrient intakes e. Not adjusted by energy f. Reference Meeting 5 or more recommended macronutrient/key nutrient intakes

248

Frailty impacts the relationship between diet and oral health in older men

Table 7.10 Multivariate logistic regression model of the micronutrient risk variable (11 or fewer), macronutrient risk variable (4 or fewer), and intake of key nutrients, with the presence of severe root decay, stratified by robust and non-robust (prefrail and frail) populations Robust Non-Robusta Severe Root Decay (≥3) Severe Root Decay (≥3) Unadjusted Adjusted Unadjusted Adjusted OR (95%CI) OR (95%CI)b OR (95%CI) OR (95%CI)c Micronutrient Good Intaked 1.00 1.00 1.00 1.00 Poor Intake 1.27 (0.43 – 3.72) 1.85 (0.49 – 6.88) 2.21 (1.07 – 4.57)e 2.02 (0.84 – 4.84) Macronutrient Good Intakeg 1.00 1.00 1.00 1.00 Poor Intake 3.63 (0.46 – 28.9) 3.94 (0.47 – 33.3) 0.75 (0.33 – 1.71) 0.78 (0.33 – 1.86) Key nutrientf Good Intakeg 1.00 1.00 1.00 1.00 Poor Intake 0.64 (0.22 – 1.83) 0.54 (0.17 – 1.66) 1.64 (0.77 – 3.51) 1.62 (0.73 – 3.56) CI, Confidence Intervals.OR, Odds Ratio. a. Frail and pre-frail population, as per CHS frailty definition(121) b. Adjusted for age, energy, SROH, brushing habits and frequency of dental visits. c. Adjusted for age, energy, numbers of natural teeth, birth country, ‘Able to prep meals’ and SROH. d. Reference Meeting 12 or more recommended micronutrient intakes e. Statistically significant, p-value <0.05 f. Not adjusted by energy g. Reference Meeting 5 or more recommended macronutrient/key nutrient intakes 3713

249

Frailty impacts the relationship between diet and oral health in older men

3714 This suggests that frailty status modifies the relationship between diet and periodontitis,

3715 although no evidence of a statistical interaction was found between the stratified

3716 outcomes.

3717

3718 The relationship between periodontitis and frailty is unclear in the literature (227, 228).

3719 There does not seem to be any causal association between periodontitis and frailty.

3720 Castrejon-Perez et al. study in adults aged 70 year and older, severe periodontitis was

3721 not significantly associated with frailty (124). Another study in older community

3722 dwelling British adults found that neither having more than 20% of tooth sites with a

3723 probing depth of 3.5mm or more, nor having 20% of tooth sites with an attachment loss

3724 of 5.5 mm or more, were significantly associated with frailty, defined by Fried’s criteria

3725 (236). Yet there are suggestions in the literature that periodontitis may be associated

3726 with some components of Fried’s frailty criteria (227). For example, in an older adult

3727 population periodontitis was a predictor of hand grip strength over a five year period

3728 (141). Furthermore, in a group of elderly subjects the number of sites with a periodontal

3729 probing depth of 6mm or more, was a strong predictor of weight loss over a two year

3730 period (237).

3731

3732 By comparison, overall diet quality has been linked to frailty in previous studies,

3733 although not necessarily by the measure used in our study (136, 137). Shikany et al.

3734 found that the highest quintile of diet quality, and therefore highest diet quality as

3735 measured by Diet Quality Index Revised (DQI-R), was significantly less likely to be

3736 frail at baseline, relative to participants who were classed as robust (238). The highest

3737 quintile of the DQI-R score, at baseline was also associated with being less likely to be

3738 pre-frail and frail at the four year clinical follow up, compared to the participants in the

250

Frailty impacts the relationship between diet and oral health in older men

3739 lowest DQI-R score quintile (238). Antioxidants also appear to be related to frailty

3740 (132, 239). In a population of elderly Japanese women Kobayashi et al. found that

3741 higher dietary anti-oxidant intake, measured by the total anti-oxidant capacity of

3742 individual foods, was associated with lower prevalence of frailty (239).

3743

3744 The frailty and oral health model suggests that poorer nutrition leads to poorer frailty

3745 outcomes (124). Poorer frailty outcomes can contribute to increased inflammatory

3746 markers, which promote periodontal disease (124). Frailty also impacts the use of health

3747 services, which would negatively affect the use of such services to effectively treat

3748 periodontitis (124). Furthermore, antioxidant intake is also associated with periodontal

3749 disease (103, 107). A longitudinal study in older adults found that those consuming the

3750 highest tertiles of vitamin C, vitamin E and beta-carotene at lowest risk of periodontal

3751 disease progression, compared to participants with consumption in the lowest tertile

3752 (107). The same study also found that higher mean daily intakes of fruit and vegetables,

3753 food groups typically high in antioxidants, were associated with lower risk of

3754 periodontal disease progression than participants with lower intakes of fruit and

3755 vegetables (107). Diet, as well as frailty, may also contribute to increased inflammatory

3756 markers, that biologically impact periodontal disease progression (107, 124). Frailty

3757 may modify the relationship between diet and periodontal disease through additional

3758 inflammation (124).

3759

3760 There are several limitations to our study. Firstly, the cross-sectional design means that

3761 the direction of the association between nutrition with oral health factors, dentition,

3762 periodontitis and tooth decay cannot be established by our results. The generalisability

251

Frailty impacts the relationship between diet and oral health in older men

Table 7.11 Multivariate logistic regression model of the presence of total periodontitis with micronutrient risk variable (11 or fewer), macronutrient risk variable (4 or fewer), and intake of key nutrients, stratified by robust and non-robust (prefrail and frail) populations Robust Non-Robusta Total Periodontitis Total Periodontitis Unadjusted Adjusted Unadjusted Adjusted OR (95%CI) OR (95%CI)b OR (95%CI) OR (95%CI)c Micronutrient Good Intaked 1.00 1.00 1.00 1.00 Poor Intake 1.85 (0.46 – 7.49) 2.50 (0.45 – 14.0) 0.96 (0.37 – 2.50) 0.63 (0.21 – 1.93) Macronutriente Good Intakef 1.00 1.00 1.00 1.00 Poor Intake 2.00 (0.36 – 11.7) 2.22 (0.34 – 14.4) 0.52 (0.12 – 2.34) 0.62 (0.13 – 2.87) Key nutriente Good Intakef 1.00 1.00 1.00 1.00 Poor Intake 0.94 (0.22 – 4.08) 0.91 (0.19 – 4.43) 3.01 (1.20 – 7.57)g 3.86 (1.42 – 10.5)g CI, Confidence Intervals.OR, Odds Ratio. a. Frail and pre-frail population, as per CHS frailty definition(121) b. Adjusted for age, energy, PASE, diabetes and SRH. c. Adjusted for age, energy, comorbidity, and tooth brushing. d. Reference Meeting 12 or more recommended micronutrient intakes e. Not adjusted by energy f. Reference Meeting 5 or more recommended macronutrient intakes g. Statistically significant, p-value <0.05

252

Frailty impacts the relationship between diet and oral health in older men

Table 7.12 Multivariate logistic regression model of the presence of severe periodontitis with micronutrient risk variable (11 or fewer), macronutrient risk variable (4 or fewer), and intake of key nutrients, stratified by robust and non-robust (prefrail and frail) populations Robust Non-Robusta Severe Periodontitis Severe Periodontitis Unadjusted Adjusted Unadjusted Adjusted OR (95%CI) OR (95%CI)b OR (95%CI) OR (95%CI)c Micronutrient Good Intaked 1.00 1.00 1.00 1.00 Poor Intake 0.43 (0.15 – 1.22) 0.38 (0.11 – 1.31) 0.98 (0.52 – 1.84) 0.82 (0.36 – 1.83) Macronutriente Good Intakef 1.00 1.00 1.00 1.00 Poor Intake 3.46 (0.41 – 28.94) 4.85 (0.53 – 44.17) 0.82 (0.37 – 1.81) 0.61 (0.26 – 1.45) Key Nutrient intakee Good Intakef 1.00 1.00 1.00 1.00 Poor Intake 0.66 (0.23 – 1.88) 0.62 (0.20 – 1.86) 1.08 (0.54 – 2.14) 0.83 (0.39 – 1.77)

CI, Confidence Intervals. OR, Odds Ratio. a. Frail and pre-frail population, as per CHS frailty definition(121) b. Adjusted for age, energy, COB, and Living status c. Adjusted for age, energy, COB, smoking, and alcohol intake d. Reference Meeting 12 or more recommended micronutrient intakes e. Not adjusted by energy f. Reference Meeting 5 or more recommended macronutrient intakes 3763

253

Frailty impacts the relationship between diet and oral health in older men

3764 of our results is also limited in relation to women or older adults residing in aged care.

3765 Furthermore, while CHAMP utilised the widely employed frailty phenotype

3766 established in the Cardiovascular Health Study (CHS), our individual components of

3767 frailty were slightly different from the original study (121). Frailty status was also

3768 dichotomised (robust/non-robust) rather than used as three tiers (robust, pre-frail and

3769 frail), to minimize the impact on the power of the statistical analysis. However,

3770 stratification of the CHAMP population did lead to smaller sample sizes for analysis,

3771 especially for the number of participant’s classed as robust. This subsequently may

3772 have impacted the power of the analysis, particularly for periodontitis (as reflected by

3773 very wide confidence intervals).

3774

3775 This study has several strengths, including the use of calibrated oral health examiners,

3776 and a validated diet history method using trained dietitians (43, 169). Oral health

3777 examiners provided objective measures of dentition, probing depth, recession, and

3778 decay experience. This is similar to other international epidemiological studies on oral

3779 health (32). However only three sites on each tooth were measured for probing depth,

3780 while the gold standard measures six sites. The validated diet history method for

3781 measuring diet is not limited by short term memory bias; however, the intakes remain

3782 as estimates and should be interpreted with caution (193, 203).

3783

3784 In conclusion, this study for the first time explores how frailty status impacts the

3785 relationship between diet and oral health. Frailty status appears to modify the

3786 relationship between diet with periodontitis, coronal decay, and the composition of

3787 FTUs, dependent on whether the population is robust or pre-frail/frail. Longitudinal

3788 studies may provide more insight into the direction of these relationships.

254

3789

3790

3791

3792

3793

3794

3795

3796

3797

3798

3799

3800 CHAPTER 8: DISCUSSION

3801

3802

3803

3804

3805

3806

3807

3808

3809

3810

3811

3812

3813

255

Discussion

3814 8.1 Discussion

3815 This thesis found dietary intake of various individual micro and macronutrients was

3816 related to composition of FTUs, total and severe periodontitis, and coronal and root

3817 decay. Frailty appears to modify the relationship between the composition of FTUs with

3818 dietary intake of nutrients, the relationship between dietary intake of nutrients with

3819 severe and total periodontitis, and the association between nutrients with coronal and

3820 root decay. Overall there appears to be an interrelationship between diet and oral health

3821 in community dwelling older Australian men.

3822

3823 Participants with no natural FTUs (Group C) were significantly more likely to not meet

3824 recommendations for magnesium and fibre intakes, compared to participants with only

3825 natural FTUs present (Group A). Participants with a mixture of natural and prosthetic

3826 FTUs (Group B) were significantly more likely to be consuming adequate intakes of

3827 protein than participants with only natural FTUs (Group A). Participants meeting

3828 vitamin E recommendations were significantly more likely to have severe periodontitis,

3829 compared to participants not meeting recommendations. Similarly, meeting vitamin E

3830 recommendations was significantly associated with ‘total periodontitis’, compared to

3831 not meeting vitamin E recommendations. However, this relationship could be due to

3832 the quality of food sources, as discussed in Chapter 6, or even a spurious result from

3833 multiple tests. Multivariate analysis revealed that participants not meeting

3834 recommendations for energy as a percentage of fat intake was associated with lower

3835 risk of coronal decay, compared to participants meeting these recommendations.

3836 Alternatively, participants not meeting fibre recommendations were significantly more

3837 likely to have root decay than participants meeting fibre recommendations. Similarly

3838

256

Discussion

Table 8.1 Summary of thesis findings Chapter and Aim Adjusted analysis findings: Chapter 4: ‘associations between Compared to the presence of 12 FTUs, composition of Functional Tooth Units participants with <7 FTUs were more likely (FTUs) and nutrient intakes’. to not meet fibre intake recommendations.

Compared to Only Natural FTUs, participants with No Natural FTUs were: - More likely to not meet fibre intake recommendations. - More likely to not meet magnesium recommendations. - More likely to have poor overall intake of macronutrientsa.

Compared to have Only Natural FTUs, participants with a mixture of Natural and Replaced FTUs were: - More likely to meet protein intake (g/kg/body weight) requirements. Chapter 5: ‘association between nutrient Compared to good intake of key nutrientsa, intake and periodontitis’. participants with poor intake were more likely to have total periodontitis.

Compared to meeting recommended intakes of vitamin E, participants not meeting recommendations were less likely to severe and total periodontitis. Chapter 6: ‘associations between dietary Participants who had a higher fat, lower intake of nutrients and diet quality and carbohydrate dietb, compared to those who presence of dental decay’. did not, were less likely to have the presence of coronal decay.

Compared to participant’s with good intake of overall macronutrientsa, those with poor intake were less likely to the presence of coronal decay.

Compared to participants were within the AMDR percentage of energy from fat, those outside the range were less likely to have coronal decay.

Compared to participants who did meet fibre recommendations, participants who did not meet fibre recommendations were less likely to have root decay.

257

Discussion

Compared to participants with good intake of micronutrientsc, participants with poor intake of micronutrients were more likely to have severe root decay.

Compared to participants who did meet thiamin recommendations, participants who did not meet thiamin recommendations were less likely to have severe root decay.

Compared to participants who did meet zinc recommendations, participants who did not meet zinc recommendations were less likely to have severe root decay. Chapter 7: ‘assess how frailty status In the non-robust population compared to impacts the relationship between diet Only Natural FTUs, participants with No quality, overall micronutrient and Natural FTUs were more likely to have poor macronutrient intake with oral health’. overall intake of micronutrientsc. This was not found in the robust population.

In the non-robust population, compared to good intake of key nutrientsa, participants with poor intake were more likely to have total periodontitis. This was not found in the robust population.

In the non-robust population compared to participant’s with good intake of overall macronutrientsa, those with poor intake were less likely to the presence of coronal decay. This was not found in the robust population.

FTUs, Functional Tooth Units. AMDR, Acceptable Macronutrient Distribution Range. a. Reference Meeting 5 or more recommended macronutrient/key nutrient intakes b. > 35% of energy intake from fat, <45% of energy intake from carbohydrates. c. Reference Meeting 12 or more recommended micronutrient intakes Frail and pre-frail population, as per CHS frailty definition 3839

3840 compared to those meeting recommendations, participants who did not meet zinc or

3841 thiamine recommendations were more likely to have severe root decay.

3842

3843 A relationship with fibre intake was found for several different aspects of oral health.

3844 This possibly highlights a bi-directional relationship between fibre intake and oral

258

Discussion

3845 health, that reflects the theoretical framework proposed in Figure 1.2. Theoretically

3846 fibre intake impacts root decay, which impacts tooth loss, which impacts fibre intake

3847 (73, 81, 84, 85). The relationship between fibre and dentition is well documented,

3848 even amongst older age groups (81, 84, 85). Ervin et al. found that males with

3849 complete mixed dentition had significantly poorer intakes of dietary fibre than males

3850 with complete natural dentition (81). Iwasaki et al. found that older adults with

3851 compromised dentition had poorer intakes of dietary fibre than those with good

3852 dentition (84). A cohort study also based in Japan found that older adults with

3853 impaired dentition had a decline in intake of dietary fibre (85). However, the

3854 relationship between fibre and root decay is less well documented, especially among

3855 older adults. One recent study found that scores for vegetable and total grain food

3856 groups were associated with lower adjusted root caries increment (defined as the

3857 number of teeth with root caries incidence and root caries reversals) (73). Vegetables

3858 and total grains are food groups that are major sources of fibre (73). Lower numbers

3859 of teeth, FTUs or poor dentition is also associated with lower intakes of foods high in

3860 fibre, such as vegetables, fruits and total grains (73).

3861

3862 Interestingly participants with no natural FTUs present were more likely to have poor

3863 intake of macronutrients (those who met the recommendations for four or fewer

3864 macronutrients) than those with only natural FTUs present. In contrast, those with poor

3865 intake of macronutrients were less likely to have coronal decay. It is difficult to say

3866 whether this relationship is the same bi-directional pathway reflected by fibre’s

3867 relationship with both root decay and FTUs composition. Poor intake of macronutrients

3868 is associated with less coronal decay, which is unlikely to contribute to tooth loss that

3869 would, in turn, contribute to poor intake of macronutrients. This may come down to the

259

Discussion

3870 individual macronutrient components of the risk variable. Out of the seven

3871 macronutrients, only fibre was associated with composition of FTUs and meeting

3872 recommended energy intake from fat (AMDR) was associated with coronal tooth

3873 decay. There appears to be an interrelationship between overall intake of

3874 macronutrients and oral health. Although, while macronutrient intakes are influenced

3875 by dentition while also impacting on tooth decay, these associations appear to be

3876 independent of each other, and do not reflect the proposed theoretical framework in

3877 Figure 1.2. This thesis does not provide evidence of a bi-directional relationship

3878 between overall macronutrient intake and oral health.

3879

3880 Poor intake of micronutrients (meeting the recommendations for 11 or fewer

3881 micronutrients) was not associated with different oral health outcomes. Overall intake

3882 of micronutrients was associated with severe root decay, but not with composition of

3883 FTUs or periodontitis. Furthermore composition of FTUs was associated with poor

3884 intake of magnesium, poorer intakes of vitamin E were associated with being less likely

3885 to have periodontitis, and poorer intakes of zinc and thiamin were associated with being

3886 more likely to have severe root decay. Our study suggests that while there is no bi-

3887 directional relationship between overall micronutrient intake and oral health, there is

3888 an interrelationship between individual micronutrients and oral health outcomes. Past

3889 literature has shown clear associations between dentition, including FTUs, and

3890 individual micronutrients, as well as food groups rich in micronutrients, like fruit and

3891 vegetables (31, 52, 80, 81, 84, 85, 88, 89). The relationship between micronutrients and

3892 root decay has not been well explored. One study has shown association between root

3893 decay and fruit and vegetables, a food group high in micronutrients (73). Another study

260

Discussion

3894 found that participants with inadequate intakes of zinc had higher rates of root decay

3895 (97).

3896

3897 The body of work presented in this thesis shows no evidence of a relationship between

3898 calcium and dentition, periodontitis, and tooth decay among older adults. Previous

3899 research has shown a significant relationship between periodontal disease and calcium

3900 intake in adult populations, as well as an association with milk and fermented dairy

3901 products, (as discussed in Chapter IV) (108, 197, 210). Past research has also shown an

3902 association between calcium with dentition. Several studies have found a significant

3903 relationship between calcium and numbers of FTUs, numbers of natural teeth, and

3904 composition of dentition (31, 78, 79, 85). Alternatively a few studies, similar to the

3905 results presented in this thesis, have found no evidence of a relationship between

3906 calcium and dentition (52, 81, 91). Similarly no association was found between vitamin

3907 C, with dentition or periodontitis despite past research showing significant associations

3908 vitamin C and dentition or periodontal disease. Discrepancies between this thesis

3909 results, and other results, could be due to different measures of dentition, periodontitis,

3910 and tooth decay.

3911

3912 Our findings showed that older men with no natural FTUs had poorer intakes of

3913 macronutrients than participants with only natural FTUs. Poor intake of macronutrients

3914 was associated with being less likely to have coronal decay, and poor intake of

3915 micronutrients was associated with the presence of severe root decay. Finally, poor

3916 intake of key nutrients was associated with total periodontitis.

3917

3918

261

Discussion

3919 Frailty

3920 Our findings suggest that frailty impacts on the relationship between composition of

3921 FTUs and macronutrients. Stratification of the sample by frailty status, into robust or

3922 non-robust (pre-frail /frail), found no association between composition of FTUs and

3923 macronutrients. The analysis of the non-robust sample found that those with no natural

3924 FTUs were more likely to have poor intake of micronutrients, compared to those with

3925 only natural functional tooth units.

3926 Meeting four or fewer recommendations for key nutrients was associated with being

3927 less likely to have total periodontitis in the non-robust population but not found the

3928 robust population. In the non-robust population poor intake of macronutrients, meeting

3929 four or fewer macronutrient recommendations, was associated with being less likely to

3930 experience tooth decay. No significant relationship was found between intakes of

3931 macronutrients and coronal decay in the robust population. Overall this suggests an

3932 interrelationship between frailty, diet and oral health.

3933

3934

3935 8.2 Limitations

3936 The findings in this thesis are based on cross-sectional analysis, therefore the causal

3937 effect and the direction of the associations between the exposure and outcome cannot

3938 be established. While past literature does suggest that dentition impacts on diet, and

3939 diet most likely impacts on periodontitis and tooth decay, results from this thesis

3940 indicate that these associations go in opposing directions. A number of measures used

3941 were self-reported, which may present measurement bias. Generalisability of results to

3942 the overall Australian older adult population is unclear, as the study focused on an all

262

Discussion

3943 male community dwelling population. The results may be limited in their applicability

3944 to older women or institutionalised older adults.

3945

3946 Some of the analyses were conducted on small sample sizes. The periodontal analysis

3947 was limited due to the exclusion of participants who had contraindication for the

3948 periodontal assessment. This limitation was exacerbated when the sample was stratified

3949 for frailty status. A small sample size may have impacted the statistical power for some

3950 of the outcomes included in the studies of this thesis.

3951 There were some limitations that arose specifically related to nutrient data collected

3952 from older adults to investigate the relationship with oral health. Diet history data

3953 collected was converted to nutrient data via a 2007 database. This database lacked

3954 information in regards to several nutrients, including vitamin B6 and B12. This

3955 database also did not distinguish ‘free sugars’ in food products, and as such this nutrient

3956 could not be adequately explored in this thesis. Another limitation was that although

3957 data entry was conducted in a systematic way, and all dietitian interviewers were

3958 trained, errors may still have occurred. Finally diet histories are subject to memory bias,

3959 and reported portion sizes are subjective, varying from participant to participant.

3960

3961

3962 8.3 Strengths

3963 The CHAMP study has a large population of community dwelling older adults, which

3964 is representative of the study population. The CHAMP study has also had a good

3965 participation rate at each of the subsequent follow ups, including the 4th wave of data

3966 collection. Furthermore, there is a large migrant cohort, which includes participants

3967 from Non-English-Speaking Backgrounds (NESB). As such the population sample

263

Discussion

3968 includes a number of participants from a diverse array of ethnicities. The CHAMP study

3969 has also collected a large array of possible confounders. This has allowed the

3970 investigation into the relationship between nutrition and oral health to consider

3971 numerous health, socio-economic and demographic variables. These variables were

3972 predominantly measured using tools that were validated to be used in older populations.

3973 Another strength of this the studies in this thesis is that the diet history was conducted

3974 by trained dietitians in person by face to face interviews using a validated methodology.

3975 The oral health examination was also conducted by trained oral health professionals,

3976 oral health therapists, who were assessed for examiner reliability (43). The oral

3977 examination itself provides objective clinical measures for a variety of oral health

3978 variables and confounders (43).

3979

3980

3981 8.4 Implication and Recommendations

3982 This is the first Australian based epidemiological study to examine the interrelationship

3983 between diet and oral health. Despite the cross-sectional nature of the study, these

3984 findings show there is a relationship between nutrition and oral health in Australian

3985 community dwelling older men. The results of this thesis also provide insight into the

3986 interrelationship between diet and oral health.

3987

3988 The next step in this area would be longitudinal analysis, preferably on a population of

3989 larger size, to better determine the direction of the relationship between oral health, diet

3990 and nutrition reflected in the theoretical framework proposed in Figure 1.2. The

3991 relationship with individual nutrients, like calcium and vitamin C is particularly

3992 inconsistent with the literature. Past studies indicate that dentition impacts the dietary

264

Discussion

3993 intake of nutrients, however the vast majority of these are cross-sectional. The

3994 association between dietary intake of nutrients with periodontitis and tooth decay is

3995 explored in longitudinal studies. Literature suggest that dietary intake of nutrients

3996 impacts on periodontal health and tooth decay, though only a few of these studies focus

3997 on older adults.

3998

3999 Intervention studies, with a larger number of participants, could also be conducted to

4000 determine if diet could have a therapeutic effect on periodontitis or tooth decay in older

4001 adults. Much research has focused on the therapeutic effect of prosthetics on diet,

4002 particularly among the edentulous. However, few studies have used diet to intervene in

4003 oral health outcomes, and those that do have small sample sizes, and focus on younger

4004 populations. Overall, further high-quality studies are also essential to forming clinically

4005 meaningful guidelines for nutrition and oral health professionals to follow.

4006

4007 Future research should also consider exploring the relationship between food groups

4008 and diet quality with oral health factors, also exploring the possibility of an inter-

4009 relationship between these variables. Researchers and nutritionists will benefit from a

4010 better understanding of how oral health interplays with individual nutrients. More large

4011 sized longitudinal cohorts to further examine the association between dietary intake of

4012 food groups with oral health is necessary to develop meaningful public health

4013 messages.

4014

4015 Conclusion

4016 In conclusion this thesis proposes a theoretical framework and provides evidence of an

4017 interrelationship between dietary intake of nutrients and oral health. In particular there

265

Discussion

4018 is also a bi-directional relationship between fibre and oral health. As future generations

4019 of older adults continue to keep more of their natural teeth, nutrition may play a role in

4020 preventing chronic oral health diseases such as periodontitis and tooth decay. Going

4021 forward there is also scope to further explore how frailty impacts nutrition and oral

4022 health in community dwelling older adults.

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4654 225. Fang MM, Lei KY, Kilgore LT. Effects of zinc deficiency on dental caries in 4655 rats. J Nutr. 1980;110(5):1032-6.

4656 226. Shaik PS, Pachava S. The Role of Vitamins and Trace Elements on Oral 4657 Health: A Systematic Review. Int J Med Rev 2017;4(1):22-31.

4658 227. Tôrres LHDN, Tellez M, Hilgert JB, Hugo FN, Sousa MDLR, Ismail AI. 4659 Frailty, Frailty Components, and Oral Health: A Systematic Review. J Am Geriatr 4660 Soc. 2015;63(12):2555-62.

4661 228. Hakeem FF, Bernabé E, Sabbah W. Association between oral health and 4662 frailty: A systematic review of longitudinal studies. Gerodontology. 2019;36(3):205- 4663 15.

4664 229. Moriya S, Muramatsu T, Tei K, Nakamura K, Muramatsu M, Notani K, et al. 4665 Relationships between oral conditions and physical performance in a rural elderly 4666 population in Japan. Int Dent J. 2009;59(6):369-75.

4667 230. Ritchie C, Joshipura K, Silliman R, Miller B, Douglas C. Oral health problems 4668 and significant weight loss among community-dwelling older adults. J Gerontol. 4669 2000;55b(4):M366-71.

4670 231. Satomi K, Hitomi S, Satoshi S, the Three-Generation Study of Women on D, 4671 Health Study G. Diet with a combination of high protein and high total antioxidant 4672 capacity is strongly associated with low prevalence of frailty among old Japanese 4673 women: a multicenter cross-sectional study. Nutr J. 2017;16(1):1-12.

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4676 233. Bollwein J, Diekmann R, Kaiser M, Bauer J, Uter W, Sieber C, et al. 4677 Distribution but not amount of protein intake is associated with frailty: a cross- 4678 sectional investigation in the region of Nürnberg. Nutr J. 2013;12(1).

4679 234. Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation 4680 in elderly people at risk from malnutrition. Cochrane Database Syst Rev. 2009;Issue 4681 2(2).

4682 235. Morilla-Herrera JC, Martin-Santos FJ, Caro-Bautista J, Saucedo-Figueredo C, 4683 Garcia-Mayor S, Morales-Asencio JM. Effectiveness of food-based fortification in 4684 older people a systematic review and meta-analysis.(Report). 2016;20(2):178.

4685 236. Ramsay SE, Papachristou E, Watt RG, Tsakos G, Lennon LT, Papacosta AO, 4686 et al. Influence of Poor Oral Health on Physical Frailty: A Population‐Based Cohort 4687 Study of Older British Men. J Am Geriatr Soc. 2018;66(3):473-9.

4688 237. Weyant RJ, Newman AB, Kritchevsky SB, Bretz WA, Corby PM, Ren D, et 4689 al. Periodontal Disease and Weight Loss in Older Adults. J Am Geriatr Soc. 4690 2004;52(4):547-53.

4691 238. Shikany JM, Barrett-Connor E, Ensrud KE, Cawthon PM, Lewis CE, Dam T- 4692 TL, et al. Macronutrients, Diet Quality, and Frailty in Older Men. J Gerontol A Biol 4693 Sci Med Sci. 2013;69(6):695-701.

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4694 239. Kobayashi S, Asakura K, Suga H, Sasaki S. Inverse association between 4695 dietary habits with high total antioxidant capacity and prevalence of frailty among 4696 elderly Japanese women: A multicenter cross-sectional study. J Nutr Health Aging. 4697 2014;18(9):827-36.

4698

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4700

4701

4702

4703

4704

4705

4706

4707

4708

4709

4710 APPENDICES

4711

4712

4713

4714

4715

4716

4717

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4723

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APPENDIX A: PRISMA 2009 CHECKLIST

304

PRISMA 2009 Checklist

Section/topic # Checklist item Reported on page #

TITLE Title 1 Identify the report as a systematic review, meta-analysis, or both. Page 1 (Line 3) ABSTRACT Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; study Page 2-3 (Lines 24 – 56) eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number. INTRODUCTION Rationale 3 Describe the rationale for the review in the context of what is already known. Page 4 – 5 (Lines 73 – 110) Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, Page 5 (Lines 112 – 120) comparisons, outcomes, and study design (PICOS). METHODS Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, Page 6 (Lines 123 – 125) provide registration information including registration number. Supplementary Item 2 Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years Page 7 (Lines 148 to 150) considered, language, publication status) used as criteria for eligibility, giving rationale. Table 1 (Page 27) Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to Page 6 (Lines 128 – 142) identify additional studies) in the search and date last searched. Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it Pages 6 – 7 (Lines 139 -140) could be repeated. Supplementary Item 3 Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if Page 7 (Lines 158 – 167) applicable, included in the meta-analysis). Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any Page 7 – 8 (Lines 170 – 174) processes for obtaining and confirming data from investigators. Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any NA assumptions and simplifications made. Risk of bias in individual 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether Page 7 (Lines 158 – 167) studies this was done at the study or outcome level), and how this information is to be used in any data synthesis. Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). NA Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of NA 2 consistency (e.g., I ) for each meta-analysis.

305

PRISMA 2009 Checklist

Section/topic # Checklist item Reported on page #

Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, Page 8 (Lines 178 to 182) selective reporting within studies). Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, NA indicating which were pre-specified. RESULTS Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for Page 7 (Lines 148 to 150) exclusions at each stage, ideally with a flow diagram. Page 9 (Lines 199 – 202) Table 1, (Page 27) Figure 1. Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up Page 9 (Lines 204 – 208) period) and provide the citations. Table 2 (Page 28 – 32) Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). Page 14 (Lines 326 – 339) Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for Pages 9 - 13 (Lines 211 – 314) each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot. Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency. NA Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15). Pages 13 - 17 (Lines 317 – 395) Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see NA Item 16]). DISCUSSION Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their Pages 18 – 19 (Lines 419 – 449) relevance to key groups (e.g., healthcare providers, users, and policy makers). Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete Pages 19 – 22 (Lines 451 – 522) retrieval of identified research, reporting bias). Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future Page 22 (Lines 525 – 536) research. FUNDING Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of Pages 22 – 23 (Lines 539 – 545) funders for the systematic review.

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097 For more information, visit: www.prisma-statement.org.

306

APPENDIX B: PROJECT PROPOSAL

307

Project Proposal

Title/question: The relationship between dietary intake of nutrients and food groups with dentition in community dwelling older adults: A systematic review

Databases - Medline, Science Direct, Cochrane library, CINAHL, Global health, Informit, Embase.

Search and screening process 1. Search each database using Key Words. 2. Download the title and abstracts of results into Endnote, placing in groups according to database 3. Remove duplicates using Endnote 4. Stage 1 Screening: Search through title and abstract, and code the first exclusion criteria in the exclusion spread sheet. If no exclusion criteria is met in the title and abstract then code ‘Inc’ for Inclusion into next stage. This will be conducted by a single reviewer (KM), with a second reviewer available for consultation.. 5. Stage 2 Screening: Those included from Stage 1 Screening have their full text obtained, screened in full and coded for the first exclusion criteria in the Excel spreadsheet. If no exclusion criterion is met, then code ‘Inc’ for Inclusion for Quality assessment. Conducted by two independent reviewers (KM & JO), with a third reviewer if a consensus cannot be reached. 6. Stage 3 Quality Assessment 7. Stage 4 Data Extraction: Data was extracted into excel sheets by one reviewer, with a second reviewer available for consultation. 8. Stage 5 Hand searching article references: All fully obtained texts were hand searched for additional references for screening.

Inclusion Criteria: - Study Design: Include Cross-sectional studies, Case control studies, Cohort Studies, Ecological studies, Randomized Control Trials, Systematic literature reviews. Literature Reviews, Case studies and non study based sources will be excluded. - Population: Aged 60 years and older, male and female, generally healthy population. During the second stage of screening, if results were stratified for those above 60 years and those 60 years or below, the study was included. - Setting: Community based population, (with a small proportion of institutionalized subjects). Where results for community and institutionalized populations were stratified the study was included. - Data collection method: Food intake: Diet Hx taken by trained professionals, FFQ, 24 hour recall, weighed food record. Oral health: Assessment by trained oral health professionals. - Explanatory/Outcome variables: either variable type must include periodontal disease or at least one nutrition component, and both periodontal and nutrition disease must be present in the study. Nutrition variable must be targeted about whole diet/food/nutrient intake, (not overall nutrition status, malnutrition, BMI or weight), via food (not supplements). Valid measurements of dietary/nutritional intake i.e. nutrient intake analysis, food group intake, (but not nutrient biomarkers in the blood). Oral health variables must be related to dentate status (numbers/types of teeth or replacements or edentulism). Valid measurements of Oral Health

308

Project Proposal

outcomes include number of teeth, functional units (or posterior occluding pairs) and presence of dentures. - Sample Size: Include all sample sizes. - English Language: Include only studies in the English Language - Dropout rate: Include all - Year Range: All articles published up until the 30th of May 2019. - Authorship: If the Author is on more than one paper, that covers the same topic, the most current study will be used.

Exclusion Criteria - Studies in specific disease related oral health/dietary issues (i.e. the whole population has this acute or chronic disease), animal studies, institutionalized only settings or populations with more than >10% of population in an institution or populations with <10% institutionalized but the results are not separated, Outcome measures of nutritional status i.e. BMI or Weight.

Exclusion Codes INC – Include EXP – Exclude: Population ( <60 yrs of age, Animal, not healthy (all have specific disease type)). (Can query populations described or classed “older” or “adults” in abstracts only). EXS – Exclude: Setting (Institutionalised only or Institutionalised and community) EXO – Exclude: Outcome (outcome isn’t valid measure of dietary or nutritional intake, or periodontal disease, e.g. serum biomarkers, food avoidance, MNA, weight, BMI, dentition, decay). Missing a oral health or nutrition outcome. Denture quality if this was the sole measure of dentition, or comparison of prosthesis or prosthodontic methods. Sel-reported dentition (except presence of dentures. EXL – Exclude : Language (non-English) EXM – Exclude: Method of collection is inappropriate. E.g. grocery item list, not actually indicated as dietary intake. EXD – Study Design: Exclude based on study design. E.g. Case Study, Narrative literature review. EXA – Authorship EXY – Exclude as outside year range/or cannot access.

Create a flow chart with numbers and reasons for exclusions (Prisma): See Figure 1.

Quality review tool – Scottish Intercollegiate Guidelines Network (SIGN) Checklist. Data extraction – Data was extracted into excel sheets by one reviewer, with a second reviewer available for consultation.

309

APPENDIX C: DATABASE SEARCH TERMS

310

Database Search Terms

Supplementary Table 2 – Database search terms 2/3/2020

MEDLINE EMBASE GLOBAL HEALTH CINAHL SCIENCEDIRECT COCHRANE INFORMIT (No additional limits) (no additional limits) (no additional limits) (no additional limits) (no additional limits) (no additional limits) (no additional limits) Exp Dentures/ Exp denture/ exp dentures/ MH "Dentures+" TITLE-ABSTR- MeSH descriptor: Denture* Exp Denture, Exp complete Denture* MH "Denture, KEY(Denture*) [Dentures] explode Denture* Complete Complete/ denture/ complete.mp. Complete+" TITLE-ABSTR- all trees Denture* partial Exp Denture, Partial/ Exp partial denture/ Denture* partial.mp. MH "Denture, KEY(Denture* MeSH descriptor: Mouth Edentulous Exp Mouth, Exp edentulousness/ Edentulous.mp. Partial+" Complete) [Denture, Complete] Jaw Edentulous Edentulous/ Exp Tooth Arch/ Dental Arch.mp. MH "Mouth, TITLE-ABSTR- explode all trees Jaw Edentulous Exp Jaw, Edentulous/ Tooth Loss.mp. Tooth Loss.mp. Edentulous+" KEY(Denture* MeSH descriptor: partially Exp Jaw, Edentulous, Functional Tooth Functional Tooth MH "Jaw, partial) [Denture, Partial] Dental Arch Partially/ Unit*.mp. Unit*.mp. Edentulous" TITLE-ABSTR- explode all trees Tooth Loss Exp Dental Arch/ “jaw Edentulous KEY(Mouth MeSH descriptor: Functional Tooth Exp Tooth Loss Exp diet/ exp diet/ Partially” Edentulous) [Mouth, Edentulous] Unit* Functional Tooth Exp Caloric intake/ exp energy intake/ MH "Dental Arch" TITLE-ABSTR- explode all trees Units.mp. Exp nutritional exp nutritional MH "Tooth Loss" KEY(Jaw Edentulous MeSH descriptor: Diet* assessment/ assessment/ “Functional Tooth ) [Jaw, Edentulous] Energy Intake exp Diet/ Exp Dietary Intake/ exp nutrient intake/ Unit*” TITLE-ABSTR- explode all trees Nutrition* exp Energy Intake/ or Exp Nutrient/ exp food intake/ KEY(Jaw Edentulous MeSH descriptor: Assessment* caloric intake Exp food intake/ dietary intake.mp. MH "Diet+" partially) [Jaw, Edentulous, Food intake exp Nutrition MH "Energy Intake" TITLE-ABSTR- Partially] explode all Nutrient Intake Assessment/ Aged/ Aged.mp. MH “Nutritional KEY(Dental Arch) trees Dietary Intake Nutrient Intake.mp. (Aged 80 and (Aged 80 and Assessment" TITLE-ABSTR- MeSH descriptor: Food Intake.mp. over).mp. [mp=title, over).mp. MH "Food Intake+" KEY(Tooth Loss) [Dental Arch] Aged Dietary Intake.mp. abstract, heading [mp=abstract, title, MH “Nutrients+” TITLE-ABSTR- explode all trees Aged 80 and over word, drug trade original title, broad “Dietary Intake” KEY(Functional MeSH descriptor: Elderly exp Aged/ name, original title, terms, heading words, Tooth Unit*) [Tooth Loss] explode Frail Elderly exp "Aged, 80 and device manufacturer, identifiers, cabicodes] MH "Aged+" all trees Geriatric* over"/ drug manufacturer, Frail Elderly.mp. MH "Aged, 80 and TITLE-ABSTR- Functional Tooth Older Adult* exp Frail Elderly/ device trade name, exp elderly/ Over" KEY(Diet*) Unit* exp Geriatrics keyword] exp geriatrics/ MH "Frail Elderly" TITLE-ABSTR- Older Adult*.mp. Exp frail elderly/ Older Adult*.mp. MH "Geriatrics" KEY(Energy Intake) MeSH descriptor: Elderly.mp. Older Adult*.mp. “Older Adult*" TITLE-ABSTR- [Diet] explode all Exp geriatrics/ “Elderly" KEY(Nutrition trees Exp Aging/ Assessment*) MeSH descriptor: TITLE-ABSTR- [Energy Intake] KEY(Food intake) explode all trees TITLE-ABSTR- MeSH descriptor:

311

Database Search Terms

KEY(Nutrient Intake) [Nutrition TITLE-ABSTR- Assessment] explode KEY(Dietary Intake) all trees Nutrient Intake TITLE-ABSTR- Food Intake KEY(Aged) Dietary Intake TITLE-ABSTR- KEY(Aged 80 and MeSH descriptor: over) [Aged, 80 and over] TITLE-ABSTR- explode all trees KEY(Elderly) MeSH descriptor: TITLE-ABSTR- [Aged] explode all KEY(Frail Elderly) trees TITLE-ABSTR- MeSH descriptor: KEY(Geriatric*) [Geriatrics] explode TITLE-ABSTR- all trees KEY(Older Adult*) MeSH descriptor: [Frail Elderly] explode all trees Older Adult* Elderly 213 511 68 58 102 26 8 Footnotes: Meshed terms were used for the Cochrane and MEDLINE databases and were adapted for all other databases (EMBASE, Global Health, CINAHL, ScienceDirect, Informit). An asterisk (*) was used for words that were truncated.

312

APPENDIX D: POOR DIETARY INTAKE OF NUTRIENTS AND FOOD GROUPS ARE

ASSOCIATED WITH INCREASED RISK OF PERIODONTAL DISEASE AMONG

COMMUNITY-DWELLING OLDER ADULTS: A SYSTEMATIC LITERATURE

REVIEW.

313 Special Article Poor dietary intake of nutrients and food groups are associated with increased risk of periodontal disease among community- dwelling older adults: a systematic literature review

Jessie-Leigh P. O’Connor, Kate L. Milledge, Fiona O’Leary, Robert Cumming, Joerg Eberhard, and Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 Vasant Hirani

Context: Periodontal disease is a chronic inflammatory gum condition that is more prevalent in older populations. The development of periodontal disease has been directly linked to inflammatory dietary habits. Objective: This systematic review aimed to 1) describe the relationship and 2) describe the direction of the relationship between dietary intake (nutrients and food groups) and periodontal disease in community-dwelling, older adults. PRISMA guidelines were followed for this review. Data Sources: A systematic search of the databases MEDLINE, EMBASE, Global Health, CINAHL, Science Direct, Informit, and Cochrane Library was conducted from the earliest possible date until September 2018. Search terms were related to main themes: “periodontal disease,” “gingivitis,” “gum diseases,” “dietary intake” and “older adults.” The search produced 779 records, and after additional publications were obtained and duplicates were removed, 666 publications underwent title and abstract screening. Included papers were written in English and were based on populations of healthy, older adults living in community-based settings. Nine papers met inclusion criteria and were included in this review. Data Extraction: Sample size, participant characteristics, inclusion and exclusion criteria, periodontal measures, dietary measures, confounders, and results were sorted by study type, author, year, and country. Data Analysis: Quality of the extracted data was analyzed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Conclusions: Inverse associations were found between fatty acids, vitamin C, vitamin E, beta-carotene, fiber, calcium, dairy, fruits, and vegetables and risk of periodontal disease. Overall, this review found a relationship between poor dietary intake and increased risk of periodontal disease; however, this needs to be further explored. Systematic Review Registration: PROSPERO Registration Number CRD42017065022.

Affiliation: J.-L.P. O’Connor, K.L. Milledge, F. O’Leary, and V. Hirani are with the Nutrition and Dietetics Group, School of Life and Environmental Sciences, the Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia. K.L. Milledge, R.Cumming, and V. Hirani are with the Centre for Education and Research on Ageing, University of Sydney, Ageing and Alzheimer’s Institute, Concord Hospital, New South Wales, Sydney, Australia. K.L. Milledge, R.Cumming, and V. Hirani are with the the ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, New South Wales, Sydney, Australia. R. Cumming is with the School of Public Health, University of Sydney, New South Wales, Sydney, Australia. J. Eberhard is with the Sydney Dental School, University of Sydney, New South Wales, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia. Correspondence: V. Hirani, Nutrition and Dietetics Group, School of Life and Environmental Sciences, Charles Perkins Centre, D17, Level 4 East, University of Sydney, New South Wales, Sydney, Australia. E-mail: [email protected]. Key words: aged, diet, geriatrics, nutrient intake, older adults, periodontal disease, periodontitis.

doi: 10.1093/nutrit/nuz035 Nutrition ReviewsVR Vol. 78(2):175–188 175

314 INTRODUCTION inconclusive, stating that no associations or only weak evidence was found from examining the association of Gingivitis and periodontitis are chronic inflammatory nutrient deficiencies with periodontal disease in elderly processes belonging to the spectrum of periodontal dis- people.26 eases, affecting the tooth-supporting tissues in response No other systematic reviews have been identified 1–6 to bacterial accumulation. Constantly forming bacte- that examine the direction of the relationship between rial deposits on the teeth cause a chronic inflammatory nutrients and food groups with periodontal health in response with many stages, ranging from reversible older populations. Therefore, the aim of this research low-level inflammatory gingivitis to irreversible higher- was to systematically review the literature and investi- Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 level inflammatory periodontitis that is, if left untreated, gate the direction of the association between dietary in- 1,2,5,7–9 followed by tooth loss. Periodontal disease show take and periodontal health in community-dwelling characteristics of opportunistic bacterial infections, older adults aged 60 years. with Porphyromonas gingivalis and Treponema denticola This systematic review has been reported according 1–6 strongly associated with periodontitis. to PRISMA guidelines (see Table S1 in the Supporting Across developed countries there is a decline in the Information online).29 rates of edentulism, with many older adults retaining more of their natural teeth than previous genera- METHODS tions.10–13 In the aging population, people should retain their natural teeth; however, the prevalence of peri- This review was registered in the PROSPERO odontal disease is increasing with age and is the highest International Prospective Register of Systematic for individuals aged 65 years: rates of 53.4% in Reviews prior to commencement (registration ID: Australia, 64.0% in the United States, and 82.0% in CRD42017065022) (see Table S2 in the Supporting 14–17 Denmark. Studies have estimated that approxi- Information online). mately 10%–15% of the world’s population has advanced periodontal disease with deep pockets of 6 Database search mm.18 There are several, modifiable risk factors that trig- Relevant studies were identified through a comprehen- ger gum inflammation and initiate the development of sive database search conducted by 1 reviewer. The elec- periodontal disease; these include, but are not limited tronic databases that were searched were Medline, to, poor oral hygiene, smoking and tobacco use, stress Science Direct, the Cochrane Library, Cumulative and depression, dietary habits, malnutrition, excessive Index to Nursing and Allied Health Literature alcohol consumption, and the presence of oral patho- (CINAHL), Global Health, Informit, and Embase. 1,3–7,19–22 gens. Although infection from bacteria is the These databases were searched using key terms for out- main cause for periodontal disease, there is a link with come and exposure variables, and included “periodontal other inflammatory conditions, such as diabetes melli- disease,” “gingivitis,” “gum diseases,” “diet,” “energy 1,3,4,7,19 tus and osteoporosis. intake,” “nutrition assessment,” “nutrient intake,” “food The development of periodontal disease has been intake,” and “dietary intake.” The population of interest 23 directly linked to diet-borne systemic inflammation. was specified in the search using keywords such as Immune-mediated inflammatory responses can be trig- “aged,” “aged 80 and over,” “frail elderly,” “geriatrics,” gered or regulated by certain dietary patterns and “older adult,” and “elderly.” All search terms were ex- nutrients; for example, the inadequate consumption of ploded to retrieve further records with more specific dairy, fruits and vegetables, fiber, calcium, antioxidants, subject headings (see Table S3 in the Supporting and fatty acids propagates pro-inflammatory mecha- Information online). Citation details and abstracts were nisms that may act as precursors for the development of exported into EndNote X8 reference management soft- 2–4,7–9,17,20,23–25 periodontal disease. Furthermore, tooth ware (Thomson Reuters), and duplicate papers were loss as a result of periodontitis may lead to difficulties removed. in chewing and may conversely affect the overall dietary 25–28 intake of various food groups and nutrients. Screening and selection criteria A 2009 systematic literature review looked at specific nutritional deficiencies and their association with The first stage of screening involved assessing the titles 26 periodontal health in adults aged 50 years. Serum and abstracts against inclusion and exclusion criteria and dietary measures of vitamin B complex, vitamin C, for each record (Table 1). This was carried out by a sin- vitamin D, calcium, and magnesium were analyzed gle reviewer. Abstracts that were screened for inclusion 26 from 8 cross-sectional studies. The results were had their full papers retrieved for the second stage of

176 Nutrition ReviewsVR Vol. 78(2):175–188

315 Table 1 PICOS criteria for inclusion and exclusion of studies Parameter Inclusion criteria Exclusion criteria Population • Community-dwelling adults aged 60 y • Animal studies • Males and females • Results not stratified to include 60 y • Generally healthy population • Acute or chronic diseases related to oral health/dietary • Results stratified by age to include 60 y issues Interventionsa Dietary intake: Dietary intake: • Target whole diet/food/nutrient intake • Missing nutritional intervention • Food sources • Not a valid measure • Valid measurements (nutrient intake analysis, • Targets overall nutrition status, malnutrition, body mass Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 food group intake) index, or weight • Diet history taken by trained professionals • Serum measures • Food-frequency questionnaire • Supplements • 24-h recall • Measuring nutrient biomarkers in the blood • Weighed food record • Food avoidance Periodontal disease: • Mini Nutrition Assessment • Related to periodontal status • Grocery item list (not indicative of intake) • Includes periodontal markers such as probing Periodontal disease: depth, clinical attachment level, and alveolar • Missing oral health intervention bone loss • Not a valid measure • Assessment by trained professionals • Dentition • Decay • Denture quality or comparison Comparisons • Any comparison populationb Outcomesa Dietary intake: Dietary intake: • Target whole diet/food/nutrient intake • Missing nutritional outcome • Food sources • Not a valid measure • Valid measurements (nutrient intake analysis, • Targets overall nutrition status, malnutrition, body mass food group intake) index, or weight • Diet history taken by trained professionals • Serum measures • Food-frequency questionnaire • Supplements • 24-h recall • Measuring nutrient biomarkers in the blood • Weighed food record • Food avoidance Periodontal disease: • Mini Nutrition Assessment • Related to periodontal status • Grocery item list (not indicative of intake) • Includes periodontal markers such as probing Periodontal disease: depth, clinical attachment level, and alveolar • Missing oral health outcome bone loss • Not a valid measure • Assessment by trained professionals • Dentition • Decay • Denture quality or comparison Study design • Cross-sectional studies • Literature reviews • Case–control studies • Case studies • Cohort studies • Narrative reviews • Ecological studies • Opinion pieces • Randomized controlled studies • Conference abstracts • Systematic literature reviews • Non-study-based sources

aFocus questions looked at the direction of the relationship between diet and periodontal disease; therefore the intervention/outcome was interchangeable. If dietary intake was the intervention, periodontal disease was the desired outcome, whereas if periodontal disease was the intervention, dietary intake was the desired outcome. bAny comparison was accepted if all other inclusion criteria were met. However, because randomized controlled studies were not included in this review, there was no comparison group to assess. screening, which was undertaken by 2 reviewers. (aged 60 y) living in a community-based setting (ie, Screening results were compared, and a consensus was noninstitutionalized individuals). Selected articles in- reached. A third reviewer was available when consensus cluded all studies published up until September 2018. could not be reached between the main reviewers. Eligible studies included an analysis of the association References of the selected papers were then hand- between diet and periodontal disease, although either searched for additional, eligible papers. These additional variable could represent the outcome. Valid measures papers underwent an identical screening process. of dietary intake included weighed food records, 24- Included studies were written in English and hour recalls, food frequency questionnaires, and diet assessed populations of healthy older adults histories taken by trained professionals. Measures of

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316 periodontal assessment were required to be conducted Study characteristics by trained professionals and to include periodontal measures such as probing pocket depth (PPD), clinical The key characteristics of the selected studies can be attachment level (CAL), and alveolar bone loss (ABL). found in Table 22,3,7–9,17,24,25,33,34. Of the 9 selected studies, the majority were prospective cohort stud- 2,3,8,9,24,25 Quality assessment ies, and the remaining 3 studies were cross- sectional.7,17,34 Because all of the studies focused on Journal articles that met the second-stage screening crite- single cohort populations, not all components of the ria had their quality independently assessed by 2 reviewers SIGN tool were applicable to the components of the Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 using the Scottish Intercollegiate Guideline Network tool assessing risk of bias in participant selection.30 All (SIGN) tool, which assesses each article for potential studies had appropriate study questions, looked at rele- biases, including selection bias, performance bias, attrition vant confounders, conducted appropriate statistical bias, and detection bias.30 All papers were assigned a qual- analysis, and chose reliable measures for their exposure ity score of either “high quality (þþ),” “acceptable (þ),” variable.30 However, although all studies had clearly de- or “unacceptable, reject paper ()”. The 2 reviewers dis- fined outcomes, 1 study did not provide a reliable as- cussed and compared results until a consensus was sessment for measuring periodontal outcomes in a reached. A third reviewer was available if a consensus population aged 60 years.7 could not be reached between the 2 main reviewers. One study did not provide a clear follow-up, and 2 had approximately 20% loss to follow-up, which was Data extraction considered acceptable, whereas 3 had a loss to follow- up that was > 20%.2,3,7–9,17,24,25 No comparison was Data extraction was carried out separately by 2 made between study participants and those lost to reviewers. Data extracted included the author, year, follow-up for 5 of the studies.2,7,17,24,25 Three of the country, study type, study aims, participant ages, sample studies were conducted retrospectively and therefore size, study selection criteria, method of periodontal data did not include repeat assessments of exposure variables collection, method of dietary intake and nutrient data or prognostic factors,7,17,34 and all studies created expo- collection, a definition of periodontal disease, relevant sure and outcome variables retrospectively, which confounders, the results, and conclusions. meant outcome measures were not blinded to exposure measures. Grading of recommendations, assessment, All of the selected studies were based on populations development, and evaluation from developed countries, including Japan (n ¼ 5), the United States (n ¼ 2), Denmark (n ¼ 1), and South Similarly, to the study by Ronnberg and Nilsson,31 Korea (n ¼ 1).2,3,7–9,17,24,25,34 All were published between the Grading of Recommendations, Assessment, the years of 2000 and 2017. The majority of included Development and Evaluation (GRADE) system was studies from Iwasaki et al were based on the same popu- adapted for use so it could be applied to studies that lation of people living in Niigata, Japan.2,3,8,9 However, were not randomized controlled trials.31,32 The overall these studies had different outcome and exposure varia- quality of evidence rating was calculated by assessing bles and were treated as separate studies.2,3,8,9 risk of bias, consistency, directness, precision, and pub- Due to the nature of the selected studies, the possi- lication bias.31,32 ble bi-directional relationship could not be assessed. Therefore, the results of this research only describe the RESULTS direction as the influence of dietary intake on periodontal health. Study selection

A total of 779 records were obtained from the database Fatty acids search. After the removal of duplicates (n ¼ 149), 666 publications had their titles and abstracts screened A longitudinal study from Niigata, Japan, on the intake against inclusion and exclusion criteria (Table 1). An of omega-3 fatty acids, including docosahexaenoic acid additional 36 papers were identified for abstract screen- (DHA) and eicosapentaenoic acid (EPA), looked at ing from the search of the references lists. From this, periodontal disease progression (3 mm CAL after 1 y).9 the full texts of 36 articles were screened, and 9 studies After adjusting for confounders, the results, as per were included for quality assessment and data extrac- Table 3,2,3,7–9,17,24,25,34 showed that there was an inverse tion (Figure 1). association between periodontal disease progression

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317 Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020

Figure 1 Flow diagram of the literature search process. and DHA intake when compared with the highest in- (vitamin C, vitamin E, alpha-carotene, beta-carotene) take tertile.9 and periodontal disease (3 mm CAL over 2 y).3 The Another longitudinal study from Niigata examined analysis showed that there was an inverse association, the dietary n-6 to n-3 ratio and the relationship with with those consuming the highest intakes of vitamin C, periodontal disease progression (3 mm CAL after 1 y).8 vitamin E, and beta-carotene having the lowest risk of After adjusting for confounders, the results from the 235 periodontal disease after adjustment for confounders participants showed that a high dietary n-6 to n-3 poly- (Table 3).3 unsaturated fatty acid (PUFA) ratio was significantly as- However 1 cross-sectional study did look at the re- sociated (P < 0.05) with periodontal disease (Table 3).8 lationship between meeting vitamin C recommenda- The 2006 Niigata study modeled the percentage of tions and the prevalence of periodontal disease (PPD energy intake from saturated fatty acid (SFA) intake as 3.5–5.5 mm).34 Although an inverse relationship be- quartiles, with the lowest quartile as the reference.2 The tween meeting vitamin C intake and periodontal disease findings suggested that higher intakes of SFA are signif- was observed in adult groups, no associations were ob- icantly associated (P < 0.05) with periodontal disease served in the age group of interest for this systematic re- events and attachment loss (3 mm CAL after 1 y) among view (ie, those aged 60 y).34 nonsmoking individuals, after adjustment for confounders (Table 3).2 Calcium and dairy

Antioxidants In 2 separate studies, both of which were cross- sectional, the association between dietary calcium and From the reviewed studies, the Niigata substudy con- periodontal disease was examined.7,17 In 1 study, after ducted by Iwasaki et al was the only study to investigate adjusting for confounders, the analysis showed that the relationship between dietary antioxidants lower calcium intakes from all dairy foods, excluding

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318 cheese, increased the risk of periodontal disease (CAL Quality of evidence 3mm) (Table 3).17 Dairy intakes from milk (P ¼ 0.028) and fermentable foods (P ¼ 0.029) were also in- Grading of Recommendations, Assessment, Development, versely and significantly associated with periodontal and Evaluation System. The overall quality of evidence disease.17 using the GRADE tool has been summarized in Table 4. In the second study, there were no significant asso- Although statistically significant data were obtained ciations (P ¼ 0.658) between dietary calcium and peri- from the 9 reviewed studies, measures of exposure and odontal disease (CAL 1.5mm) when stratified by sex outcomes were not directly comparable and there was (Table 3).7 limited evidence across the groups of foods and Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 nutrients. Possible publication bias, heterogeneity among studies, inclusion of observational studies, and Fiber exclusion of higher quality study designs, such as randomized controlled trials, meant the overall GRADE A prospective US cohort study examined the relation- system quality of evidence was rated as very low. ship between quintiles of good to excellent fiber intake from food sources and periodontal disease Risk bias. Quality assessment showed that 44% of stud- progressioninmenaged65 years (Table 2).24 After ies had “high quality (þþ),”2,3,8,9 whereas 56% of stud- adjusting for confounders, the analysis showed that ies were of “acceptable quality (þ),”7,17,24,25,34 there were inverse associations between total intake of suggesting minimal risk of bias. However, because these good to excellent fiber foods and ABL progression studies were observational, none included randomiza- and tooth loss (Table 3).24 Inverse associations tion in their population, allocation, concealment, or were also found between consumption of good to ex- blinding. Therefore, there may be a high risk of bias cellent fiber fruits and ABL progression (40%), PPD due to these factors. progression (2mm), and tooth loss (within 2– 24 y).24 Inconsistency. The 9 studies could not be directly compared with one another due to inconsistencies among the outcome measures of periodontal disease and the Fruits, vegetables, and other food groups types of nutrients examined (Table 3). However, it was observed that all 9 studies had a similar direction of ef- Two longitudinal studies included an assessment of fect. Six of the studies looked at nutrient intakes and periodontal disease progression with fruit and vegetable periodontal disease progression,2,3,8,9,24,25 whereas the 3 intake. The longitudinal study that examined the rela- cross-sectional studies looked at the associations be- tionship between dietary antioxidants and periodontal tween nutrients and periodontal disease.7,17,34 Among disease progression also looked at the association be- these outcomes, the defining CAL measure also varied tween fruit and vegetable intake and periodontal disease among studies. The majority of studies defined the out- progression (3 mm CAL after 2 y).3 These results come as 3 mm over a 1-year period, with others defin- showed that higher intakes of fruits and vegetables ing the outcome as 2 mm or 1.5 mm (Table 3). were each associated with fewer teeth with periodontal The exposure variables also varied among the stud- disease progression in the Japanese population ies as each study examined a different dietary compo- (Table 3).3 nent and different dietary measures were used. The Another longitudinal study in Japan investigated dietary measures used included questionnaires,2,3,8,24,25 the relationship between food groups and periodontal a diet history interview,17 a 24-hour recall,7,34 and a disease (3 mm CAL after 1 y) in individuals aged weighed food record.9 70 years (Table 2).25 The results of the multiple regression analysis showed that there was a negative associa- Indirectness Each of these studies contained indirect evi- tion between the intake of dark green and yellow dence; indirect comparisons were made among the vegetables and the number of periodontal disease interventions of interest due to differences in periodon- events.25 These findings show that an increased intake tal outcome measures, differences in dietary exposure, of dark green and yellow vegetables decreases the num- and differences in the population.35 Many of these indi- ber of periodontal disease events (Table 3). After adjust- rect comparisons meant that the results may not be gen- ment for confounders, a significant positive association eralizable to populations other than those examined. (P ¼ 0.042) was found between higher intakes of cere- Each of the selected studies were comparable by als, nuts, and confectionaries and periodontal disease population because they included populations of the (3 mm CAL after 1 y).25 target interest who were generally healthy, community-

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319 urto Reviews Nutrition Table 2 Characteristics of systematically reviewed studies Study Location Type of study Quality Sample size Participant characteristics Recruitment Inclusion / exclusion criteria assessment Iwasaki et al Japan Longitudinal High quality • Final sample: 36/62 • Mean age: 73 y Niigata, Japan longitudinal in- Exclusion: Participants 9 • V

R (2010) (þþ) (58.1% participation) 44.4% females, mean BMI 22.3 terdisciplinary study of ag- with incomplete data o.78(2):175–188 Vol. • Withdrew/excluded: 19 (males) and 22.9 kg/m2 ing (1998). Recruitment for (females) 2001 follow-up Iwasaki et al Japan Longitudinal High quality • Final sample: 235/331 • Mean age: 75 y Niigata, Japan longitudinal in- Exclusion: Participants (2011)8 (þþ) (71.0% participation) • 48.5% females, mean BMI 23.1 terdisciplinary study of ag- with incomplete data, • Withdrew/excluded: 96 kg/m2, 46.8% regular dentist ing (1998). Subset 2003– edentulous at baseline visit 2006 Iwasaki et al Japan Longitudinal High quality • Final sample: 265/353 • Mean age: 75 y Niigata, Japan longitudinal in- Exclusion: Participants (2011)2 (þþ) (75.1% participation) • 45.8% female, most non- terdisciplinary study of ag- with incomplete data, • Withdrew/excluded: 69 smokers, smoker BMI: 22.8 kg/ ing (1998). Subset study edentulous at baseline m2, nonsmoker BMI: 23.1 kg/m2, 2003–2004 17.0% nonsmoker low income, 13% smoker low income Iwasaki et al Japan Longitudinal High quality • Final sample: 264/334 • Mean age: 75 y Niigata, Japan longitudinal in- Exclusion: Participants (2012)3 (þþ) (79.0% participation) • 46.6% females, mean BMI 23.0 terdisciplinary study of ag- with incomplete data, • Withdrew/excluded: 70 kg/m2, 11.4% low income ing (1998). Subset study edentulous at baseline 2003–2005 Nishida et al United Cross-sectional Acceptable (þ) • Final sample (60 y): • 31.0% of total population cur- Third National Health and Inclusion: 20 y of age (2000)7 States 2806/12 419 rently smoke Nutrition Examination • Remaining 9613 partici- Survey (NHANES III) in the pants aged 20–59 yr United States (1988–1994). Centers for Disease Control Prevention (1992)33 Adegboye et Denmark Cross-sectional Acceptable (þ) • Final sample: 135/783 • Mean age: 76.3 y (66.6–95.5 y) Copenhagen, Denmark longi- Inclusion: Verbal commu- al (2012)17 • 53.0% females, 20.0% seden- tudinal study (1982). Subset nication, travel, and at- tary, 31.8% education >7yr population from subset of tend dental clinic ongoing longitudinal study Schwartz et United Longitudinal Acceptable (þ) • Final sample (65 y): • Mean age (65 y group): 70 y Massachusetts, United States Inclusion: People still ac- al (2012)24 States 204/668 • All males, mean BMI 26.1 kg/ longitudinal studies on den- tive in study (partici- • Final sample (<65 y): m2, 77.0% education beyond tal health (1968) and aging pated in all previous y) 421/668 high school (1963). Sixth dental cycle fol- • Withdrew/Excluded: 43 low-up (1984–2009) Yoshihara et Japan Longitudinal Acceptable (þ) • Final sample: 261/600 • Mean age: 70 y Niigata, Japan longitudinal in- Inclusion: At least 1 tooth al (2009)25 • 44.8% females, mean BMI 22.0 terdisciplinary study of ag- at baseline, completed kg/m2 (males), 22.8 kg/m2 ing (1998) all 7 y of follow-up (females), education was 10.7 y (male) and 9.4 y (female) Lee et al South Korea Cross-sectional Acceptable (þ) • Final sample (60 y): • (Ages 19–70þ): Korean National Health and Inclusion: Adults aged (2017)34 2633/10 930 • 24.0% aged >60 y, 55.4% fe- Nutrition Examination >19 yr, with valid peri- • Remaining 8297 partici- male, 17.7% in low income, Survey in South Korea con- odontal data and not 3

20 pants aged 19–59 56.3% never smoked, 31.0% ducted 2007–2009, con- edentulous, partici-

181 obese ducted by Korea Center for pants without missing Disease Control variables

Abbreviations: BMI, body mass index. Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 November 01 on user Sydney of University by https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 from Downloaded 182 Table 3 Data extracted from systematically reviewed studies Study and Location Type of study Quality Periodontal measurements Dietary intake measures Statistical methods and Adjusted results Quality assessment confounders Assessment Iwasaki et al Japan Longitudinal High quality • Methods: 4 calibrated • Methods: Self-recorded 3-day • Negative binomial • Highest (3rd) tertile as reference (2010)9 (þþ) dentists measured 6 sites weighed food record regression (1.00) per tooth • Measures: Mean total daily en- • Confounders: Number of • DHA (1st): IRR ¼ 1.49 (1.01–2.21), • Measures: Number of ergy intake, DHA, EPA, omega-3 teeth and mean CAL at P ¼ 0.045. teeth, periodontal condi- • Outcome: Daily intake of en- baseline, sex, BMI, • EPA (1st): IRR ¼ 1.47 (0.97–2.21), tion (CAL) ergy, DHA, EPA, omega-3 smoking P ¼ 0.067 • Outcome: Periodontal disease event ¼ CAL 3mm per surface/teeth each year over a 5-y period Iwasaki et al Japan Longitudinal High quality • Methods: Calibrated • Methods: Validated BDHQ (in- • Poisson regression • Lowest (1st) tertile as reference (2011)8 (þþ) examiners measured 6 complete questionnaires fol- • Confounders: Number of (1.00). sites per tooth lowed up) teeth and mean CAL at • n-6/n-3 ratio (3rd): RR ¼ 1.29 • Measures: Number of • Measures: Mean intakes of en- baseline, sex, BMI, hypo- (1.10–1.51), P<0.05 teeth and periodontal ergy, PUFA, ALA, LA, AA, EPA, albuminemia, hypergly- • n-6 (3rd): RR ¼ 1.07 (0.92–1.25), condition (CAL) DHA, total n-3, total n-6, calcu- cemia, smoking, dental nonsignificant • Outcome: Periodontal lated by ad hoc computer cleaning • n-3 (3rd): RR ¼ 0.92 (0.79–1.07), disease event ¼ CAL system nonsignificant 3mm per surface per • Outcome: Energy-adjusted fatty year over a period of 3 y acids, n-3 and n-6 intake modeled as tertiles, n-3/n-6 ratio modeled as tertiles Iwasaki et al Japan Longitudinal High quality • Methods: 4 calibrated • Methods: Validated BDHQ • Univariate and multivari- • Lowest (1st) quartile as reference (2011)2 (þþ) dentists measured 6 sites • Measures: SFA intake as per- ate Poisson models (1.00) per tooth centage of energy, calculated • Confounders: Number of • Periodontal events: Nonsmokers • Measures: Number of by ad hoc computer system teeth and mean CAL at (4th): RR ¼ 1.92 (1.19–3.11), teeth and periodontal • Outcome: SFA modeled as quar- baseline, sex, low in- P<0.05 Smokers (4th): RR ¼ 1.04 condition (CAL) tiles of intake come, low education, (0.74–1.45), nonsignificant • Outcome: Periodontal BMI, smoking, dental • Attachment loss: Nonsmokers (4th): disease event ¼ CAL cleaning and visits RR ¼ 3. Smokers (4th): RR ¼ 0.54 urto Reviews Nutrition 3mm over 1 y per sur- (0.17–1.20), nonsignificant face/tooth Iwasaki et al Japan Longitudinal High quality • Methods: Calibrated • Methods: Validated BDHQ • Poisson regression. • Lowest (1st) tertile as reference (2012)3 (þþ) examiners measured 6 • Measures: Mean intake of en- • Confounders: Number of (1.00) sites per tooth ergy, vitamin C, vitamin E, al- teeth and mean CAL at • Vitamin C (3rd): IRR ¼ 0.72 (0.56– V R • Measures: Number of pha-carotene, beta-carotene, baseline, sex, low in- 0.93), P<0.05 o.78(2):175–188 Vol. teeth and periodontal mean intake of fruits and vege- come, low education, • Vitamin E (3rd): IRR ¼ 0.55 (0.42– condition (CAL) tables, calculated by ad hoc BMI, hypoalbuminemia, 0.72), P<0.05 • Outcome: Periodontal computer system hyperglycemia, brushing • Alpha-carotene (3rd): IRR ¼ 0.89

3 disease progression ¼ (0.68–1.15), nonsignificant 21

(continued) Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 November 01 on user Sydney of University by https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 from Downloaded urto Reviews Nutrition Table 3 Continued Study and Location Type of study Quality Periodontal measurements Dietary intake measures Statistical methods and Adjusted results Quality assessment confounders Assessment number of teeth/partici- • Outcome: Nutrients/food frequency, smoking, den- • Beta-carotene (3rd): IRR 0.73 V ¼ R

o.78(2):175–188 Vol. pant with CAL 3mm groups energy adjusted and tal cleaning and visits (0.56–0.95), P<0.05 over 2 y modeled as tertiles • Vegetables (3rd): IRR ¼ 0.68 (0.52– 0.88), P<0.05 • Fruits (3rd): IRR ¼ 0.74 (0.57–0.95), P<0.05 Nishida et al United Cross-sectional Acceptable (þ) • Methods: Examiners • Methods: 24-h dietary recall • Multiple logistic • Calcium intake (males): OR ¼ 1.11 (2000)7 States measured 2 randomly conducted by nutritionist regression (0.71–1.71), P ¼ 0.658 chosen quadrants (maxil- trained in study methodology • Confounders: Age, sex, nonsignificant lary and mandibular). • Measures: Calcium intake as a tobacco consumption, • Calcium intake (females): OR ¼ Assessed at 2 sites per continuous variable gingival bleeding 1.13 (0.86–1.48), P ¼ 0.404, tooth • Outcome: Calcium categorized nonsignificant • Measures: Distance from by milligrams (20–499 mg, 500– CEJ to gingival margin 799 mg, 800mg). and PD, mean attachment loss • Outcome: CAL 1.5mm over a 6-y period Adegboye et al Denmark Cross-sectional Acceptable (þ) • Methods: Dentists mea- • Methods: Diet history interview • Poisson regression. • Total calcium from dairy: IRR ¼ (2012)17 sured 6 sites per tooth using precoded questions, cups • Confounders: Age, sex, 0.97 (0.96–0.99), P ¼ 0.021 • Measures: PD, bleeding photo series, measures education, sucrose in- • Calcium intakes: Milk: IRR ¼ 0.97 on probing, gingival • Measures: Usual dietary intake take, alcohol, smoking, (0.95–0.99), P ¼ 0.025 Cheese: IRR recession of past month, total dietary cal- physical activity, vitamin ¼ 0.99 (0.96–1.03), P ¼ 0.701, non- • Outcome: Number of cium (mg/d), total dairy food D, heart disease, tooth significant Fermented dairy: IRR ¼ teeth with CAL 3mm (g/d), dietary calcium measured brushing, dental visit, 0.96 (0.92–0.99), P ¼ 0.030 using Dankost program dental floss, remaining Nondairy: IRR ¼ 0.99 (0.96–1.02), P • Outcome: Calcium food source teeth, bleeding on ¼ 0.340, nonsignificant (dairy, nondairy), dairy food probing • Total dairy intake: IRR ¼ 0.96 (milk, fermented foods, cheese, (0.96–0.99), P ¼ 0.003 other) • Dairy intakes: Milk: IRR ¼ 0.96 (0.93–0.99), P ¼ 0.028 Cheese: IRR ¼ 0.95 (0.78–1.16), P ¼ 0.625, non- significan. Fermentable foods: IRR ¼ 0.97 (0.95–0.99), P ¼ 0.029 Schwartz et al United Longitudinal Acceptable (þ) • Methods: Measures by • Method: 126-item Harvard FFQ, • Analysis of covariate: • ABL progression: Total good to ex- (2012)24 States single calibrated 19 items recognized as good to • Confounders: Age, smok- cellent food sources: HR ¼ 0.76 periodontist excellent sources of fiber (2.5 ing, number of teeth, (0.60–0.95), P<0.05 Good to excel- • Measures: Maximum PD, g fiber) brushing habits lent fruits: HR ¼ 0.86 (0.78–0.95), ABL • Measures: Total daily fiber • Periodontal disease pro- P<0.05 • Outcome: ABL progres- intake gression: Multivariate cox

3 sion 40% or tooth loss; 22

183 (continued) Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 November 01 on user Sydney of University by https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 from Downloaded 184 Table 3 Continued Study and Location Type of study Quality Periodontal measurements Dietary intake measures Statistical methods and Adjusted results Quality assessment confounders Assessment or PPD progression by • Outcome: Total fiber intake (as proportional hazards re- • PPD progression or tooth loss: 2 mm or tooth loss; or quintiles), food intake of good gression analysis Good to excellent fruits: HR ¼ 0.95 tooth loss only in a pe- to excellent fiber (as quintiles) • Confounders: Tooth (0.91–0.99), P<0.05 riod of 2–24 y brushing, smoking, edu- • Tooth loss only: Total good to ex- cation, BMI, exercise, cellent food sources: HR ¼ 0.72 number of decayed/filled (0.53–0.97), P<0.05 Good to excel- surfaces, caffeine and lent fruits: HR ¼ 0.88 (0.78–0.99), carotene intake, calculus P<0.05 and periodontal measures Yoshihara et al Japan Longitudinal, Acceptable (þ) • Methods: 4 calibrated • Method: Validated semi-quanti- • Multiple linear regression • Dark green and yellow vegetables: (2009)25 follow-up: dentists measured 6 sites tative FFQ used in face-to-face • Confounders: Alcohol, Coefficient ¼0.64 (1.00– once per per tooth interviews sex, education, BMI, 0.27), P ¼ 0.001 year for 6 y • Measures: Numbers of • Measures: Responses for indi- number of family mem- • Cereals, nuts and seeds, sugar and teeth and CAL. Teeth vidual food items were con- bers, number of remain- sweeteners, confectionaries: with periodontal pro- verted to average daily intake ing variables Coefficient ¼ 0.19 0.01–0.38), gression were counted of food groups P ¼ 0.042 and excluded from fur- • Outcome: Food groupings (i. ther analysis Fish, shellfish, meat, beans, • Outcome: Periodontitis eggs; ii. Milk and milk products; event ¼ CAL of >3mm iii. Dark green and yellow vege- over a period of 6 y tables; iv. Other vegetables and fruits; v. Cereals, nuts and seeds, sugar and sweeteners, confectionaries; vi. Fats and oils). Lee et al South Cross-sectional Acceptable (þ) • Methods: Calibrated • Method: 24-h dietary intake re- • Multiple logistic regres- • Vitamin C inadequate or adequate (2017)34 Korea dentists cord, and examination with in- sion analysis intake: • Measures: 5 CPI scores: terview using questionnaire • Confounders: Age, in- • Age 60–69: 1.03 (0.80–1.34) (CPI 0) Normal gingiva, • Measures: Vitamin C intake come, tooth brushing, • Age 70: 0.92 (0.67–1.27) (CPI 1) bleeding on prob- • Outcome: Vitamin C intake was flossing, dentist visits, al- • Male: Age 60–69: 0.92 (0.65–1.31) ing, (CPI 2) presence of categorized as adequate and in- cohol drinking frequency, • Age 70: 0.94 (0.61–1.45) urto Reviews Nutrition gingival calculus, (CPI 3) adequate according to EAR val- smoking, diabetes, hy- • Female: Age 60–69: 1.17 (0.83– shallow periodontal ues and quartile values percholesterolemia, hy- 1.67) pocket 3.5–5.5 mm, and pertension, BMI • Age 70: 0.96 (0.59–1.57) (CPI 4) deep periodontal pocket of 5.5 mm

V • R Outcomes: o.78(2):175–188 Vol. • Periodontal disease was defined as CPI 3 and 4 (shallow and deep peri-

3 odontal pockets) 23 Abbreviations: AA, arachidonic acid; ABL, alveolar bone loss; ALA, alpha-linolenic acid; BDHQ, brief-type self-administered diet history questionnaire; BMI, body mass index; CAL, clinical attachment level; CEJ, cement-enamel junction; CPI, community periodontal index; DHA, docosahexaenoic acid; EAR, estimated average requirement; EPA, eicosapentaenoic acid; FFQ, food-frequency questionnaire; HR, hazard ratio; IRR, incidence rate ratio; LA, linoleic acid; OR, odds ratio; PD, probing depth; PPD, probing pocket depth; PUFA, polyunsaturated fatty acid; RR, relative risk; SFA,

saturated fatty acid. Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 November 01 on user Sydney of University by https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 from Downloaded Table 4 Assessment of quality using the GRADE system No. of studies Risk bias Inconsistency Indirectness Imprecision Publication bias Quality (total no. of participants) 9 (6839) 2 High (Very serious) Could not assess heterogeneity 1 Indirect (Serious) Neutral Undetected Low dwelling individuals aged 60 years or older, but the This systematic review identified a relationship be- studies varied by country. These populations came from tween dietary intake and periodontal health; however, high-income countries, which may affect the the possible bi-direction was unable to be thoroughly Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 applicability of these results to low- or middle-income described due to a lack of studies providing evidence of countries.35 the effect of periodontal disease on dietary intake. Furthermore, the majority of studies used various Based on the findings of the 9 reviewed studies, measures for assessing periodontal health (Table 3). better quality diets were associated with a lower severity There is a lot of variation in this outcome measurement, of periodontal disease.36 Periodontal disease prevalence which affects the applicability of the results and the clas- was associated with excess intakes of SFAs, the “cereals, sification of disease.35 Finally, the dietary measures in- nuts and seeds, sugar and sweeteners, and con- cluded in the selected studies, although reliable, varied fectionary” food group, and a high ratio of n-6 to n-3 in each study, again impacting on the applicability. fatty acids.2,8,25,36 It was also inversely associated with intakes of DHA, vitamin C, vitamin E, beta-carotene, milk, fermented dairy products, dietary fiber, fruits, and Imprecision. The total number of participants was large 1,3,9,24,25,36 (n ¼ 4206); however, it was not possible to calculate vegetables. These results correspond to find- overall treatment effect and, therefore, relative risk due ings by Salazar et al, who found associations between better quality diets and lower prevalence of periodontal to differences in outcome definitions for periodontal 36 disease. The studies were not directly comparable, disease. which meant that pooled relative risk and confidence A diet high in sugar is associated with the presence intervals could not be calculated, and a meta-analysis of tooth decay; however, 1 study found that the “cereals, could not be conducted. nuts and seeds, sugar sweeteners, and confectionary” food group was associated with periodontal disease.25 It is possible that poor nutrition, such as a diet high in Publication bias. It was not possible to develop a funnel sugar, could lead to a build-up of oral bacteria.2,3,8,9 It is plot because there was no summary estimate of the these oral bacteria that can cause the inflammation and overall effect; however standard errors and odds ratios swelling that leads to the destruction of the alveolar were examined in each of the selected studies. Each of bone and connective tissue that is characteristic of peri- these 9 studies found a positive outcome and included a odontal disease.2–4,7–9,17,19,20,24,25,36 relatively large population. Publication bias cannot be The majority of the reviewed studies focused on ruled out because each of the studies showed significant Japanese older adults,2,3,8,9,25 whereas the remaining 3 results about the relationships between dietary intake studies included populations of Caucasian older adults and periodontal health; perhaps studies with nonsignifi- in Denmark17 and the United States.7,24 It may be that cant findings were not published. the results of the studies on fatty acids, antioxidants, and food groups may only be specific to Japanese popu- DISCUSSION lations, whereas the studies on calcium, dairy, and fiber may only relate to Caucasian older adults. This systematic review aimed to describe the direction The majority of included studies from Iwasaki et al and strength of the association between dietary intake were based on the same population of people living in through nutrients and food groups and periodontal Niigata, Japan.2,3,8,9 Each of these Niigata substudies health in community-dwelling older adults. As used the same methods for collecting periodontal data highlighted, only 1 other systematic review has been (Table 2).2,3,8,9 However, because these studies had dif- performed that assessed the association between ferences in the outcome and exposure variables nutrients, through serum measures, and periodontal (Table 3) and different follow-up time periods, they disease in older people. This study by van der Putten were treated as separate studies.2,3,8,9 et al26 did not aim to assess the possible bi-directional Although all of the studies adjusted for confound- relationship and included serum concentrations of ers, several studies did not control for poor oral hy- nutrients rather than focusing on intakes of nutrients giene.2,3,8,17,24 A recent systematic review on oral and food groups. hygiene and periodontal disease found poor oral

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324 hygiene to increase the risk of periodontal disease by 2- et al34 only looked at the prevalence of periodontal to 5-fold.37 It is difficult to attribute risk to any specific disease. nutrients in the context of the included observational Only one study assessed the overall dietary intake studies. The included studies focused on populations in as food groups.25 These food groupings were unconven- developed countries, which means that nutrients were tional, in particular grouping “cereals, nuts and seeds, not consumed in isolation; instead nutrients and food sugar and sweeteners, and confectionaries” as a food groups in these nations are typically consumed in ag- group.25 This unusual grouping of foods is a major limi- gregate.2,3,7–9,17,24,25 The beneficial effects of consuming tation of this study because there is no clear way to de- nutrients such as calcium may be counteracted by the termine which individual foods and nutrients within Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 deleterious effect of other nutrients such as saturated the food group impact on periodontal health. fats.2,7,17 A few studies were assessed as being weak in qual- As outlined in the quality of evidence, the outcome ity, which limited the certainty of an association be- measures of periodontal disease varied among the in- tween dietary intake and periodontal health. cluded studies. Nishida et al7 defined periodontal dis- Conclusions were unable to be made from the study on ease as CAL of 1.5 mm over a 6-year period, whereas omega-3 fatty acids because it was based on a small studies such as those by Iwasaki et al2,3,8,9 defined peri- sample size (n ¼ 36) and is not representative of a odontal disease events as 3 mm or more over varying broader population.9 The study on SFAs included wide time frames (after 1 or 2 y). Although the variability be- confidence intervals and unclear P values.2 The P values tween these defining measures of periodontal disease is of the SFA study were only described as being < 0.05; a limitation of this systematic review, another limitation no exact P value was specified, and the confidence inter- is the expected inter-examiner variability. vals were the widest of all of the reviewed studies. These Two cross-sectional studies looked at the relation- wide confidence intervals show weak strength and limit ship between dietary calcium and periodontal disease the certainty of the relationship between SFAs and peri- and had conflicting results.7,17 One study found that to- odontal disease progression. tal dairy, milk, and fermented foods were inversely as- This systematic review provides an accurate and re- sociated with periodontal disease,17 whereas the other liable review of the current literature available. Overall, study found no substantial associations.7 One of the the studies each assessed the same direction of associa- possible reasons for the discrepancies is the definition tion from dietary intake to periodontal health, despite of periodontal disease. In the Danish study, periodontal measuring different nutrients and food groups. Within disease was defined as a CAL of 3 mm, 17 which was the individual studies and their limitations, a relation- consistent with the majority of the reviewed stud- ship was identified between dietary intake and peri- ies.2,3,8,9,16,25 The other cross-sectional study defined odontal health. Despite this, the direction of association periodontal disease as a CAL of 1.5 mm for the total needs to be further explored in order to identify stratified study population.7 This was only appropriate whether there is a bi-directional relationship. This sys- for the younger age group of individuals aged tematic review found no relevant, high-quality studies 20 years rather than the older populations, such as that looked at the other direction of association (if peri- those in this review.7 This means that the results of the odontal health impacts dietary intake). Past studies have 2 studies cannot be compared and that further quality identified that periodontal disease is a risk factor for research targeting calcium and dairy intakes needs to tooth loss, which may result in a poor-quality diet and take place. malnutrition.25–28 These studies were of low quality and Two studies also looked at the association between were not included in the review. vitamin C and periodontal disease, with differing Other limitations relate to screening, language, ex- results.3,34 There are a few possible reasons for this. The posure variables, and quality assessment. The screening first is in the way vitamin C was measured as an expo- of titles and abstracts was performed by 1 author on 3 sure variable. One study compared periodontal disease separate occasions, with further screening stages carried outcomes between participants in the highest tertile of out by 2 authors, with a third author available for dis- vitamin C intake versus the lowest tertile of vitamin C cussion. Another limitation was that the reviewed stud- intake.3 The other study compared adequate intake of ies only examined individual components of the diet vitamin C to inadequate intake of vitamin C.34 Another rather than the diet as a whole. This made it difficult to reason for the difference in the association could be in assess the overall quality of studies because a meta- how periodontal disease was measured as an outcome. analysis was not possible and a funnel plot could not be Iwasaki et al3 looked at the risk of developing periodon- developed for use in the GRADE system. Furthermore tal disease, whereas the cross-sectional study by Lee tooth loss and subsequent poor nutrition may also be

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325 attributed to dental caries, another leading risk factor to REFERENCES for tooth loss.38 1. Adegboye AR, Boucher BJ, Kongstad J, et al. Calcium, vitamin D, casein and whey protein intakes and periodontitis among Danish adults. Public Health Nutr. 2016;19:503. CONCLUSIONS 2. Iwasaki M, Manz MC, Moynihan P, et al. Relationship between saturated fatty acids and periodontal disease. J Dent Res. 2011;90:861–867. 3. Iwasaki M, Moynihan P, Manz MC, et al. Dietary antioxidants and periodontal dis- Based on the available literature found by this system- ease in community-based older Japanese: a 2-year follow-up study. Public Health atic review, positive associations were identified be- Nutr. 2012;16:1–9. 4. Nishida M, Grossi SG, Dunford RG, et al. Dietary vitamin C and the risk for peri-

tween dietary intake and periodontal health among the odontal disease. JPeriodontol.2000;71:1215–1223. Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020 populations in developed countries, as shown by the 5. Kinane DF. Aetiology and pathogenesis of periodontal disease. Ann R Australas Coll Dent Surg. 2000;15:42–50. results of the 9 reviewed studies. Included studies iden- 6. Popova C, Dosseva-Panova V, Panov V. Microbiology of periodontal diseases. A re- tified associations between periodontal disease and view. Biotechnol Biotechnol Equipment. 2013;27:3754–3759. 7. Nishida M, Grossi SG, Dunford RG, et al. Calcium and the risk for periodontal dis- lower intakes of DHA, vitamin C, vitamin E, beta- ease. JPeriodontol.2000;71:1057–1066. carotene, milk, fermented dairy products, dietary fiber, 8. Iwasaki M, Taylor GW, Moynihan P, et al. Dietary ratio of n-6 to n-3 polyunsaturated fatty acids and periodontal disease in community-based older Japanese: a fruits and vegetables, and higher intakes of the n-6 to n- 3-year follow-up study. Prostaglandins, Leukot Essent Fatty Acids. 3 PUFA ratio and SFAs. The overall evidence base 2011;85:107–112. 9. Iwasaki M, Yoshihara A, Moynihan P, et al. Longitudinal relationship between die- needs to be further explored to assess whether peri- tary [omega]-3 fatty acids and periodontal disease. Nutrition. 2010;26:1105. odontal health leads to dietary change in older people. 10. Sanders AE, Slade GD, Carter KD, et al. Trends in prevalence of complete tooth loss among Australians, 1979–2002. Aust N Z J Public Health. 2004;28:549–554. 11. Slade G, Spencer A, Robert -Thompson K. Australia’s Dental Generations: The National Survey of Adult Oral Health 2004–06, Cat.no DEN 165. Canberra: Acknowledgments Australian Institute of Health and Welfare; 2007. 12. Crocombe LA, Slade GD. Decline of the edentulism epidemic in Australia. Aust Dent J. 2007;52:154. The authors thank the school librarian, Erica Demian, 13. Gooch BF, Eke PI, Malvitz DM. Public health and aging: retention of natural teeth for assistance with setting up the database search among older adults—United States, 2002. JAMA. 2004;291:292–293. 14. Chrisopoulos S, Harford J, Ellershaw A. Oral health and dental care in Australia: strategy. key facts and figures 2015. Canberra: Australian Institute of Health and Welfare; 2016. 15. Krustrup U, Erik Petersen P. Periodontal conditions in 35-44 and 65-74-year-old Author contributions. V.H. and K.L.M. conceived the adults in Denmark. Acta Odontol Scand. 2006;64:65–73. study design. K.L.M. extracted the data. J.-L.P.O. and 16. Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91:914–920. K.L.M. screened articles by full text and assessed the 17. Adegboye ARA, Christensen LB, Holm-Pedersen P, et al. Intake of dairy products quality of included studies with supervision from V.H. in relation to periodontitis in older Danish adults. Nutrients. 2012;4:1219–1229. 18. Petersen PE, Ogawa H. Strengthening the prevention of periodontal disease: the J.-L.P.O. conducted the GRADE assessment and drafted WHO approach. J Periodontol. 2005;76:2187–2193. the initial manuscript with supervision from V.H. and 19. Machida T, Tomofuji T, Ekuni D, et al. Severe periodontitis is inversely associated with coffee consumption in the maintenance phase of periodontal treatment. K.L.M. V.H. supervised the overall work. All other Nutrients. 2014;6:4476–4490. authors reviewed and approved the final version of the 20. Moynihan PJ. The role of diet and nutrition in the etiology and prevention of oral manuscript. All authors have primary responsibility for diseases. Bull World Health Organ. 2005;83:694. 21. Shay K, Ship JA. The importance of oral health in the older patient. J Am Geriatr the final content. Soc. 1995;43:1414. 22. Najeeb S, Zafar MS, Khurshid Z, et al. The role of nutrition in periodontal health: an update. Nutrients. 2016;8:pii:E530. Funding. No funding was received to support this work. 23. Kotsakis GA, Chrepa V, Shivappa N, et al. Diet-borne systemic inflammation is as- K.L.M. is a PhD student at the University of Sydney, sociated with prevalent tooth loss. Clin Nutr. 2018;37:1306–1312. 24. Schwartz N, Kaye EK, Nunn ME, et al. High-fiber foods reduce periodontal disease funded by Centre of Excellence in Population Ageing progression in men aged 65 and older: the Veterans Affairs Normative Aging Research. Study/Dental Longitudinal Study. J Am Geriatr Soc. 2012;60:676–683. 25. Yoshihara A, Watanabe R, Hanada N, et al. A longitudinal study of the relationship between diet intake and dental caries and periodontal disease in elderly Japanese Declaration of interest. The authors have no relevant subjects. Gerodontology. 2009;26:130–136. 26. van der Putten G-J, Vanobbergen J, De Visschere L, et al. Association of some spe- interests to declare. cific nutrient deficiencies with periodontal disease in elderly people: a systematic literature review. Nutrition. 2009;25:717–722. 27. Borges-Yanez SA, Maupome G, Martinez-Gonzalez M, et al. Dietary fiber intake and dental health status in urban, urban-marginal, and rural communities in cen- tral Mexico. JNutrHealthAging. 2004;8:333–339. Supporting Information 28. Walls AWG, Steele JG. The relationship between oral health and nutrition in older people. Mech Ageing Dev. 2004;125:853–857. 29. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic The following Supporting Information is available reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264. through the online version of this article at the publish- 30. Scottish Intercollegiate Guidelines Network. Critical Appraisal Notes and Checklists. Edinburgh, Scotland: Health Care Improvement; 2015. er’s website. 31. Ronnberg AK, Nilsson K. Interventions during pregnancy to reduce excessive ges- Table S1 PRISMA 2009 checklist tational weight gain: a systematic review assessing current clinical evidence using the Grading of Recommendations, Assessment, Development and Evaluation Table S2 Periodontal project protocol (GRADE) system: interventions during pregnancy to reduce excessive gestational Table S3 Periodontal database search terms weight gain. BJOG. 2010;117:1327–1334.

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326 32. GRADE Working Group. GRADE Handbook. Ontario, Canada: McMaster University; 2013. 36. Salazar CR, Laniado N, Mossavar-Rahmani Y, et al. Better-quality diet is associated 33. Centers for Disease Control and Prevention. National Health and Nutrition with lower odds of severe periodontitis in US Hispanics/Latinos. J Clin Periodontol. Examination Survey III: Oral Health Component. Rockville, MD: Westat, Inc; 1992. 2018;45:780–790. 34. Lee JH, Shin MS, Kim EJ, et al. The association of dietary vitamin C intake with peri- 37. Lertpimonchai A, Rattanasiri S, Arj-Ong Vallibhakara S, et al. The association be- odontitis among Korean adults: results from KNHANES IV. PLoS One. tween oral hygiene and periodontitis: a systematic review and meta-analysis. Int 2017;12:e0177074. ( Dent J. 2017;67:332–343. 35. Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines: 8. Rating the quality of ev- 38. Locker D, Ford J, Leake JL. Incidence of and risk factors for tooth loss in a popula- idence—indirectness. JClinEpidemiol. 2011;64:1303–1310. tion of older Canadians. J Dent Res. 1996;75:783. Downloaded from https://academic.oup.com/nutritionreviews/article/78/2/175/5545429 by University of Sydney user on 01 November 2020

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327 APPENDIX E: ORAL HEALTH AND AGEING SELF COMPLETED QUESTIONNAIRE

328 CHAMP ID:

Oral Health and Ageing

Self-Completed Questionnaire

Chief Investigators

Professor Robert Cumming Professor Fredrick A C Wright Dr Vasant Hirani

A/Professor Vasi Naganathan A/Professor Fiona Blyth Dr Jane Harford

Professor David Handelsman Professor David Le Couteur

Professor Markus Seibel Dr Louise Waite

329 330 CHAMP ID:

CHAMP Self-Completed Questionnaire

Thank you for assisting us with our research and taking the time to complete this questionnaire. The information you provide will help us understand many important issues about older men’s health. We would like to assure you the answers you provide will remain strictly confidential.

Instructions 1. In general, we would like you to complete this questionnaire on your own. If you find that you need assistance please call the CHAMP Office on Freecall 1800 174 287 and we will assist you. If your spouse or partner assist you, please indicate this on the front cover of the questionnaire.

2. Please answer every question (unless you are asked to skip questions because they don’t apply to you). Please be as accurate as you can and choose the response that best describes your situation. 3. If you are unsure how to answer a question please give the best answer you can and make a comment in the left margin.

4. Answer every question by ticking the appropriate box . Some questions also require a written response.

Statement of confidentiality Information that would permit the identification of any person completing this questionnaire will be regarded as strictly confidential. All information provided will be used only for the CHAMP Study and will not be disclosed or released for any other purpose without your consent.

CHAMP Clinic Suite 201 Concord Hospital Medical Centre Concord Repatriation General Hospital Hospital Road Concord NSW 2139

Freecall:1800 174 287 Phone: 9767 7269 Fax: 9767 5419 E-mail: [email protected]

331 CHAMP ID:

Section 1 – General Information

1. What is today’s date? / / day month year

2. How old are you? years old

3. What is your current marital status? Married Living with a partner/de facto Widowed Divorced Separated Never married

Other (please specify)

4. Who else lives in your home? (Mark all that apply) No one, I live alone Wife/partner Daughter(s) Son(s) Brother(s) Sister(s) Grandchildren

Other (please specify)

332 CHAMP ID:

5. What is your housing arrangement? Are you: The outright owner of your home Paying off your home Leasing, purchasing (or other financial plan) in a retirement village Paying rent or board to a private landlord Paying rent to the government for public housing Living rent or board free

Other (please specify)

6. Are you currently in paid employment?

Yes Go to Question 7 No

6a.If no, how old were you when you retired completely? years old

7. Which of the following are sources of income for you?(mark all that apply)

Age pension Own business/farm/partnership Repatriation pension, Veteran’s pension Wage or salary

Superannuation or other private income Other (please specify)

8. Are you currently driving at least once in a while?

Yes Go to Section 2, Question 1 No

8a. If no, have you ever driven a car or have you given up driving?

Never drove Go to Section 2, Question 1 Gave up driving

8b. If you gave up driving, how old were you when you stopped driving?

years old

333 CHAMP ID:

Section 2 – Medical History

1. Has a doctor or other health care provider ever told you that you had or have:

Diabetes? Yes If yes, are you currently being treated Yes No for this condition by a doctor? No

High thyroid, Grave’s disease Yes If yes, are you currently being treated Yes or an overactive thyroid gland? No for this condition by a doctor? No Low thyroid or an under active Yes If yes, are you currently being treated Yes thyroid gland? No for this condition by a doctor? No Osteoporosis, sometimes called Yes If yes, are you currently being treated Yes thin or brittle bones? No for this condition by a doctor? No Paget’s disease? Yes If yes, are you currently being treated Yes No for this condition by a doctor? No

A stroke, blood clot in the brain Yes If yes, are you currently being treated Yes or bleeding in the brain? No for this condition by a doctor? No Parkinson’s disease? Yes If yes, are you currently being treated Yes No for this condition by a doctor? No Kidney stones? Yes If yes, are you currently being treated Yes No for this condition by a doctor? No

Dementia? Yes If yes, are you currently being treated Yes No for this condition by a doctor? No Depression? Yes If yes, are you currently being treated Yes No for this condition by a doctor? No

Epilepsy or fits? Yes If yes, are you currently being treated Yes No for this condition by a doctor? No Hypertension or high blood pressure? Yes If yes, are you currently being treated Yes No for this condition by a doctor? No Heart attack, coronary or Yes If yes, are you currently being treated Yes myocardial infarction? No for this condition by a doctor? No Angina (chest pain)? Yes If yes, are you currently being treated Yes No for this condition by a doctor? No Congestive heart failure Yes If yes, are you currently being treated Yes or enlarged heart? No for this condition by a doctor? No Intermittent claudication or pain in your Yes If yes, are you currently being treated Yes legs from a blockage of the arteries? No for this condition by a doctor? No Chronic obstructive lung disease, chronic Yes If yes, are you currently being treated Yes bronchitis, asthma, emphysema or COPD? No for this condition by a doctor? No Liver disease? Yes If yes, are you currently being treated Yes No for this condition by a doctor? No Chronic kidney (renal) disease or Yes If yes, are you currently being treated Yes kidney (renal) failure? No for this condition by a doctor? No

334 CHAMP ID:

2. Has a doctor or other health care provider told you that you have arthritis or gout?

Yes No Go to Question 3

2a. If yes, what type of arthritis did the health care provider say it was? (mark all that apply)

Rheumatoid arthritis Osteoarthritis or degenerative arthritis Gout

Some other type of arthritis(please specify) Don’t know

2b. Which of your joints have arthritis? (mark all that apply)

Hip Ankle Neck Hand/Fingers Knee Elbow Back Wrist Foot/Toes

Shoulder Other (please specify)

335 CHAMP ID:

3. During the past 12 months, have you fallen and landed on the floor or ground, or fallen and hit an object like a table or chair?

Yes No Go to Section 3, Question 1

3a. If yes, how many times have you fallen in the past 12 months?

Once Twice Three times Four times Five times Six or more times

3b. Which of the following injuries did you have? (mark all that apply)

I broke or fractured a bone I hit or injured my head I had a sprain or a strain I had a bruise or bleeding I had some other kind of injury I did not have any injuries from a fall in the past 12 months

336 CHAMP ID:

Section 3 – Prostate Health

Not Less Less About More Almost at all than 1 than half half the than half always time in 5 the time time the time

1. Over the PAST MONTH, how often have you had a sensation of not emptying your bladder completely after you finish urinating?

2. Over the PAST MONTH, how often have you had to urinate again less than two hours after you finished urinating?

3. Over the PAST MONTH, how often have you found you stopped and started again several times when you urinated?

4. Over the PAST MONTH, how often have you found it difficult to postpone urination?

5. Over the PAST MONTH, how often have you had a weak urinary stream?

6. Over the PAST MONTH, how often have you had to push or strain to begin urination?

7. Over the PAST MONTH, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

None Three times Once Four times Twice Five or more times

337 CHAMP ID:

8. If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

Delighted Pleased Mostly satisfied Mixed, about equally satisfied and dissatisfied Mostly unsatisfied Unhappy Terrible

Many men leak urine some of the time. We are trying to find out how many men leak urine, and how much this bothers them. We would be grateful if you could answer the following questions, thinking about how you have been, on average, over the PAST FOUR WEEKS.

9. How often do you leak urine?

Never About once a week or less often Two or three times a week About once a day Several times a day All the time

We would like to know how much you think leaks.

10. How much urine do you usually leak (whether you wear protection or not)?

None A small amount A moderate amount A large amount

338 CHAMP ID:

11. Overall, how much does leaking urine interfere with your everyday life? Please circle a number between 0 (not at all) and 10 (a great deal)

0 1 2 3 4 5 6 7 8 9 10

Not at all A great deal

12. When does urine leak?(Mark all that apply)

Never – urine does not leak Leaks before you can get to the toilet Leaks when you cough or sneeze Leaks when you are asleep Leaks when you are physically active/exercising Leaks when you have finished urinating and are dressed Leaks for no obvious reason Leaks all the time

13. Over the PAST MONTH, how many pads or other incontinence aids, if any, did you usually use to help with leaking or dripping?

No pads 1 pad per day 2 pads per day 3 or more pads per day

14. The Prostate Specific Antigen (PSA) test is a simple blood test that men are sometimes offered by their doctor, as a check for prostate disease. In the last TWO YEARS, have you had a PSA test? (Do not include the test done by CHAMP) Yes No

339 CHAMP ID:

15. A digital rectal exam is an exam in which a doctor, nurse, or other health professional places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. In the last TWO YEARS, has a doctor or other health care provider checked your prostate by a digital rectal exam?

Yes No

16. Since your last CHAMP Clinic visit has a doctor or other health care provider told you that you have or had an enlarged prostate, also known as benign prostatic hyperplasia (BPH)? This means an enlarged prostate that is NOT due to cancer.

Yes No Go to Question 17

16a. Treatments for BPH usually are to improve urinary symptoms and flow. Have you ever had treatment for BPH?

Yes No Go to Question 17

16b. If yes, what type of treatment have you received? (Mark all that apply)

Surgery (laser surgery or transurethral resection of the prostate, sometimes called TURP or re-bore) Prescription medications

Other (please specify)

17. Since your last CHAMP Clinic visit has a doctor or other health care provider told you that you have or had prostatitis (inflammation or infection of the prostate)?

Yes No Go to Question 18

17a. If yes, are you currently being treated for this condition by a doctor? Yes No

340 CHAMP ID:

18. Since your last CHAMP Clinic visit has a doctor or other health care provider told you that you have prostate cancer?

Yes No Go to Question 19

18a.If yes, how old were you at first diagnosis?

years old

18b.What type of treatment did you receive? (Mark all that apply)

Radiation Surgery to remove prostate gland Surgery to remove testicles Hormone treatment No treatment or careful observation by a doctor

Other (please specify)

19. Since your last CHAMP Clinic visit has a doctor or other health care provider told you that you have any other cancer?

Yes No Go to Section 4, Question 1

19a. If yes, what cancer(s) were you diagnosed with? List all the cancers you have had diagnosed. If you have been diagnosed with more than 3 cancers please list other cancers and the age at diagnosis in the blank space at the bottom of the page.

Cancer: Age at diagnosis:

CHAMP SELF-COMPLETED QUESTIONNAIRE 341 CHAMP ID:

Section 4 – Tobacco and Alcohol Use

1. Do you smoke cigarettes now?

Yes No

1b. How old were you when 1a. About how many you stopped smoking? cigarettes do you smoke per day? years old

cigarettes 1c. I never smoked

2. Do you smoke a pipe or cigars regularly?

Yes No

2a. About how much do 2b. How old were you when you smoke? you stopped smoking? years old pipes or cigars per week 2c. I never smoked

Section 5 – Sun Exposure This section is not included in this follow-up.

342 CHAMP ID:

Section 6 – Physical Activity

1. Do you take walks for exercise, daily or almost everyday?

Yes No Go to Question 2

1a. On the average, how many kilometres do you walk each day for exercise?

kilometres

2. Over the PAST YEAR, have you spent more than one week confined to a bed or a chair as a result of any injury, illness or surgery?

Yes No Go to Question 3

2a. How many weeks over this PAST YEAR were you confined to a bed or chair?

weeks

The next few questions ask about your physical activity during the last 7 days. If the last 7 days have not been typical because of illness or bad weather, please estimate based on two or three weeks ago.

3. Over the PAST 7 DAYS, how often did you participate in sitting activities such as reading, watching TV, computing or doing handcrafts?

Never Go to Question 4

Seldom (1-2 days) Sometimes (3-4 days) Often (5-7 days)

3a. What were these activities?

3b. On average, how many hours per day did you engage in these sitting activities?

Less than 1 hour Between 1 and 2 hours 2-4 hours More than 4 hours

CHAMP SELF-COMPLETED QUESTIONNAIRE 343 CHAMP ID:

4. Over the PAST 7 DAYS, how often did you take a walk outside your home or yard for any reason? For example, for fun or exercise, walking to work, walking the dog, etc.

Never Go to Question 5 Seldom (1-2 days) Sometimes (3-4 days) Often (5-7 days)

4a. What were these activities?

4b. On average, how many hours per day did you spend walking?

Less than 1 hour Between 1 and 2 hours 2-4 hours More than 4 hours

5. Over the PAST 7 DAYS, how often did you engage in light sport or recreational activities such as bowling, golf with a buggy, fishing from a boat or pier, or other similar activities?

Never Go to Question 6 Seldom (1-2 days) Sometimes (3-4 days) Often (5-7 days)

5a. What were these activities?

5b. On average, how many hours per day did you engage in these light sport or recreational activities?

Less than 1 hour Between 1 and 2 hours 2-4 hours More than 4 hours

344 CHAMP ID:

6. Over the PAST 7 DAYS, how often did you engage in moderate sport and recreational activities such as doubles tennis, ballroom dancing, golf without a buggy, softball or other similar activities?

Never Go to Question 7 Seldom (1-2 days) Sometimes (3-4 days) Often (5-7 days)

6a. What were these activities?

6b. On average, how many hours per day did you engage in these moderate sport or recreational activities?

Less than 1 hour Between 1 and 2 hours 2-4 hours More than 4 hours

7. Over the PAST 7 DAYS, how often did you engage in strenuous sport and recreational activities such as jogging, swimming, cycling, singles tennis, aerobic exercise, skiing (downhill or cross country) or other similar activities?

Never Go to Question 8 Seldom (1-2 days) Sometimes (3-4 days) Often (5-7 days)

7a. What were these activities?

7b. On average, how many hours per day did you engage in these strenuous sport or recreational activities?

Less than 1 hour Between 1 and 2 hours 2-4 hours More than 4 hours

CHAMP SELF-COMPLETED QUESTIONNAIRE 345 CHAMP ID:

8. Over the PAST 7 DAYS, how often did you do any exercise specifically to increase muscle strength and endurance, such as lifting weights or pushups, etc.?

Never Go to Question 9 Seldom (1-2 days) Sometimes (3-4 days) Often (5-7 days)

8a. What were these activities?

8b. On average, how many hours per day did you engage in exercise to increase muscle strength and endurance?

Less than 1 hour Between 1 and 2 hours 2-4 hours More than 4 hours

9. During the PAST 7 DAYS, have you done any light housework, such as dusting or washing dishes? Yes No

10. During the PAST 7 DAYS, have you done any heavy housework or duties, such as vacuuming, scrubbing floors, washing windows or carrying wood? Yes No

11. During the PAST 7 DAYS, did you engage in any of the following activities? 11a. Home repairs, like painting, wallpapering, electrical work, etc.? Yes No

11b. Lawn work or yard care, including leaf removal, wood chopping, etc.? Yes No

11c. Outdoor gardening? Yes No

11d. Caring for another person, such as children, dependent spouse, or another adult? Yes No

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12. During the PAST 7 DAYS did you work, either for pay or as a volunteer?

Yes No Go to Section 7, Question 1

12a. If yes, how many hours in the past week did you work for pay and/or as a volunteer? hours

12b. Which of the following categories best describes the amount of physical activity required on your job and/or volunteer work? Mainly sitting with slight arm movements Examples: office worker, watchmaker, seated assembly line worker, bus driver

Sitting or standing with some walking Examples: cashier, general office worker, light tool and machinery worker

Walking, with some handling of materials generally weighing less than 50 kgs Examples: postman, waiter/waitress, construction worker, heavy tool and machinery worker

Walking and heavy manual work often requiring handling materials weighing more than 50 kgs Examples: stone mason, farm or general labourer

CHAMP SELF-COMPLETED QUESTIONNAIRE 347 CHAMP ID:

Section 7 – Lifestyle (SF12)

1. Compared to other people your own age, how would you rate your overall health? Excellent for my age Good for my age Fair for my age Poor for my age Very poor for my age

The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

2. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf? Yes, limited a lot Yes, limited a little No, not limited at all

3. Climbing several flights of stairs? Yes, limited a lot Yes, limited a little No, not limited at all

During the PAST 4 WEEKS, have you had any of the following problems with your work or other regular daily activities because of your physical health?

4. Accomplished less than you would like Yes No

5. Were limited in the kind of work or other activities Yes No

348 CHAMP ID:

During the PAST 4 WEEKS, have you had any of the following problems with your work or other regular daily activities because of any emotional problems (such as feeling depressed or anxious)?

6. Accomplished less than you would like Yes No

7. Didn’t do work or other activities as carefully as usual Yes No

8. During the PAST 4 WEEKS, how much did pain interfere with your normal work (including both work outside the home and housework)? Not at all A little bit Moderately Quite a bit Extremely

These questions are about how you feel and how things have been with you during the PAST 4 WEEKS. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the PAST 4 WEEKS...

9. Have you felt calm and peaceful?

All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time

10. Did you have a lot of energy? All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time

CHAMP SELF-COMPLETED QUESTIONNAIRE 349 CHAMP ID:

11. Have you felt downhearted and blue?

All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time

12. During the PAST 4 WEEKS, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?

All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time

The following questions are about your health and how you have been feeling in the LAST 4 WEEKS. In the LAST 4 WEEKS:

13. Have you felt keyed up or on edge? Yes No

14. Have you been worrying a lot? Yes No

15. Have you been irritable? Yes No

16. Have you had difficulty relaxing? Yes No

17. Have you been sleeping poorly? Yes No

18. Have you had headaches or neckaches? Yes No

19. Have you had any of the following: trembling, tingling, dizzy spells, sweating, diarrhoea or needing to pass water more often than usual? Yes No

20. Have you been worried about your health? Yes No

21. Have you had difficulty falling asleep? Yes No

350 CHAMP ID:

Section 8 – Activities of Daily Living

We are interested to know about some of your activities of daily living, things that we all need to do as part of our daily lives. We would like to know if you can do these activities without any help at all, or if you need some help to do them, or if you can’t do them at all.

1. Can you use the telephone? Without help, including looking up numbers and dialing With some help (can answer phone or dial operator in an emergency, but need a special phone or help in getting the number or dialing) Or are you completely unable to use the telephone?

2. Can you get to places out of walking distance? Without help (can travel alone on buses, taxis, or drive your own car) With some help (need someone to help you or go with you when travelling) Or are you unable to travel unless emergency arrangements are made for a specialised vehicle like an ambulance?

3. Can you go shopping for groceries or clothes (if you have transportation)? Without help (taking care of all shopping needs yourself, assuming you had transportation) With some help (need someone to go with you on all shopping trips) Or are you completely unable to do any shopping?

4. Can you prepare you own meals? Without help (plan or cook full meals for yourself) With some help (can prepare some things but unable to cook full meals yourself) Or are you completely unable to prepare any meals?

5. Can you do your housework? Without help (can scrub floors, etc.) With some help (can do light housework but need help with heavy work) Or are you completely unable to do any housework?

CHAMP SELF-COMPLETED QUESTIONNAIRE 351 CHAMP ID:

6. Can you take your own medications? Without help (in the right doses at the right time) With some help (are able to take medications if someone prepares it for you and/or reminds you to take it) Or are you completely unable to take your medication?

7. Can you handle your own money? Without help (write cheques, pay bills etc.) With some help (manage day-to-day purchases but need help with managing your cheque book and paying your bills) Or are you completely unable to handle money?

8. Are you able to do heavy work around the house, like washing windows, walls, or floors without help? Yes No

9. Are you able to walk up and down stairs to the first floor without help?

Yes No

10. Are you able to walk half a mile (approximately one kilometre) without help?

Yes No

352 CHAMP ID:

Section 9 – Caring

1. Do you have the main responsibility in caring for someone who has a long- term illness, disability, or other problems? (i.e. problems that would prevent them from managing their household tasks or personal care independently.)

Yes No Go to Section 10, Question 1

1a. If yes, who do you care for? (Mark all that apply)

Wife/partner Son Daughter Grandchild Friend Mother Father

Other (please specify)

Section 10 – Use of Health Services

1. In the LAST 12 MONTHS, have you consulted a GP or local doctor about your health?

Yes No Go to Question 2

1a. If yes, in the LAST 2 WEEKS, have you consulted a GP or local doctor about your health?

Yes No

2. In the LAST 12 MONTHS, have you visited or been visited by a community nurse or a private nursing service? Yes No

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3. In the LAST 12 MONTHS, have you visited or been visited by a podiatrist or chiropodist? A podiatrist/chiropodist is a person who is specially trained to provide foot care. Yes No

4. In the LAST 12 MONTHS, have you visited or been visited by a physiotherapist? Yes No

5. In the LAST 12 MONTHS, have you spent at least one night in a hostel/nursing home? Yes No

6. In the LAST 12 MONTHS, have you spent at least one day in an Aged Care Day Centre? Yes No

7. In the LAST 12 MONTHS, have you been visited by Home Care to help with household or personal duties? Yes No

8. In the LAST 12 MONTHS, have you used the services of the Community Aged Care Packages (CACPs) to help with any duties? Yes No

9. In the LAST 12 MONTHS, did any service deliver or prepare your meals for you at home? For example, Meals-On-Wheels. Yes No

354 CHAMP ID:

Section 11 – Social Support

1. How many times during the PAST WEEK did you spend some time with someone who does not live with you? For example, you went to see them or they came to visit you, or you went out together.

None Once Twice Three times Four times Five times Six times Seven or more times

2. How many times did you talk to someone – friends, relatives or others – on the telephone in the PAST WEEK (either they called you, or you called them)?

None Once Twice Three times Four times Five times Six times Seven or more times

355 CHAMP ID:

3. About how often did you go to meetings of social clubs, religious meetings, or other groups that you belong to in the PAST WEEK? None Once Twice Three times Four times Five times Six times Seven or more times

4. Does it seem that your family and friends (i.e. people who are important to you) understand you most of the time, some of the time, or hardly ever? Hardly ever Some of the time Most of the time

5. Do you feel useful to your family and friends (i.e. people who are important to you) most of the time, some of the time, or hardly ever? Hardly ever Some of the time Most of the time

6. Do you know what is going on with your family and friends most of the time, some of the time, or hardly ever? Hardly ever Some of the time Most of the time

356 CHAMP ID:

7. When you are talking with your family and friends, do you feel you are being listened to most of the time, some of the time, or hardly ever?

Hardly ever Some of the time Most of the time

8. Do you feel you have a definite role (place) in your family and among your friends most of the time, some of the time, or hardly ever? Hardly ever Some of the time Most of the time

9. Can you talk about your deepest problems with at least some of your family and friends most of the time, some of the time, or hardly ever?

Hardly ever Some of the time Most of the time

10. How satisfied are you with the kinds of relationships you have with your family and friends very dissatisfied, somewhat dissatisfied, or satisfied? Very dissatisfied Somewhat dissatisfied Satisfied

11. How many persons in this area (within one hours travel of your home) do you feel you can depend on or feel very close to?

Number of family members

Number of people who are NOT family members

None

357 CHAMP ID:

Section 12 – Back and Joint Health

1. During the PAST 12 MONTHS, have you had any back pain?

Yes No Go to Question 2

1a. If yes, how often were you bothered by back pain in the PAST 12 MONTHS?

All of the time Most of the time Some of the time Rarely Never

1b. When you have had back pain, how bad was it on average?

Mild Moderate Severe

1c. In what part or parts of your back is the pain usually located? (Mark all areas that apply with an X)

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1d. In the PAST 12 MONTHS, have you had pain that goes down your leg?

Yes No Go to Question 2

1e. If yes, has this pain spread below the knee?

Yes No

2. During the PAST 12 MONTHS, have you limited your activities because of back pain?

Yes No Go to Question 3

2a. If yes, how many days did you stay in bed (or lie down) at least half of the day because of your back? days 2b. How many days did you limit or cut down on your usual activities because of back pain? Do not include days in bed. days

3. In the PAST 12 MONTHS, have you had pain in or around either hip joint, including the buttock, groin, or either side of the upper thigh, on most days for at least one month? Do not include pain from the lower back.

Yes No Go to Question 4

3a. If yes, was this pain in the left hip, right hip or both hips? Left hip Right hip Both hips

4. In the PAST 12 MONTHS, have you had pain, aching or stiffness in either knee on most days for at least one month? Include pain, aching and stiffness in or around your knee, including the front, back and side of knee.

Yes No Go to Section 13, Question 1

4a. If yes, was this pain in the left knee, right knee or both knees? Left knee Right knee Both knees

359 CHAMP ID:

Section 13 – Geriatric Depression Scale

Choose the best answer for each of the following questions for how you felt over the LAST WEEK.

1. Are you basically satisfied with your life? Yes No

2. Have you dropped many of your activities and interests? Yes No

3. Do you feel that your life is empty? Yes No

4. Do you often get bored? Yes No

5. Are you in good spirits most of the time? Yes No

6. Are you afraid something bad is going to happen to you? Yes No

7. Do you feel happy most of the time? Yes No

8. Do you often feel helpless? Yes No

9. Do you prefer to stay at home, rather than going out and doing new things? Yes No

10. Do you feel you have more problems with memory than most? Yes No

11. Do you think it is wonderful to be alive now? Yes No

12. Do you feel pretty worthless the way you are now? Yes No

13. Do you feel full of energy? Yes No

14. Do you feel that your situation is hopeless? Yes No

15. Do you think that most people are better off than you are? Yes No

Section 14 – Family History This section is not included in this follow-up.

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Section 15 - Use of Oral Health Services

1. Are you eligible for dental care under the Department of Veterans’ Affairs?

Yes No Don’t know

2. In the past 5 years, have you been referred to the Medicare Enhanced Primary Care (EPC) program or Medicare Chronic Disease Dental Scheme by your doctor or other health professional?

Yes No Don’t know

3. In the past month (four weeks) have you sought any advice or information regarding your dental health and or problems with your mouth or dentures?

Yes No Don’t know

4. Where do you go FIRST for advice regarding dental care and information about your teeth, gums and mouth?

Family Newspaper/magazine articles/television Internet Dentist or other dental provider Doctor or local medical centre Local Pharmacist Community or club service Other (Please specify)

5. How often do you USUALLY visit a dental professional (dentist/dental prosthetist/ dental technician/dental hygienist about your teeth, dentures or gums?

Two or more times per year

Once a year

Once every two years

Less often than once every two years

I have never been to the dentist Go to Question 12 361 CHAMP ID:

6. What is the USUAL reason for your dental visits?

Check up Dental problem Can't recall

7. When was your LAST visit to a dental professional (dentist/dental prosthetist/dental technician/dental hygienist?

Less than 12 months ago 1 month to less than 2 years ago 2 years to 5 years ago 5 years to 10 years ago 10 years ago or more

8. What was the reason for your LAST dental visit?

Check up Dental problem Can't recall

9. What was the main treatment you received at you LAST dental visit? (Mark all that apply)

Dental inspection/ examination & cleaning Dental filling(s) Tooth extraction(s) Gum treatment Denture repair or new denture Fillings and extractions Advice on how to care for my teeth and gums Other (please specify)

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10. Where did you make your LAST dental visit?

A private dental clinic (including specialist) A government dental clinic (including dental hospital) Dental prosthetist or dental technician Health insurance clinic Other (please specify)

11. How did you pay for your LAST dental visit?

Paid all own expenses Health insurance paid some or all Government paid for some or all Other payment arrangement (please specify)

12. Do you think you need dental treatment NOW?

Yes No Go to Question 13

12a. If yes, what sort of treatment do you think you need? (Mark all that apply)

363 CHAMP ID:

13. How would you rate your Dental Health AT THE MOMENT?

Excellent

Very good Good

Fair

Poor Don't know

364 CHAMP ID:

Section 16 - Oral Health Impact Profile We are interested to know how the health of your teeth, gums and mouth impacts your daily life. Please answer the following questions even if you only wear dentures.

1. In the LAST 12 MONTHS, have you had trouble pronouncing any words because of problems with your teeth, mouth or dentures?

Never

Hardly ever Occasionally

Fairly often

Very often

2. In the LAST 12 MONTHS, have you felt that your sense of taste has worsened because of problems with your teeth, mouth or dentures?

Never

Hardly ever

Occasionally

Fairly often

Very often

3. In the LAST 12 MONTHS, have you had painful aching in your mouth? Never

Hardly ever

Occasionally

Fairly often Very often

365 CHAMP ID:

4. In the LAST 12 MONTHS, have you found it uncomfortable to eat any foods because of problems with your teeth, mouth or dentures?

Never Never

Hardly ever Hardly ever

Occasionally Occasionally

Fairly often Fairly often Very often Very often

5. In the LAST 12 MONTHS, have you been self-conscious because of problems with your teeth, mouth or dentures?

Never

Hardly ever Occasionally

Fairly often

Very often

6. In the LAST 12 MONTHS, have you felt tense because of problems with your teeth, mouth or dentures?

Never

Hardly ever

Occasionally

Fairly often

Very often

7. In the LAST 12 MONTHS, has your diet been unsatisfactory because of problems with your teeth, mouth or dentures?

366 CHAMP ID:

8. In the LAST 12 MONTHS, have you had to interrupt meals because of problems with your teeth, mouth or dentures?

Never

Hardly ever

Occasionally

Fairly often

Very often

9. In the LAST 12 MONTHS, have you found it difficult to relax because of problems with your teeth, mouth or dentures?

Never

Hardly ever

Occasionally

Fairly often

Very often

10. In the LAST 12 MONTHS, have you been a bit embarrassed because of problems with your teeth, mouth or dentures?

Never

Hardly ever

Occasionally

Fairly often

Very often

11. In the LAST 12 MONTHS, have you been a bit irritable with other people because of problems with your teeth, mouth or dentures?

Never

Hardly ever

Occasionally

Fairly often

Very often 367 CHAMP ID:

12. In the LAST 12 MONTHS, have you had difficulty with your work or other regular daily activities because of problems with your teeth, mouth or dentures?

Never

Hardly ever

Occasionally

Fairly often

Very often

13. In the LAST 12 MONTHS, have you felt that your life in general was less satisfying because of problems with your teeth, mouth or dentures?

Never

Hardly ever

Occasionally

Fairly often

Very often

14. In the LAST 12 MONTHS, have you been unable to function because of problems with your teeth, mouth or dentures?

Never

Hardly ever

Occasionally

Fairly often

Very often

15. How often does your mouth feel dry?

Never

Hardly ever

Occasionally

Fairly often Very often

CHAMP SELF-COMPLETED QUESTIONNAIRE 368 CHAMP ID:

16. Have you ever been worried that you may have bad breath?

Never

Hardly ever

Occasionally Fairly often

Very often

17. In the PAST MONTH, how often has your mouth felt dry?

Never

Hardly ever Occasionally

Fairly often

Very often

18. In the PAST MONTH, how often have you had difficulty eating dry foods?

Never

Hardly ever

Occasionally

Fairly often Very often

19. In the PAST MONTH, how often has your mouth felt dry when eating a meal?

Never

Hardly ever

Occasionally

Fairly often

Very often

369 CHAMP ID:

20. In the PAST MONTH, how often have you had difficulties swallowing certain foods?

Never

Hardly ever

Occasionally

Fairly often

Very often

21. In the PAST MONTH, how often have your lips felt dry?

Never

Hardly ever

Occasionally

Fairly often Very often

Thank you for completing this questionnaire. We will collect this questionnaire during your CHAMP Oral Health Clinic.

370 371 Postal address: CHAMP, Reply Paid 72908, Concord Repatriation Hospital NSW 2139 Freecall: 1800 174 287 Phone: (02) 9767 7269 Fax: (02) 9767 5419 Email: [email protected]

372 APPENDIX F: ORAL HEALTH AND AGEING CLINIC QUESTIONNAIRE

373 CHAMP ID:

Oral Health and Ageing

Clinic Questionnaire

Chief Investigators

Professor Robert Cumming Professor Fredrick A C Wright Dr Vasant Hirani

A/Professor Vasi Naganathan A/Professor Fiona Blyth Dr Jane Harford

Professor David Handelsman Professor David Le Couteur

Professor Markus Seibel Dr Louise Waite

374 CHAMP ID: CHAMP ID:

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING

375 CHAMP ID: CHAMP ID:

Section 1 – Specimen Collection This section is not included in this follow-up.

Section 2 – Alcohol Use

A card that lists the measures of standard drinks should be shown while asking these questions.

1. “In the past 12 months, have you had at least 12 drinks of any kind of alcoholic beverage?”

Yes No Don’t know Refused

1a. In the past 12 months, on the average, how many days per week, month, or year did you drink any alcoholic beverage?

days per Week Month Year

1b. On the average, on the days that you drank alcohol, how many drinks did you have per day?

drinks

1c. In the past 12 months, how many days per week, month, or year did you have five or more drinks on a single day? Include all types.

days per Week Month Year

Participant did not have at least five drinks on any day

1d. In the past 12 months, on the average, how many days per week, month, or year did you drink any red wine? days per Week Month Year

1e. On the average, on the days that you drank red wine, how many drinks did you have?

drinks

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 1

376 CHAMP ID:

Section 3 – Functional Disability

“Do you need help from another person or special equipment or device to do any of the following things?” No, does not Yes, Unable need help needs help to do this

1. Walking across a small room?

2. Bathing, either a sponge bath, tub bath, or shower?

3. Personal grooming, like brushing hair, brushing teeth, or washing face?

4. Dressing, like putting on a shirt, buttoning and zipping, or putting on shoes?

5. Eating like holding a fork, cutting food, or drinking from a glass?

6. Getting from a bed to a chair?

7. Using the toilet?

Section 4 – Pain

1. “In the last 6 months, have you experienced pain in any part of your body which has lasted for 3 months or more, that is pain experienced every day for at least 3 months?”

Yes No

1a. In which part(s) of your body have you experienced this pain? (mark all that apply) Hands Shoulders Neck Ankles Wrist Face Hips Feet Elbows Jaw Knees Back

Other (please specify)

2 CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 377 CHAMP ID:

Section 5 – Cognition Say to the participant: “In the next section we're going to do some tasks which you may find challenging. That's normal, because some of them are difficult. We're doing these tasks to look at your memory and concentration…things like that. You won't get them all right – that's impossible. The important thing is that you try your best. Also, I will not tell you whether your answers are right or wrong during this session.”

ADDENBROOKE’S COGNITIVE EXAMINATION (ACE) Write the participants answer in the space provided in the response column. 1= Correct 0= Incorrect R=Refused U=Unable due to physical or language reasons

Question Response Score

1. What is the year? Year 1 0 R U 2. What is the season? Season 1 0 R U (Current season OR within 1 week of upcoming season OR within 2 weeks of previous season) 3. What is the date? (±2 days) Date 1 0 R U 4. What is the day? Day 1 0 R U 5. What is the month? Month 1 0 R U 6. What is the country we are in? Country 1 0 R U 7. What state are we in? State 1 0 R U 8. What city are we in? City 1 0 R U 9. What is the name (or address) Name 1 0 R U of this place? 10. What room (or floor) of the Floor 1 0 R U building are we in?

11. Listen carefully. I am going to say Apple 1 0 R U three words. After I have said them, I want you to repeat them. Table 1 0 R U Remember what they are because I am going to ask you to name Penny 1 0 R U them again in a few minutes. Please repeat the names for me: No of trials necessary APPLE for the participant to TABLE repeat the sequence PENNY (Score first try (0-3), but keep saying all 3 until subject can repeat all 3, up to 6 trials. Record number of trials required.)

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 3

378 CHAMP ID:

Question Response Score

12. Now I’d like you to subtract 7 93 1 0 R U from 100. Then keep subtracting 86 1 0 R U 7 from each answer until I ask 79 1 0 R U you to stop. 72 1 0 R U (If subject cannot or will not perform 65 1 0 R U this task, administer 12b, WORLD)

12b. ADMINISTER ONLY IF SUBJECT CANNOT DO 12. Now I am going to give you a word and ask you to spell it L forwards and backwards. The R Refused word is WORLD. First, can you O spell it forwards? Now spell it W Unable backwards. (Repeat if necessary, and help subject spell world forward, if necessary. Score number of letters given in correct order.)

13. What are the three objects Apple 1 0 R U I asked you to remember? Table 1 0 R U Penny 1 0 R U 14. I am going to read a name and 14a. Trial 1 /7 address – I want you to repeat it Peter Marshall Refused when I have finished. Wait until I 42 Station Unable finish telling you the complete St Geelong address. Victoria (Now read aloud the following name and address.) 14b. Trial 2 /7 Peter Marshall Peter Marshall Refused 42 Station Street 42 Station Unable Geelong St Geelong Victoria Victoria Regardless of the score after the first trial, say “Now I’m going to 14c. Trial 3 /7 read the name and address again Peter Marshall Refused and I want you to repeat it again 42 Station Unable when I am finished.” St Geelong Repeat this instruction and test twice. Victoria Record score for each of the three trials.

15. Tell me the name of: • the Prime Minister PM 1 0 R U • the previous Prime Minister Last PM 1 0 R U • the Leader of the Opposition Opposition 1 0 R U • the President of the USA President 1 0 R U United States of America

4 CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 379 CHAMP ID:

Question Response Score

16. Tell me all the words you can Number think of beginning with the of words letter P, but don’t tell me names correct of people or places. Remember, no people or place names. (Time the patient for 60 seconds and list all the answers in the space provided. The score is the number of words they think of. Refused If the person mentions a person or a place Unable you may remind them of the rules once.)

Number 17. Now tell me names of all the of words animals you can think of correct (it doesn’t matter what letter they start with). (Time the patient for 60 seconds and list all the answers in the space provided. The score is the number of words they think of.) Refused Unable

18. (Show wrist watch) Watch 1 0 R U What is this called?

19. (Show pencil) Pencil 1 0 R U What is this called?

20. Show 10 pictures. Giraffe 1 0 R U Ask patient to name the pictures. Kite 1 0 R U Allow close synonyms. Helicopter 1 0 R U Pig 1 0 R U Ask the patient: Kangaroo 1 0 R U What do you call this? Crown 1 0 R U Windmill 1 0 R U Goat 1 0 R U Barrel 1 0 R U Camel 1 0 R U

21. Please obey the following simple commands: • Point to the door Point to the door 1 0 R U • Point to the ceiling Point to the ceiling 1 0 R U • Point to the ceiling then the door Ceiling to door 1 0 R U • Point to the door after touching Desk to door 1 0 R U the desk

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 5 380 CHAMP ID:

Question Response Score

22. Read the words on this page, then do what it says. Close your eyes 1 0 R U (The paper reads “CLOSE YOUR EYES”. Correct if subject closes eyes.)

23 . I’m going to give you a piece of paper. When I do, take the paper in your right hand, fold the paper Right hand 1 0 R U in half with both hands, and put Fold in half 1 0 R U the paper down on your lap. Put it on lap 1 0 R U (Read the full statement, THEN hand over paper. Do not repeat instructions or coach. Score 1 point for each correct step.)

24. Repeat each of these words after me. Brown 1 0 R U • Brown Conversation 1 0 R U • Conversation Articulate 1 0 R U • Articulate

25. I would like you to repeat each of these phrases after me: No ifs, ands 1 0 R U “No ifs, ands or buts.” “The orchestra played and Orchestra 1 0 R U the audience applauded.” (Allow only one trial.)

26. Please read these words aloud: • Shed Shed 1 0 R U • Wipe Wipe 1 0 R U • Board Board 1 0 R U • Flame Flame 1 0 R U • Bridge Bridge 1 0 R U

27. Please read these words aloud: • Sew Sew 1 0 R U • Pint Pint 1 0 R U • Soot Soot 1 0 R U • Dough Dough 1 0 R U • Height Height 1 0 R U

6 CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 381 CHAMP ID:

Question Response Score

28. Write any complete sentence on Sentence: 1 0 R U that piece of paper for me. (If examinee needs a sentence ask them to write about the weather. Ask subject to write on the page they folded in half. Sentence must contain a subject and a verb and be sensible. Correct grammar and punctuation are not necessary.)

29. Can you tell me the name and Peter Marshall /7 address that I told you before 42 Station Refused (the one you practiced 3 times)? St Geelong Unable Victoria

30. Here are two drawings. Pentagon 1 0 R U Please copy the drawings on Wire cube 1 0 R U the same paper.

31. Can you please draw a Correct circle 1 0 R U clock-face with numbers and Numbering 1 0 R U the hands at ten past five. Position of hands 1 0 R U

32. Does the participant have any physical/functional disabilities or other problems that caused the participant difficulty in completing any of the tasks. Yes No

32a. If yes, what is the most significant reason?

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 7 382 CHAMP ID:

Section 6 – Fracture History

This section is not included in this follow-up.

8 CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 383 CHAMP ID:

Section 7 – Height, Weight and Pulse

1. Standing Height Say to the participant: “Please stand with your back against this board. Your legs should be together and your heels, your buttocks and your back should be touching the board. Look straight ahead and stand tall.” Bring the horizontal bar down firmly onto the top of the participant’s head. Place the bean bag on the headboard to make sure the horizontal bar makes contact with the top of the scalp. Ask the participant to: “Take a deep breath.” Record the reading on the stadiometer just before the participant exhales. Then say: “Breathe out.” Ask the participant to step away from the stadiometer, then step back into the measurement position. Take the second measurement as before.

1a. Measurement 1: mm 1b. Measurement 2: mm

1c. Does measurement 1 and measurement 2 differ by 4 or more mm? Yes No

If yes: complete Measurements 3 and 4 1d. Measurement 3: mm 1e. Measurement 4: mm

1f. Does the participant have kyphosis?

Yes No

2. Weight Say to the participant: “In order to measure your weight, please remove your shoes and heavy jewellery, and empty your pockets. Please step forward onto the centre of the scale.”If the participant needs support you can tell them they can use the bars of the scales to steady themselves.

Weight kg

2a. If weight was not measured, explain why

3. Circumferences

Waist 3a. Measure 1: mm 3b. Measure 2: mm 3c. Measure 3: mm Hip 3d. Measure 1: mm 3e. Measure 2: mm 3f. Measure 3: mm

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 9 384 CHAMP ID:

4. Radial Pulse 4a. Measurement 1: beats per 30 seconds x 2 = Measurement 1: beats per minute 4b. Measurement 2: beats per 30 seconds x 2 = Measurement 2: beats per minute

Blood Pressure

5. Exclusion criteria If any of these are ticked, DO NOT TEST Open wounds, ulcerations Unable to lie at <45 degree angle Bilateral amputation Participant refused

6. Cuff size Small Regular Large Thigh

7. Arm Used

Right Left Why wasn’t the right arm used?:

8. Blood pressure while participant SITTING DOWN Blood Pressure 1 8a. Systolic Measurement 1: mmHg 8b. Diastolic Measurement 1: mmHg Blood Pressure 2 8c. Systolic Measurement 2: mmHg 8d. Diastolic Measurement 2: mmHg

10 CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 385 CHAMP ID:

Section 8 – Functional Vision

This section is not included in this follow-up.

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 11 386 CHAMP ID:

Section 9 – Muscle Strength

GRIP STRENGTH

Say to participant: “This device measures your arm and upper body strength.”

1. “Do you have any pain or arthritis in your hands?” Yes No Go to Question 2

1a. Has any of it become worse recently?

Yes No Don’t Know Refused

1b. If yes, which side?

Left (do not test) Right (do not test) Both (do not test either side)

2. “Have you had any surgery on your hands or wrists in the past 3 months (12 weeks)?” Yes No Don’t Know Refused

2a. If yes, which side?

Left (do not test) Right (do not test) Both (do not test either side)

Script: “I’d like you to take your right/left arm, rest it on the table, and bend your elbow. Grip the bars in your hand, like this. Please slowly squeeze the bars as hard as you can.” Hand the dynamometer to the participant. “Does that feel like a comfortable grip?”Adjust if needed. Script: “Now try it once just to get the feel of it. For this practice, just squeeze gently. It won’t feel like the bars are moving, but your strength will be recorded. Are the bars the right distance apart for a comfortable grip?” Show dial to participant. Test twice on the right side, then twice on the left side. Script: “We’ll do this two times. This time counts, so when I say squeeze, squeeze as hard as you can. Ready? Squeeze! Squeeze! Squeeze! Now, Stop!”

Right side Left side 3a. Trial 1 kg 3c. Trial 1 kg

Refused Unable (did not attempt) Refused Unable (did not attempt) 3b. Trial 2 kg 3d. Trial 2 kg

Refused Unable (did not attempt) Refused Unable (did not attempt)

12 CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING

387 CHAMP ID:

Section 10 – Neuromuscular Function

Script: “I'm going to ask you to try a 6m walking test. I will first describe it to you then I'd like you to try to do it. If you cannot complete the test or you feel it would be unsafe to try to do it, please tell me and we'll move on to the next exercise.”

1. Ask the participant: “Do you use any walking aids, such as a cane?”

No aids Cane or quad cane Walker, wheelchair, leg brace, crutches

2. Does the participant have any of the following?(mark all that apply)

Orthosis Missing limbs Prosthesis Paralysis of extremity or side of body

6 METRE USUAL PACE The participant should be wearing comfortable walking shoes. He may use a walking aid, but should be encouraged to walk without one if he is comfortable doing so.

Script: “This is a walking test. I want you to walk to the end normally, at a comfortable pace. We will do this test twice.”

Ask the subject to stand behind the line at one end of the course. Script: “Place your feet with your toes behind, but touching the yellow starting line. Wait until I say “Go.” Remember, I want you to walk at a comfortable pace.”

Demonstrate and return. Walk past the yellow finish line each time.

“Any questions? Ready? Go.”

Start the stopwatch at the first foot fall, and stop timing when the first footfall (complete or partial) crosses the finish line. Count the number of steps taken to cover the course (NOT ALOUD). One step is counted when either foot is placed down on the floor, including the first step and the step which a participant's foot crosses or touches the end line. Record time and number of steps.

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 13

388 CHAMP ID:

3. Trial 1 (6m usual pace)

3a. : seconds 3b. steps 3c. Trial 1 Aid used: No aid Straight cane Quad cane Walker Crutch

3d. Trial 1 not attempted Trial 1 attempted but unable

When the participant crosses the end line, ask him to turn around and stand at the end line as before. Script: “Now, do the same thing in the other direction. Walk at your usual pace and go all the way, past the finish line, to the other end. Ready? Go.” Record time and number of steps below.

4. Trial 2 (6m usual pace) 4a. : seconds 4b. steps

4c. Trial 2 Aid used: No aid Straight cane Quad cane Walker Crutch

4d. Trial 2 not attempted Trial 2 attempted but unable

14 CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 389 CHAMP ID:

Section 11 – Spirometry

This section is not included in this follow-up.

Section 12 – Urinary Function

This section is not included in this follow-up.

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 15

390 CHAMP ID:

Section 13 – Heel Ultrasound This section is not included in this follow-up.

Section 14 – DEXA

This section is not included in this follow-up.

16 CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 391 CHAMP ID:

Section 15 – Medication Use

1. “Do you use any type of testosterone treatment such as capsules (tablets), gel, patches, injections or implants?”

Yes No Go to Question 2

1a. When did you start having testosterone treatment? Date / month year

1b. Do you use gel or patches?

Yes No Go to Question 1d

1c. Are you still using this testosterone treatment (in the last week)? Yes No

1d. Do you use injections or implants?

Yes No Go to Question 2

1e. How many times a year do you have this testosterone treatment? times

1f. When was your last treatment? Date / month year

2. “Have you ever taken medicine to treat osteoporosis, Paget’s disease or other bone diseases?” Yes No

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 17

392 CHAMP ID:

3. “Have you ever taken Bisphosphonates?” Yes No Go to Question 4

If yes, when did you start and stop taking bisphosphonates? 3a. Start date / 3b. Stop date / month year month year 3c. Which bisphosphonates have you ever taken? (mark all that apply) Alendronate (Fosamax) Clodronate (Bonefos) Etidronate (Didronel) Ibandronate (Bondronat) Pamidronate (Aredia) Risedronate (Actonel) Tiludronate (Skelid) Other/don’t know

4. “Have you ever taken any of the following:” Start date Stop date Month/Year Month/Year Fluoride Yes No (or Sodium Fluoride) Calcitonin Yes No (or miacalcin) Vitamin D (Ostelin or Yes No cod liver oil) (Caltrate, Sandocal, Calcium supplements Yes No Citrical, etc.)

Strontium Yes No (Protos) Other medication for bone health Yes No

Other (please specify)

5. “Have you ever taken steroids such as Cortisone or Prednisone for asthma, arthritis or other conditions for more than one month?” Yes No Don’t know

5a. If yes, were the steroids: (mark all that apply) Oral Inhaled Nasal

Injected Other (please specify)

18 CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING

393 CHAMP ID:

MEDICATION INVENTORY

6. Does the participant take any medication, daily or almost daily, for at least the past month? This includes both prescription and non-prescription medication. Yes No

Prescription

Name Strength No of tablets Duration (mg) per tablet per day (months)

Non-Prescription

Name Strength No of tablets Duration (mg) per tablet per day (months)

CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING 19

394 CHAMP ID:

7. “Are there any other medications that you take that you have not brought with you?” (This question is a prompt in case they have forgotten anything. Enter medications in the appropriate table on previous page.)

Do you regularly take any medicines prescribed by a doctor? Do you regularly take any medicines purchased over the counter? Do you take any sleeping tablets? Do you take any nerve tablets? Do you take any fluid tablets? Do you take any laxatives/bowel medicines? Do you take any headache tablets/painkillers? Do you take any antacid/indigestion medicines?

20 CHAMP CLINICAL QUESTIONNAIRE – ORAL HEALTH & AGEING

395 396 Postal address: CHAMP, Reply Paid 72908, Concord Repatriation Hospital NSW 2139 Freecall: 1800 174 287 Phone: (02) 9767 7269 Fax: (02) 9767 5419 Email: [email protected]

397 APPENDIX G: ORAL HEALTH AND AGEING NUTRITION QUESTIONNAIRE

398 CHAMP ID:

Oral Health and Ageing

Nutrition Questionnaire

Chief Investigators

Professor Robert Cumming Professor Fredrick A C Wright Dr Vasant Hirani

A/Professor Vasi Naganathan A/Professor Fiona Blyth Dr Jane Harford

Professor David Handelsman Professor David Le Couteur

Professor Markus Seibel Dr Louise Waite

399 CHAMP ID: CHAMP ID:

400 CHAMP ID:

CHAMP NUTRITION QUESTIONNAIRE CHAMP NUTRITION QUESTIONNAIRE

401 CHAMP ID: CHAMP ID:

Location (circle) Home/ Clinic

Date / /

Respondent Self Self + Family Self + Friend / carer Family only

Friend / carer only

Completed by

1. Do you have any services deliver or prepare meals for you? e.g. Meals-on-Wheels

Yes No Go to Question 2

1a. If yes, how many days per week do you receive this service? 1-2 days 3-5 days 5-7 days

1b. Which meals does this service deliver? (Mark all that apply) Breakfast Lunch Dinner Snacks

2. Do you receive meals from family or friends outside of your household?

Yes No Go to Question 3

2a. If yes, how many days per week on average do you receive meals from family or friends?

1-2 days 3-5 days 5-7 days

2b. Which meals do your family or friends usually provide? (Mark all that apply) Breakfast Lunch Dinner Snacks

402 CHAMP ID:

3. Who mostly shops for food in your household? Self

Wife

Both

Other (please specify)

4. Who mostly does the cooking in your household? Self

Wife

Both

Other (please specify)

5. Are you on a special diet as advised by a health professional?

Yes No Go to Question 6

5a. If yes, what type of diet are you on?

Low fat diet

Diabetic diet

Low lactose diet

Gluten free diet

Other (please specify)

5b. How long have you been on this diet for?

Less than one month

1 – 2 months

2 – 3 months

Longer than 3 months

403 CHAMP ID:

6. Have you changed your diet in the past 3 MONTHS due to: (Mark all that apply)

6a. Chewing problems? Yes No

6b. Swallowing problems? Yes No

6c. Nausea Yes No

6d. Heartburn or reflux Yes No

6. Other reasons (please specify)

7. If you changed your diet in the past three months, when did you change it?

Yes No Go to Question 8

7a. If yes, what type of diet are you on? Less than one month

1 – 2 months

2 – 3 months

Longer than 3 months

8. How would you describe your appetite? Very poor

Poor

Average

Good

Very good

9. In the past 3 MONTHS, have you been limited in the types and amounts of food that you were able to buy due to:

9a. Difficulty getting to/ from the shops Yes No

9b. Difficulty carrying groceries? Yes No

9c. The cost of groceries? Yes No

9d. Other reasons (please specify)

404 CHAMP ID:

10. Are you currently able to chew the following foods: (Mark all that apply)

10a. Boiled egg Yes No N/A

10b. Boiled vegetables Yes No N/A

10c. Pasta Yes No N/A

10d. Fresh lettuce salad Yes No N/A

10e. Hamburger Yes No N/A

10f. Dried apricot Yes No N/A

10g. Pizza Yes No N/A

10h. Firm meat such as steak Yes No N/A

10i. Fresh apple Yes No N/A

10j. Fresh carrot Yes No N/A

10k. Nuts Yes No N/A

405 CHAMP ID:

PROMPT FOR DIETITIAN: If the participant is on a modified consistency diet, show card A and record type of modification: A, B, or C or a combination in the notes section

What do you USUALLY eat and drink for your BREAKFAST? (in the past 3 months) Number of days Time Notes per week

Cereal

Milk / Soy - full / light / skim L/ days/ week

Sugar/ Sweetener

Fruit/ Fruit juice

Bread / toast - white / w'meal / multigr / other slices

Butter/ Margarine / Spread

Hot food

Beverage - tea / coffee/ other + milk + sweetener - fruit juice / water

Mo Tu We Th Fr Sa Su

406 CHAMP ID:

PROMPT FOR DIETITIAN: If the participant is on a modified consistency diet, show card A and record type of modification: A, B, or C or a combination in the notes section

What do you USUALLY eat and drink for your LIGHT MEAL? (in the past 3 months) Number of days Time Notes per week white, w'meal, m'grain, Soup Bread other slices/ day Sandwich Butter/ marg g/ weeks

Hot food Cold meats eg ham, devon, corned beef, salami

Salad Fish

Fruit Cheese g/ wks

Dairy dessert Eggs / wk Size g

Cake / biscuit / nuts etc Baked beans Spaghetti

Beverage tea / coffee/ water / fruit juice / soft drink / beer / wine / port / sherry / Salad veges spirits/ other

Mo Tu We Th Fr Sa Su

407 CHAMP ID:

PROMPT FOR DIETITIAN: If the participant is on a modified consistency diet, show card A and record type of modification: A, B, or C or a combination in the notes section

What do you USUALLY eat and drink for your MAIN MEAL? (in the past 3 months) Number of days Time Notes per week

Soup Meat g = serves Beef / lamb/ pork / chicken / steak/ chops / roast / casserole / curry / Sandwich mince / sausages

Trim fat from meat None / some / most / all Hot food Remove skin from chicken Yes / No

Salad Fish g = serves Fry / poach / bake / grill

Fruit

Potato / Pasta / Rice/ Noodle

Dairy/ Cake/ biscuit/ nuts etc Vegetables

Beverage tea / coffee / water / fruit juice / soft drink / beer / wine / port / sherry / spirits / other

Sauces / gravy / dressings

Mo Desserts Tu Custard We Ice cream Th Yoghurt Fr Cheesecake Sa Pies/ tarts Su Cream Jelly Other

OIL for cooking / salads

408 CHAMP ID:

PROMPT FOR DIETITIAN: If the participant is on a modified consistency diet, show card A and record type of modification: A, B, or C or a combination in the notes section

What do you USUALLY have for SNACKS? (in the past 3 months)

Number Food and Drinks Time of day of days per (in past 3 months) week Morning Time Biscuits, cheese, cakes, fruitcake, lollies, liquorice nuts, chocolate, fruit, potato crisps, olives, etc Time

Afternoon Tea Tea, coffee, cocoa, Milo, Time Ovaltine, Sustagen, Ensure etc.

Water, soft drink, beer, wine, Time sherry, port, whisky, scotch etc.

Evening Time

Time

Night Time

Time

409 CHAMP ID:

Other Notes

410 CHAMP ID:

Postal address: CHAMP, Reply Paid 72908, Concord Repatriation Hospital NSW 2139 Freecall: 1800 174 287 Phone: (02) 9767 7269 Fax: (02) 9767 5419 Email: [email protected]

411 APPENDIX H: MANUAL FOR NUTRITIONAL DATA ENTRY

412 Manual for nutritional data entry – Sheet 1: List of foods

Sheet 1: List of foods and corresponding FoodWorks entry

Food Item FoodWorks entry Weight Animal and vegetable fat Fat,solid,blend of animal&vegetable oils Abalone Abalone 1 Abalone is 85g Alcoholic Ale Beer, Ale 1 cup = 150g (based on weight of 1 cup of white alfredo pasta Alfredo Pasta pasta cooked). 1 cup = 264g (4.4g per piece according to Calorie Agnolotti sundried tomato Agnolotti Sundried Tomato King) 1tb:6g or 1 cup:75g (based on cocnut, grated and Almond meal Almond meal desicated) Amaranth flour Flour,rice n/a Antipasti nfs Olives, green, black, drained n/a Anchovy, in oil Anchovy,canned in oil,drained Use tuna tin (95g) to estimate Custard apple Apple,unpeeled,raw,nfs n/a 1 whole custard apple edible portion is 288 g Custard Apple Custard Apple according to calorie king Custard, baked Custard,egg,vanilla,baked n/a Apple,unpeeled,baked,with dried fruit,nfs Apple,unpeeled,baked,with dried fruit,nfs 1 apple = 24.4g as per foodworks Apple/fruit, stewed Apple,peeled,stewed,nfs n/a Apple, peeled Apple,red skin,peeled,raw 1 medium (6-8cm dia)

Apricot delight/slice nfs Slice,muesli,w oats,apricots & sultanas,homemade n/a Apricot nectar BERRI JUICE APRICOT NECTAR n/a Apricot, dried Apricot,dried n/a Apricot, fresh Apricot,fresh,raw Enter as no. of apricots 1 cup =210g (based on 1 cup of peach, canned Fruit, apricot, canned Apricot,canned in light syrup,drained in light syrup, drained arancini Arancini 1 piece = 50g, (based on 1 dim sim piece). Artichoke Artichoke,globe,boiled Use medium globe option

413

Manual for nutritional data entry – Sheet 1: List of foods

Asparagus Asparagus,boiled,drained Medium Spear (unless stated otherwise) Avocado nfs Avocado,raw,nfs Based off 1 whole avocado. Enter as no. of rashers or if they specify middle rasher or "no tail" then put in as bacon,middle Bacon, rasher Bacon,breakfast rasher,grilled rasher,lean & fat,grilled. Baked rice Pudding,rice n/a Rice,paella style,w chicken,prawns & mixed baked rice, savoury vegetables 1 cup = 209g 1 cup = 192.5g (based on the weight of 1 cup of Baklava Baklava Danish, custard style fruit filled) Banana Banana,cavendish,peeled,raw use medium Banana, dried Banana chip n/a

Bar, Rice Crispie Bar, chocolate & rice crisps, milk chocolate coated n/a Basil basil,green,fresh,raw Bean, baked Baked beans,canned in tomato sauce 1 large can= 420g, small can=220g

1 cup = 170g based on 1 cup of Bean, black Bean,black,boiled,drained Bean,broad,fresh,boiled,drained. Bean, black sauce, beef stir fry Beef,stir fry,black bean sauce,bok choy & onion Use T/A container Bean, borlotti Bean,red kidney,canned in brine,drained n/a Bean, broad Bean,broad,fresh,boiled,drained n/a Bean, cannelini Bean,cannellini,canned in brine,drained n/a Bean, dried nfs Bean,butter,fresh,boiled,drained n/a Bean, green/string Bean,green,fresh,boiled,drained n/a Bean, mixed, canned Bean,mixed,canned in brine,drained n/a Bean, sprout Sprout,bean,raw n/a Bean, sweet Beans, cooked, nfs n/a Beans, nfs Beans, cooked, nfs 1/2 cup =95g

414

Manual for nutritional data entry – Sheet 1: List of foods

Beef, blade Beef,blade steak,lean grilled n/a Beef, chuck Beef,chuck steak,untrimmed,grilled/bbq n/a beef nfs Beef, cooked, nfs Beef, corned Beef,corned,canned n/a Beef, fillet Beef,fillet,lean,grilled n/a Beef Jerky Beef,jerky,all flavours 1 piece = approx 20g according to calorie king Beef, minced nfs Beef,mince,cooked,nfs n/a Beef, roasted Beef,rump steak,lean,baked/roasted 0.5 Cup = 150g (approx) Beef, roasted, cold Beef,roast,deli-sliced,ready-to-eat n/a Beef, schnitzel Meat,crumbed,fried,ns oil,nfs n/a Beef, shoulder Meat,cooked,nfs n/a Beef, silverside Beef,silverside,corned,lean & fat,boiled n/a Beef, steak Beef,rump steak,lean,grilled n/a Beef, stew nfs Beef,stewed,nfs n/a Beef,stew/casserole,tomato sauce & vegetables Beef, stew with vegetables including potato 1 cup= 253g- based on beef curry, 1 cup Beef, T-bone Beef,t-bone steak,lean,grilled n/a Beef, topside beef,topside steak,lean,grilled/BBQ n/a Beef,steak,new york Beef,sirloin steak,lean,grilled n/a Beef/Red meat roast Beef,rump steak,lean,baked/roasted n/a Beer nfs Beer,lager n/a Beer, light Beer,reduced alcohol/light style n/a Soft drink,ginger ale,creamy soda/other non-fruit Beer/ale, ginger flavours,intense sweetened n/a Soft drink,ginger ale,creamy soda/other non-fruit Beer/ale, ginger (non-diet) flavours, n/a Beer, stout Beer, stout Beetroot nfs Beetroot,canned,drained Use no. of slices if not sure. Beneprotein powder Nestle Beneprotein powder Nestle 1 level scoop (1.5 Tblspn) = 7 g or 1 sachet = 7g

415

Manual for nutritional data entry – Sheet 1: List of foods

Benefibre Powder Novartis Benefibre Powder Novartis 3g = 2 teaspoons

Berries,mixed berries, mixed, nfs (strawberry,raspberry,blueberry,blackberry),fresh,raw Biscuit nfs Biscuit,sweet,plain No. of biscuits. Biscuit, almond UNIBIC ALMOND BISCOTTI BISCUIT n/a Biscuit, Amaretti Biscuit,sweet,macaroon Use no. of biscuits Biscuit, ANZAC Biscuit,sweet,Anzac/butternut style n/a Biscuit, Arnotts, Full o fruit ARNOTTS FULL O FRUIT Biscuit, arrowroot ARNOTTS MILK ARROWROOT n/a Biscuit, biscottini/savoiardi ITAL BISCUITS BISCOTTINI n/a PARADISE BISCUIT SHORTBREAD Biscuit, butterscotch BUTTERSCOTCH 9G PER BISCUIT Biscuit, cherry slice ARNOTTS CHERRY SLICE n/a Biscuit, chocolate Biscuit,sweet,chocolate coated n/a Biscuit, chocolate chip Biscuit,sweet,chocolate chip n/a Biscuit, chocolate cream (2 round biscuit (6cm Biscuit,sweet,chocolate coated,chocolate dia) flavour,sandwiched w cream filling n/a Biscuit, Chocolate Mint ARNOTTS CHOCOLATE MINT SLICE 1 Biscuit round = 15g Chocolate peanut biscuit ARNOTTS CHOC PEANUT CRUNCH (13G) Biscuit, coffee Biscuit,sweet,chocolate coated,coffee flavour n/a Biscuit, cracker Biscuit,savoury,cracker,nfs n/a Biscuit,sweet,chocolate flavour,sandwiched w cream Biscuit, cream (round biscuit- 6cm dia) filling No. of biscuits. Biscuit, digestive MCVITIES DIGESTIVES n/a Biscuit,sweet,sponge finger style Biscuit,sweet,sponge finger style 1 finger = 12g Biscuit, fruit Biscuit,sweet,with dried fruit n/a Biscuit, fruit and nut Biscuit,sweet,with dried fruit & nut n/a Biscuit, ginger nut HOME BRAND GINGER NUT n/a Biscuit, Granita, Arnotts ARNOTTS GRANITA PLAIN

416

Manual for nutritional data entry – Sheet 1: List of foods

Biscuit, Gaiety ARNOTTS CHOCOLATE GAIETY Biscuit, Iced vovo ARNOTTS ICED VO VO Enter as 1 biscuit (20g) Biscuit,sweet,jam-filled Biscuit,sweet,jam-filled use biscuit no. Biscuit, lattice ARNOTTS LATTICE Use no of biscuits Biscuit, Lemon filling biscuit ARNOTTS LEMON CRISP Biscuit, malt PARADISE BISCUIT MALT Use no. of biscuits Biscuit, monte carlo ARNOTTS MONTE CARLO ORIGINAL n/a biscuit, peanut/nut Biscuit,sweet,with nuts n/a Biscuit, rice cracker Biscuit,savoury cracker,rice n/a biscuit, salada ARNOTTS SALADA ORIGINAL Biscuit, Sakata, rice cracker SAKATA RICE CRACKER PLAIN n/a Biscuit, savoury nfs Biscuit,savoury,cracker,nfs Biscuit 7x7

Biscuit, sesame and wheat Biscuit,savoury,wholemeal wheat flour with sesame n/a 1 shape= ~2.5g (based on one small packet Biscuit, shape ARNOTTS SAVOURY SHAPES =25g, with 10 biscuits in pack) or 1 box= 175g Biscuit, shortbread Biscuit,shortbread style Use no. of biscuits Biscuit, shortbread cream ARNOTTS SHORTBREAD CREAMS n/a FRITZ PFEFFERNUSSE ICED SPICY Biscuit, spice, hungarian GINGERBREAD Use no. of biscuits Biscuits, vita wheat, nfs ARNOTTS VITA WHEAT 9 GRAINS Use no. of biscuits Biscuit,sweet,wafer layers,sandwiched w cream filling Biscuit, wafer (other flavours) n/a ARNOTTS WAGON WHEELS CHOCOLATE Biscuit, wagon wheel WHEATEN n/a Biscuit, wheaten ARNOTTS CHOCOLATE WHEATEN MILK n/a Biscuit, wheatmeal, sweet Biscuit,sweet,wheatmeal n/a Biscuit, wholemeal, savoury Biscuit,savoury,wholemeal wheat flour n/a Bittermelon Melon,bitter,boiled/steamed n/a

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Manual for nutritional data entry – Sheet 1: List of foods

30 mL (1 nip) = 28.5 g based on 30 mL of whisky or Bitters Bitters 1 tb = 19g (based on 1 tb of whisky) Blueberry Blueberry,fresh,raw n/a 0.75 cup minced meat, 0.5 onion, 2 eggs, 333ml light Bobotie milk Recipe is equal to 1 cup Bok choy nfs/Asian green/ gai choy Cabbage,bok choy,stir-fried without oil cup (cooked) Beef,bolognaise pasta sauce,mince,tomato & olive Bolognaise oil,homemade 1 cup = 170g BONNOX Spread,beef extract 1tb makes 1 cup Branston Chutney/pickle,fruit,intense sweetened n/a Brandy Brandy 1 nip = 30mL Bread pastry, Apple Bakers Del Apple licious 69g 1 scroll = 69 grams Bread,from white flour,crusty,e.g. french Bread, baquette/french stick stick/baguette Use no. of 1.5cm thick slices Bread, bagel, white Bagel,from white flour Bread,chapatti,no added fat Bread,chapatti,no added fat 1 chapatti = 17.5 Bread,from white flour,dutch style fruit loaf,extra dried Bread loaf nfs fruit n/a Bread nfs Bread,fresh,nfs n/a Bread roll nfs Bread roll,nfs n/a Bread/bread roll,from white flour,topped w cheese & Bread roll, bacon and cheese bacon n/a Bread roll, coles bakery COLES IN STORE BAKED WHITE ROLLS n/a Bread roll, multigrain Bread roll,mixed grain,nfs n/a Bread roll, White Bread roll,from white flour n/a bread roll, wholemeal Bread roll,from wholemeal flour n/a Bread, bakers delight white BAKERS DELIGHT WHITE BLOCK n/a Bread, burgen BURGEN MIXED GRAIN BREAD n/a HELGAS CONTINENTAL TRADITIONAL WHITE Bread, continental BREAD n/a

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Bread, crisp nfs HOME BRAND CRISP BREAD 97% FF n/a

Bread, crisp, wholemeal Biscuit,savoury crispbread,wholemeal wheat flour n/a bread, custard on the top Bun,no dried fruit,iced,with custard n/a Bread, fruit nfs/ Panetonne Bread,from white flour,dried fruit,nfs n/a Bread, finger bun, iced Bun,with dried fruit,iced (finger bun) 1 bun = 80 g Bread, garlic Bread,garlic,made with butter n/a Bread, gluten freen, toasted, nfs Bread,gluten free,commercial,toasted n/a Bread, Helgas, Rye HELGAS BREAD LIGHT RYE n/a Bread, Helga's, Sandwich thin HELGAS TRADITIONAL BREAD WHITE 1 THIN = 42.5G Bread,from white flour,italian style e.g. ciabatta,pane Bread, Italian loaf di casa Slice medium Bread,herb,made with butter (Toscano Pizza Bruschettina) Bread,herb,made with butter 1 slice = 45g Bread, lebanese nfs Bread,flat (pita/lebanese style),wholemeal Lebanese slice (18cm dial) Bread,flat (pita/lebanese),white Bread,flat (pita/lebanese),white 1 pita - 83g 18cm diameter as per wholemeal Bread, Low GI BUTTERCUP LOW GI BREAD n/a Bread, mixed grain, Helgas HELGAS BREAD MIXED GRAIN OATS n/a 1 cup = 241g (based on 1 cup of bread, molenburg Bread,from wholemeal flour,grain & seeds Cauliflower,boiled,drained,with white sauce) Bread, multigrain Bread,from wholemeal flour,grain & seeds n/a

Bread, multigrain toasted Bread,from wholemeal flour,grain & seeds,toasted n/a 1 slice = 35g based on one slice of bread with Bread, cooked with olives Bread, cooked with olives grains 1 McCains pizza base is approx 233g. Approx 8 Bread, pizza base (no topping) Bread,pizza base,commercial slices in each pizza. 1 slice = approx 30 g Bread, raisin toast nfs TIP TOP RAISIN BREAD (TOASTED) n/a Bread, roll multigrain Bread roll,mixed grain n/a Bread, rye or pumpernickel Bread from rye flour, fresh, nfs n/a

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Bread, Rye, Light Bread,from rye flour,light n/a Bread, sourdough Bread,from white flour,sour dough 1 roll = approx 50g Bread, soy and linseed Bread,from white/wholemeal flour,soy & linseed n/a Bread, stick , grissini VITA VIGOR GRISSINI BREAD STICK n/a Bread, toasted, Rye & Soy nfs Bread,from rye flour,light,soy & linseed,toasted n/a Bread, toasted, sourdough Bread,from white flour,sour dough,toasted n/a Bread, toasted, white Bread,from white flour,toasted n/a Bread, toasted, wholemeal Bread,from wholemeal flour,toasted n/a Plain turkish bread Bread,foccacia/turkish style bread,plain use bakers delight option Bread, Vienna COLES WHITE ITALIAN VIENNA n/a Bread, white Bread,from white flour n/a Bread, white added fibre Bread,from white flour,added fibre n/a Bread, wholemeal Bread,from wholemeal flour n/a

Bread, wholemeal, helgas HELGAS TRADITIONAL BREAD WHOLEMEAL n/a Bread,from wholemeal flour,dried fruit,nuts & Bread, with nuts and fruit seeds,added folate Bread, wrap Bread,flat (pita/lebanese),white 1 pita Brioche Brioche 1 slice = 30g (based on one slice if white bread). 1 stick = 110g (based on 1 Doughnut,dusted with Fried White Bread Fried White bread cinnamon & sugar (bar 14 x 7 x 4cm) Broccoli Broccoli,fresh,boiled,drained n/a 0.5 cup = 82g based on Broccoli,fresh,stir-fried Broccoli,fresh,stir-fried without oil Broccoli,fresh,boiled,drained Broccoli,fresh,boiled,drained,with cheese sauce Broccoli,fresh,boiled,drained,with cheese sauce Broth, beef Soup,beef,broth style,condensed,canned n/a Soup, Beef, can Soup,beef,broth style,condensed,canned Brownie Brownie, chocolate with nuts, homemade n/a Bruschetta Bruschetta 1 slice = 138 g based on Calorie King estimate.

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Brussel sprout Brussels sprout,fresh,boiled,drained Use no. of sprouts 1 cup of cooked buckwheat = 168g (estimated from http://nutritiondata.self.com/facts/cereal-grains-and- Buckwheat, groats, cooked, no added salt Buckwheat, groats, cooked, no added salt pasta/5683/2) Bulgur/crushed wheat Barley,pearl,boiled without added salt/fat n/a

Burger, bacon and egg mcmuffin MCDONALDS,MCMUFFIN,BACON&EGG (132 G) 1 burger = 132g Burger, chicken, nfs MCDONALDS,BURGER,MCCHICKEN 1 burger = 137g Burger, fish MCDONALDS,BURGER,FILET-O-FISH (137 G) n/a Vegetarian burger,vegetarian pattie & salad Burger, veggie (lettuce,tomato,onion),takeaway style n/a

Chicken, butter Chicken,curry,butter,Indian restaurant style I cup = 253g. Based on 1 cup of beef curry. Butter nfs Butter,nfs n/a Butter, lurpak LURPAK SLIGHTLY SALTED BUTTER n/a Light Butter Devondale butter light Dairy blend,butter & canola oil spread,reduced fat butter canola blend (44%) & salt n/a Butter,garlic,home made Butter,garlic,home made n/a butter and oil spread Dairy blend,butter & edible oil spread Buttermilk Buttermilk,cultured,2% fat n/a Cabbage, cooked Cabbage,white,boiled,drained n/a Cabbage, raw Cabbage,white,raw n/a Cabbage,white,stir-fried Cabbage,white,stir-fried without oil n/a Red Cabbage Cabbage,red,boiled,drained 1 jar = 450g cabbage, preserved, kimchi cabbage, preserved, kimchi 1 cup ~ 76g cabbage roll stuffed with vegetables Cabbage rolls stuffed with vegetables 1 cabbage roll = 130g Cake, nfs Cake,sponge,plain,unfilled,uniced,commercial Slice Cake, carrot, nfs Cake,carrot,iced,commercial Slice

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Manual for nutritional data entry – Sheet 1: List of foods

Cake,cheesecake,other flavours,biscuit base,cream 60g = 1 slice. Based on Sara Lee cheese cake Cake, cheese cake french/fruit cheese topping (360g with 6 serves) Cake,cheesecake,chocolate flavour,biscuit Cake, cheeseceke base,cream cheese topping chinese soft flour cake Chinese Soft flour cake Enter as 1 serve = 48g Cake,chocolate,standard style,uniced,homemade Cake, chocolate from basic ingredients 1 small slice; 90g or 1 large slice; 140g Cake, coffee, iced Cake, coffee, iced 1 slice = 88g using food model Cake,coconut Cake,coconut & lemon,uniced,homemade 1 slice = 88g (use food model) Cake, date and walnut BAKERS DELIGHT CAPE FRUIT & NUT LOAF n/a Walnut/Pecan cake Walnut/Pecan cake Use chocolate cake model. Cake, friand Cake,almond,plain,friand style Use no. of friands Cake, fruit/sultana, Cake Cake,fruit,rich style,uniced,commercial 1 slice: 88g Cake, lamington (small) Cake,lamington,unfilled 1 is 125g

Cake, mud cake Cake,chocolate,rich/mud style,uniced,homemade 1 slice: 88g Cake, orange Cake,almond & orange,uniced,homemade 1 slice: 88g Cake, Panettone Cake,fruit,rich style,uniced,commercial 1 slice: 88g Cake,cupcake or muffin, ornage & poppyseed, Cake, poppy seed prepared from dry mix,undefined fat,uniced 1 slice 88 g Cake, rock Biscuit,sweet,chocolate chip n/a Cake,sponge,Swiss roll (jam & mock cream Cake, rollette/swiss roll filling),commercial 1 slice: 88g cake, Sponge with cream cake sponge, with dairy cream filling/topping n/a Cake, tea cake, cinnamon Cake,tea cake,cinnamon topped,homemade Use food model 1 slice = 88g Cake,plain/buttercake,uniced,homemade from basic Cake, vanilla/plain/madeira/buttercake ingredients 1 slice (medium cupcake): 132g

Cake, walnut/nut nfs Muffin,cake/American style,with nuts,homemade 1 slice or muffin: 80g Cake/Bread, banana Cake,banana,uniced,homemade 1 slice of banana bread: 1 piece (1/10 of loaf) Calamari Squid/calamari,baked/grilled n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Squid/calamari,crumbed,fried,restaurants & take Calamari, takeaway away outlets use ring option 1 serve = 150g based on estimation from Calorie Cannoli filled with ricotta Cannoli filled with ricotta King 1 large serve = 150g based on estimation from Cannelloni,spinach & ricotta Cannelloni,spinach & ricotta Calorie King Capsicum Capsicum,raw,nfs use medium Capsicum,red,stir-fried Capsicum,red,stir-fried without oil n/a 1 stuffed capsicum = 400g (not a whole capsicum, Capsicum stuffed nfs Capsicum stuffed nfs not half). 1 stuffed capsicum = 400g (not a whole capsicum, Capsicum stuffed with meat and rice Capsicum Stuffed with Meat and Rice not half). Capers, from bottle, drained, condiments. Capers,bottled,drained Caro, Nestle (powder), caffeine free, coffee substitute Caro, Nestle (powder) CalorieCount estimates 1 tsp = 2.5g 0.5 cup = 77g according to 0.5 cup peeled, boiled, Carrot, baked Carrot,mature,peeled,baked without oil drained Carrot, cooked Carrot,mature,peeled,boiled,drained n/a Carrot, juice Juice,carrot n/a Carrot, raw Carrot,mature,peeled,raw n/a Casserole nfs Beef,stew/casserole,gravy n/a Casserole, beef Beef,stew/casserole,gravy n/a Vegetarian protein,stew/casserole,in tomato sauce,w Vegetarian casserole vegetables (including potato) 1 cup = 253g 1 tbs approximately 5g (based on Breakfast cereal,mixed grain (wheat,corn,oat),clusters,nuts,added vitamins Cashew, Almond, Hazelnut and Coconut Cashew, Almond, Hazelnut and Coconut Cluster, Be B1,B2 & folate & Fe, entry). 3/4 CUP = 45g Cluster, Be Natural Natural according to calorie king. Cauliflower Cauliflower,boiled,drained n/a Cauliflower Mornay Cauliflower,boiled,drained with white sauce Cauliflower with cheese sauce Cauliflower,boiled,drained,with cheese sauce 1 cup = 122g Celery Celery,raw 1 bunch =~ 5 medium stalks

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Celery,stir-fried Celery,stir-fried without oil n/a Cereal, All Bran KELLOGGS ALL BRAN g/cup/tb/tsp 1 teaspoon = 5g, 1 Tablespoon = 20g based on Cereal beverage powder Ecco Nestle Ecco Instant Cereal beverage Nestle intant coffee Breakfast cereal,mixed cereal Cereal, breakfast nfs (oat,corn,rice,barley),extruded,unfortified n/a Cereal, Just right KELLOGGS JUST RIGHT ORIGINAL n/a Cereal, Kelloggs advantage KELLOGGS BRAN FLAKES HIGH FIBRE n/a Cereal, Kelloggs Sustain KELLOGGS SUSTAIN 1 cup =60g as per foodworks Guardian cereal KELLOGGS GUARDIAN CEREAL FREEDOM FOODS RICE FLAKES CEREAL NAS Cereal, gluten free GLUTEN WHEAT FREE LOW FAT n/a Cereal, Shredded Wheat UNCLE TOBYS SHREDDED WHEAT 1 biscuit = 23.5 grams 0.5 cup = 50g according to website. Use cereal Cereal, Goodness Superfood Heart Cereal, Goodness Superfood Heart model Cereal, uncle toby's oat crisp UNCLE TOBYS OAT FLAKES n/a Champagne Champagne 150ml = one standard drink. Assume 150g = 150ml Chelsea bun Bun,with dried fruit,uniced Use no. of buns Cheese nfs Cheese,cheddar (mild,tasty & vintage styles) n/a Cheese, blue vein / roquefort Cheese,blue vein n/a Cheese, bocconcini Cheese,Mozzarella 1 ball = 30g Cheese, Brie Cheese,brie Use no. of wedges Cheese, Camembert Cheese,camembert Use no. of wedges Cheese, cheddar, reduced fat/light Cheese,cheddar,reduced fat (~ 25%) n/a Cheese,cheddar,processed Cheese,cheddar,processed 21g for 1 indivdual slice Cheese, cottage Cheese,cottage,creamed,unflavoured n/a Cheese, cream, light/ reduced fat Cheese,cream,light (~15% fat) n/a Cheese, cream, regular Cheese,cream Laughing cow wedges are 21g each Cheese,edam Cheese,edam n/a Cheese, fetta Cheese,feta (fetta),sheep & cows milk n/a

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Cheese, fontina Cheese,gouda n/a Cheese Fruit and Nut Cheese fruit and nut 1tb = 20.2g Cheese, goat Cheese,goat n/a Cheese, gorgonzola Cheese,blue vein n/a Cheese, haloumi Cheese,haloumy n/a Cheese,havarti style Cheese,havarti style n/a

Cheese, jarlsberg Cheese,Swiss n/a Cheese, light Cheese,cheddar,reduced fat (~ 15%) n/a Cheese, parmesan Cheese,parmesan,shaved 1 tb = 6.8g Cheese, pecorino Cheese,pecorino style 1 tb = 6.8g (based on shaved parmesan) Cheese, provolone Cheese,provolone style n/a Cheese, ricotta Cheese,ricotta n/a Cheese, romano Cheese,romano style n/a Cheese, sweet Cheese,nfs n/a Cheese, swiss Cheese,Swiss n/a Cheese, tasty Cheese,cheddar (mild,tasty & vintage styles) n/a Cherry Cherry,fresh,raw 0.5 cup (nfs) Cherry Ripe Cherry Ripe 1 individual bar is approx 55g Cherry, canned Cherry,black,canned in syrup,drained n/a Chicken,stew/casserole,tomato sauce,vegetables Chicken, cacciatore including potato n/a chicken casserole chicken stew/casserole gravy 1 cup = 253g Chicken, nfs Chicken,grilled/BBQ,nfs n/a Chicken,stir fry,sweet & sour sauce,capsicum,carrot & Chicken, apricot onion n/a Chicken, breast nfs Chicken,breast,lean,baked n/a Chicken, boiled/steamed with skin Chicken breast, boiled/steamed, skin eaten Use food model Chicken, breast, crumbed, nfs Chicken,breast,lean,crumbed,fried,ns oil n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Chicken canned Chicken canned Based on canned goods. Standard can is 85g. Chicken,breast,lean,crumbed,topped w cheese & Chicken Cordon Bleu ham,baked w oil Use Food model Chicken, drumstick, baked Chicken,drumstick,lean,baked n/a

Chicken drumstick, fried (KFC Style) Chicken,drumstick,lean,skin & fat,crumbed,fried,ns oil Use drumstick food model KFC,GRAVY,TUB,SMALL (50 G) KFC,GRAVY,TUB,SMALL (50 G) 50g small KFC,POTATO KFC,POTATO CHIPS,SEASONED,REGULAR (133 CHIPS,SEASONED,REGULAR (133 G) G) 133g regular 1 chicken feet = 45g (estimated from a range 35- Chicken feet Chicken feet 55kg) chicken, fried Chicken,fried,ns oil,nfs n/a Chicken, kebab Chicken,kebab,grilled/BBQ Use no. of kebabas Chicken, kiev FARMLAND CHICKEN KIEV n/a Chicken,battered,w lemon/honey sauce,Chinese Chicken, lemon, chinese style restaurant style cup= 143g Chicken, Luncheon style Chicken roll,processed luncheon meat n/a Chicken, maryland Chicken,maryland,lean,baked n/a Chicken, nugget Chicken,nugget,frozen,cooked,nfs Use no. of nuggets Chicken,baked w tomato,eggplant & Chicken, parmagiana cheese,parmigiana style n/a 174 g = 1 indivdiual pie based on 1 indivdual meat Chicken and vegetable pie Chicken and vegetable pie pie Chicken, rissole/meatball chicken patty/meatball,plain,fried,ns oil n/a Chicken, roast Chicken,baked/roasted,nfs n/a Chicken,stir fry,black bean sauce Chicken,stir fry,black bean sauce n/a 1 cup=253 g as per pork stirfry sweet & sour Chicken, satay / stir fry satay Chicken,stir fry,satay sauce Chinese restaurant style Chicken, stew nfs Chicken,stewed/braised,nfs n/a Chicken,stew/casserole,tomato sauce,vegetables Chicken, stew with vegetable including potato n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Chicken and Cashew Nut stir fry Chicken and cashew nut stir fry 1 cup = 253g Chicken, tenderloin Chicken,breast,lean,baked n/a Chicken, thigh, crumbed Chicken,thigh,lean,crumbed,stir-fried n/a Chicken, thighs nfs Chicken,thigh,lean,skin & fat,baked n/a Chicken, whole, bbq Chicken,whole,lean,baked/roasted n/a Chicken, wing, nfs Chicken,wing,lean,grilled/bbq n/a Chicken, wing, marinated Chicken,wing,lean,marinated,grilled/BBQ n/a Chickpea Chickpea,canned in brine,drained n/a Chickpeas, roasted, salted Chic Nuts Individual packet = 25g = approx 0.25 cup Chicory Chicory,boiled,drained n/a Chilli Chilli (chili),red,raw n/a Chilli Con Carne, beef Beef,stew with kidney beans,chilli con carne n/a Chilli flakes Chillies,dried,ground n/a Prawns, chilli Prawn,garlic,king,home prepared n/a Omelette,w prawn & vegetables,Chinese restaurant Chinese prawn based dish, nfs style 2 egg omelette Chinese steamed buns (Mantou) Bun,no dried fruit,uniced Use no. of buns Beef,stir fry,chow mein (beef & noodles),Chinese 1 cup =253g (Using beef stir fry and veg to Chinese t/a nfs restaurant style estimate) Chinese, fish and lemon sauce Fish,stew/casserole,simmer sauce,with onion 1 cup= 253g - based on beef curry, 1 cup 1 cup = 20g - based on crisp/chip Chips/ crisps Crisp/chip,potato,nfs potato,unflavoured,salted

Chocolate,after dinner mint Chocolate,other type,with filling,after dinner mint 1 mint = 8g Chocolate, CADBURY PICNIC CADBURY PICNIC 1 share pack size = 19g (calorie king) 1 small bar= 18g. If it is a 'Cadbury Favourite' Chocolate bar nfs Chocolate/chocolate bar,filled,nfs they weigh 9.7g each Chocolate cover nut or dried fruit Dried fruit & nut mix,milk chocolate-coated n/a

Chocolate finger HOME BRAND CHOCOLATE WAFER FINGERS 1 biscuit; 2-layers

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Manual for nutritional data entry – Sheet 1: List of foods

Chocolate fruit and nut Chocolate,milk,with dried fruit & nut n/a 1 piece = 6.6g (based on 1 piece chocolate rum and raisin chocolate rum and raisin Chocolate,milk,with dried fruit & nut). White Chocolate Chocolate,white Chocolate or Dark chocolate nfs Chocolate,dark,high cocoa solids 1 piece (nfs) or 1 block= 250g Chocolate, Kit Kat NESTLE KIT KAT BREAK 1 Kit kat bar is 45g 1 piece nfs or 1 block= 250g. 1 Lindt ball = Chocolate, milk Chocolate,milk,with added milk solids approx 9g Chocolate,milk,with added milk solids (then select Chocolate, milk, freddo freddo from quantity list) n/a Bar,nougat,caramel & peanut centre,milk chocolate- Chocolate, snickers bar coated n/a Chocolate, with nuts Chocolate,milk,with nuts n/a Chocolate, Smarties or MnMs NESTLE SMARTIES fun size = 13g per pack 1 piece equal 6.6g (based on 1 piece Chocolate coated ginger Chocolate coated ginger Chocolate,milk,with dried fruit & nut) Choko Choko,peeled,boiled,drained n/a Chop (meat) nfs Lamb,loin chop,lean,grilled n/a Chorizo Sausage,pork,cooked,nfs n/a Choy sam Cabbage,bok choy,stir-fried without oil n/a Chutney, nfs Chutney,fruit,commercial n/a Clam/Pippy/Cockle/shellfish Clam,boiled un unsalted water n/a Apple cider Cider,apple,non-alcoholic n/a Apple Cider Alcoholic Cider Alcoholic 1ml = 1g (based on Cider, apple non alcoholic) Cinnamon Cinnamon,ground Club meal, roast of the day Meat,baked,nfs n/a Cocoa, powder Cocoa powder Coco pops KELLOGGS COCO POPS n/a Coconut,cream Coconut,cream n/a Coffee nfs Coffee,from instant coffee powder,no milk n/a 428

Manual for nutritional data entry – Sheet 1: List of foods

Beverage,from coffee,drinking chocolate & regular fat Coffee, mocha style milk,mocha/mochaccino style 1 cup = 180mL based on 1 standard cup Only use this option when unable to determine how Coffee, skim milk Coffee,from instant coffee powder,with skim milk much milk bought across a week. Only use this option when unable to determine how much milk bought across a week. Individual sachet Coffee, reduced fat milk Coffee,from instant coffee powder,w reduced fat milk 15g.

Coffee,from ground coffee beans,cappuccino,latte/flat Coffee, cappucino, regular milk white style,w regular fat milk n/a

Coffee,from ground coffee beans,cappuccino,latte/flat Coffee, cappucino, light milk white style,w reduced fat milk n/a Coffee,from ground coffee beans,espresso style,no Coffee, espresso milk n/a Coffee,from espresso coffee,regular fat milk,ice & Coffee, iced sugar,iced coffee style n/a

Coke (size ns) MCDONALDS,SOFT DRINK,COCA COLA,MEDIUM n/a Cone, Ice cream Cone,wafer style,for ice cream n/a Congee Rice porridge (congee),cooked n/a

Continetal pasta pack nfs CONTINENTAL INSTANT CHEESE SAUCE (40G) n/a Note: this is cordial base without water. Use Cordial, nfs Cordial base,25% citrus fruit juice no. of tablespoons or juice model.

Cordial,diet Cordial base,25% citrus fruit juice,intense sweetened n/a cordial citrus diluted. Cordial,25% citrus fruit juice,recommended dilution Corn Sweetcorn,frozen,boiled,drained n/a Corn, canned Sweetcorn,canned in brine,drained 1 can= 125g (small) Corn chip Corn chip,toasted,unflavoured,unsalted n/a

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Corn, cob Sweetcorn,fresh on cob,boiled,drained 1 medium ear Corn, creamed Sweetcorn,creamed,canned,heated n/a Corn Fritter Corn fritter,homemade n/a REAL FOODS CORN THINS ORIGINAL (97% FAT Corn, thins/cakes/crackers FREE) (5.8G) 1 thin = approx 5.8g Cornetto ice cream Ice cream,vanilla,regular fat,with wafer cone Cone=122g Cornflakes COLES CORNFLAKES n/a Cottage pie Pie,meat,with potato topping 1 cup = 152g Couscous nfs Couscous, boiled without added salt n/a Crab, nfs Crab,various types,fresh only,boiled/steamed n/a Cracker, premium LANES CRACKER PREMIUM 98% FF n/a Japanese Rice Crackers Japanese rice crackers 0.5 cup = 32g, based on THIS = THAT book. 1 cranberry= 1.4g - based on weight of a Craisin/Cranberry Cranberry,dried,sweetened sultana

Cream nfs Cream,regular thickened,35% fat Cream, light, regular thickened Cream,regular thickened,light (~18% fat) n/a Cream, sour Cream,sour n/a Cream,whipped Cream,whipped,aerosol,regular fat (~28%) n/a Creamed rice HEINZ CREAMED RICE VANILLA n/a Creme brulee DIVINE CLASSIC CARAMEL CREME (150G) n/a Crème caramel DIVINE CLASSIC CARAMEL CREME (150G) n/a Crepe, plain Pancake,plain,homemade n/a Croissant,plain Croissant,plain 1 med ~12-15cm Croissant,chocolate filled Croissant,chocolate filled n/a 1 croissant filled with cheese and ham = 90g Croissant,cheese & ham filled Croissant,cheese & ham filled according to Calorie King Crumbed cutlet/meat Meat,crumbed,fried,ns oil,nfs n/a Crumble, fruit, nfs Crumble,apple 1 cup = 266g according to calorie king

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Manual for nutritional data entry – Sheet 1: List of foods

Crumpets Crumpet,from white flour,toasted Crumpet, round Crunchy nut cornflakes KELLOGGS CORN FLAKES CRUNCHY NUT n/a Cruskits, Light ARNOTTS CRUSKITS 98% FF Use no. of crispbread Cucumber Cucumber,common,unpeeled,raw Whole=262g Cupcake Cake,cupcake,iced,commercial n/a Curry, nfs Beef,curry,tandoori,home prepared n/a

Curry, beef nfs Beef,curry,prepared w curry powder,onions & stock n/a Curry, beef, Indian Beef,curry,vindaloo,Indian restaurant style 1 cup= 253g - based on beef curry, 1 cup Beef,curry,coconut cream,Vietnamese restaurant Curry, beef, Vietnamese style coconut style 1 cup = 253g based on 1 cup of beef curry Chicken,curry,korma,home prepared w purchased Curry, chicken, homemade/nfs sauce 1 cup= 253g - based on beef curry, 1 cup Curry, chicken, tikka masala Chicken,curry,tikka,Indian restaurant style 1 cup= 253g - based on beef curry, 1 cup Curry, chickpea/lentils/legumes Curry,legume (dhal),Indian restaurant style n/a Curry, fish Fish,curry,made with curry powder 1 cup= 253g - based on beef curry, 1 cup

Curry, lamb Lamb,curry,prepared w curry powder,onions & stock n/a

Pork curry Beef,curry,prepared w curry powder,onions & stock Curry, prawns Prawn,curry,tandoori style n/a Curry,mixed vegetables (cauliflower & Curry, vegetable mushroom),Tandoori n/a Curry,mixed vegetables,made w curry paste & Curry, vegetable, Thai coconut milk n/a curry puff Curry puff,beef,deep-fried in oil 1 curry puff = 1 serving Custard nfs Custard,dairy,vanilla,regular fat,commercial n/a DAIRY FARMERS TRIO FLAVOURED CUSTARD Custard, banana BANANA (100G) n/a Custard, low/reduced fat Custard,dairy,vanilla,reduced fat,commercial n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Custard, sago Pudding, nfs n/a Dairy soft, devondale DEVONDALE DAIRY SOFT n/a Danish pastry Danish style pastry,custard & fruit filled n/a Date Date,dried Date loaf BAKERS DELIGHT COFFEE & DATE ROLL n/a Dessert, apple pie/streudel nfs Pie,apple,commercial,family size,RTE 1 small (eg nanas mini= 125g) Dessert, apple turnover Turnover, Apple 1 medium ~120g, based on calorieKing Whole cake is 410g from Woolworths. 8 slices Dessert, bavarian Dessert,bavarian cream,vanilla flavoured per cake. 1 slice = 51.25g. Dessert, nfs eg at club Pie,apple,commercial,family size,RTE n/a Dessert, Trifle, homemade Trifle,homemade Use cups etc Devon/luncheon Devon/fritz,processed luncheon meat n/a Dhal Curry,legume (dhal),Indian restaurant style n/a Dim sim Dim sim,meat & vegetable filling,deep fried n/a Dinner Winner, nfs (frozen meal) Pasta bolognese,Italian restaurant style 1 frozen meal Dip, nfs Dip,nfs 1 cup =260g (using hommus 1 cup) Dip, Capsicum Dip, Capsicum 1 cup = 260g (using hommus 1 cup) Dip, Chilli and nut Dip, Chilli and nut 1 cup = 260g (using hommus 1 cup) Dip, eggplant, Baba Ganoush Dip,eggplant n/a Beetroot and Almond dip Beetroot and Almond dip 1 tb = 21g (based on wt of 1 tb of hummus) Dip, Taramasalata Dip, Taramasalata 1 commercial Tub of dip = 250g or use Tb Dip,Tzatziki Dip,cucumber & yoghurt,Indian restaurant style n/a Vine leaf,stuffed w rice & tomato,Lebanese restaurant Dolmade (vine leaf stuffed with rice) style Use roll option Doughnut nfs Doughnut,iced (non-chocolate) Use no. of doughnuts Wendy's cinnamon donut ~50g/donut as per Donut, with cinnamon and sugar Doughnut,dusted with cinnamon & sugar website Dressing, french Dressing,french,regular,homemade n/a Dressing, nfs Dressing,commercial,nfs n/a

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Dressing,italian,regular,commercial Dressing,italian,regular,commercial n/a Dressing creamy Dressing,cream style,home-made

Berries,mixed Dried berries eg Gogi berry (strawberry,raspberry,blueberry,blackberry),dried 1 cup = 170g (Using sultanas 1 cup weight) Dry Bean Casserole Dry Bean casserole 1 cup= 253g- based on beef curry, 1 cup Duck, nfs Duck,lean,stewed/casseroled n/a Duck,battered,w sweet & sour sauce,Chinese 1 cup = 253g (based on weight of 1 cup of beef stir Duck sweet and sour restaurant style fry). BBQ duck Duck,lean,skin & fat,baked/roasted Dumpling, no filling Dumpling, no filling 1 bread dumpling = 100g according to calorie king Easiyo yoghurt Yoghurt,natural,regular fat (~4%) n/a Éclair,chocolate Eclair,chocolate,iced,cream/custard filling 1 large = 240g (calorie king) Egg, nfs Egg,chicken,whole,cooked,nfs n/a Egg, boiled Egg,chicken,whole,hard-boiled n/a Egg, curried Egg,hardboiled,in curry flavoured white sauce Use no of mashed eggs as s/w filling Egg, fried Egg,chicken,whole,hard-boiled n/a Egg, poached Egg,chicken,whole,poached Egg, scrambled Egg,chicken,scrambled,cooked without fat Egg white (albumen) only,raw Egg,chicken,white (albumen) only,raw n/a Eggplant Eggplant,grilled 1 cup= 101g Endive Endive,raw n/a Energy Drink, nfs V ENERGY DRINK 350mL standard can Enprocal Enprocal based on 100g. 1 serve is 35g. Ensure Ensure Ensure Plus Ensure Plus Escargot/snails Clam,boiled in unsalted water Fennel, cooked Fennel bulb, boiled, drained n/a Fennel,raw Fennel,bulb,raw n/a Ferrero Rocher chocolate (piece) Chocolate,milk,with nuts n/a

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Fish, ball, Asian Fish ball,Asian style,raw n/a Fish, barramundi Barramundi,aquacultured fillets,baked/grilled n/a Fish, bassa nfs Bassa (basa),baked/grilled n/a Fish, battered Fish,battered,frozen,baked,nfs n/a Fish, bream Bream,flesh,steamed n/a Fish,cocktail size,battered,deep fried,purchased Fish cocktails from takeaway shop RTE,nfs use fish cocktail option Fish, crumbed Silver perch,aquacultured,crumbed,fried,olive oil n/a Catfish Silver perch,aquacultured,steamed/poached Fish, dory Trevally,dory,ling,cod,flounder/sole,baked/grilled n/a Fish, smoked cod Cod,smoked,steamed/poached Fish, finger nfs Fish finger,crumbed,frozen,baked/roasted n/a Fish, flathead nfs Flathead,flesh only,baked/grilled n/a Fish, frozen fillets Fish,fillet,frozen,glazed & flavoured,baked n/a Fish, herring Silver perch,aquacultured,baked/grilled Fish, herring, pickled, tinned Fish, Herring, Pickled, Tinned 1 tin = 110g Fish, hoki Blue grenadier (hoki),baked n/a Fish, leather jacket Silver perch,aquacultured,baked/grilled n/a

Kippers Kippers 1 tin = 200g Three quarters of the meatloaf model makes up 75g Fish, Mackerel,nfs Mackerel, Canned in Brine, Drained of mackerel steak (based on THIS=THAT) Marinara mix,w fish & Fish, marinara shellfish,fresh,poached/steamed n/a Fish roe (caviar),black Fish roe (caviar),black n/a Fish, salmon nfs Salmon,Atlantic,fillet,grilled Medium Steak

Fish, salmon patties/cake Fish cake,contains salmon,crumbed,frozen,baked n/a Fish, salmon, crumbed Salmon,Atlantic,crumbed,baked/grilled n/a

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Fish, salmon, fried Salmon,Atlantic,fillet,fried,olive oil n/a Fish, salmon, smoked Salmon,smoked,sliced Use slice option (12x8cm) Fish, salmon, canned Salmon,canned,drained,nfs n/a Fish, sardines Sardine,canned in tomato sauce,undrained 1 sardine = 15g (Ausnut 2013) sardines, canned in oil Sardine, canned in olive oil Usually 105g tin Fish, shark nfs Shark (flake),skinless fillet,baked/grilled n/a Fish, snapper nfs Snapper,flesh,steamed n/a Fish, sword Fish, sword Average fillet weight 150g according to Calorie King Fish, trout nfs Trout,rainbow,aquacultured,baked/grilled n/a Casserole / Stew, fish Fish,stew/casserole,simmer sauce,with onion 1 cup= 253g - based on beef curry, 1 cup Fish, whiting Whiting,king george,flesh only,steamed n/a Fish/Tuna, canned in oil Tuna,canned in vegetable oil n/a Fish/Tuna, canned Tuna,canned in brine,drained 1 sml can/ 1 lg can Tuna, flavoured Tuna,flavoured,canned in oil,drained Tuna, canned in water Tuna,canned in water,drained Use can 95g

Fish/Tuna, yellowfin steak grilled Tuna,yellowfin steaks,grilled/barbecued w olive oil n/a use fish model or tin, (base weight on Tuna canned Smoked Tuna Smoked Tuna in oil, drained. Flummery, fromage, fruche PETIT MIAM FROMAGE BERRY TUBES 1 tub = 60g 1 slice = 73g (1/4 of Bakers deligjht turkish bread, based on focaccia /turkish style bread, savoury,w Focaccia Mediterranean Focaccia mediterranean cheese toasted). Fortune Cookie Biscuit,sweet,plain n/a Fortisip, Nutricia Fortisip, Nutricia French dressing Dressing,french,regular,commercial n/a French toast French toast,plain n/a Fresh fruit nfs /bowl Fruit,fresh,nfs n/a Rice,fried,w meat,seafood,egg & vegetables,Chinese Fried rice/ Asian Meal, based on rice restaurant style 1 cup= 209g

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Manual for nutritional data entry – Sheet 1: List of foods

Omelette,w prawn & vegetables,Chinese restaurant Frittata nfs style n/a Beef,stew/casserole,tomato sauce & vegetables Frozen beef meal including potato n/a Chicken,stew/casserole,tomato sauce,vegetables Frozen chicken meal including potato n/a Frozen meal, nfs LEAN CUISINE NZ HOKI MEAL (180G) n/a On the Menu Frozen Meals Beef Lasagne On the Menu Frozen Meals Beef Lasagne 1 Serve = 260g On The Menu Frozen Meals Prawn Alfredo On The Menu Frozen Meals Prawn Alfredo 1 Serve = 260g On the Menu Frozen Meals Spaghetti and Meatballs On the Menu Frozen Meals Spaghetti and Meatballs 1 Serve = 260g Nuts,mixed (peanut,cashew,hazelnut,brazil nut),w Fruit and nut mix dried fruit n/a Fruit Roll BAKERS DELIGHT CAPE FRUIT & NUT ROLL 87g=1 serve/roll Large tin= 825g (Based on Goulbourn Valley Fruit salad, fresh Fruit salad,fresh,commercial,with melon Fruit salad tins) Fruit salad/tinned fruit/ fruit nfs Fruit salad,canned in syrup Use food models or ask to see tin Fruit, apple Apple,red skin,unpeeled,raw 1 medium (6-8cm dia) Fruit, apple, peeled Apple,red skin,peeled,raw 1 medium (6-8cm dia) Fruit, apricot, canned Apricot,canned in light syrup,drained n/a fruit drink nfs Fruit drink,25% orange juice Fruit, mixed, dried Mixed fruit,dried n/a Fruit, Fig Fig,unpeeled,raw Use medium option Fig,dried Fig,dried Fruit, passion Passionfruit,raw n/a Fruit, pie fruit nfs Pie,apple,commercial,family size,RTE Fruit, puree tub Fruit puree,apple & strawberry 1 tub =140g (Goulbour valley fruit tub) Fruit, stoned nfs Peach,fresh,unpeeled,raw Use medium Fudge, nfs Fudge,caramel-flavoured Use cake slice model Persimmon Persimmon,peeled,raw n/a

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Manual for nutritional data entry – Sheet 1: List of foods

1 cup = 190g based on beans, cooked. Note 0.5 cup Curry, legume (dhal), Indian restaurant style is Ful Medames Ful Medames a very similar amount). Gai lan (chinese broccoli) Broccoli,fresh,boiled,drained n/a Garlic Garlic,peeled,raw n/a Gatorade, sport drink (600ml) GATORADE SPORT DRINK LEMON LIME n/a Gelato Gelato,various flavours,commercial n/a Gherkin,pickled,drained,commercial Pickled cucumber n/a Ginger,peeled,raw Ginger,peeled,raw n/a Ginger, preserved Ginger,crystallised,sweetened & preserved Use no. of pieces Bundaberg ginger Beer Ginger beer Usually 375ml bottles Glucose Powder Glucose Powder 1 Tb = 11g based on 1 Tb of Sugar,white,icing Gnocchi Gnocchi,potato,boiled n/a Goat Meat, cooked, nfs n/a 1 cup = 253g (using beef, stew/casserole, gravy 1 Goat Casserole/Stew nfs Stew, Goat, with tomato based sauce, Homemade cup = 253g). Goji berries Goji Berries 1 tsp = 3.22g based on 1 tsp of cranberries Golden syrup Syrup,golden Beef,stew/casserole,tomato sauce & vegetables Goulash including potato 1 cup= 253g - based on beef curry, 1 cup Gow Gee/dumpling (Asian) Dumpling,meat filled,Chinese style Use no. of dumplings Pastry,spinach & cheese filling (spanakopita),Greek Gozleme spinach and cheese style,RTE Use lasagne model. Biscuit,savoury crispbread,white & wholemeal wheat Grain wave flour w grains & seeds n/a Grape Grape,raw,nfs 84g (15 grapes) (Based on food model) Grapefruit Grapefruit,peeled,raw n/a Guacamole Dip,guacamole (avocado),homemade n/a Guava nectar GOLDEN CIRCLE JUICE GUAVA NECTAR n/a Guava,pulp,canned Guava,pulp,canned n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Halvah, sweet, treat Halvah,plain n/a Use food model or ask to see can size. Plum Rose Ham, leg, canned Ham,leg,canned,lean & fat brand is 200g. Ham, cold Ham,leg,non-canned,lean & fat n/a Ham, prosciutto, cured ham Ham,prosciutto/parma style,raw Hamburger,beef pattie w cheese,lettuce,onion & Hamburger, nfs sauce,takeaway style Enter as no. of burgers Hand roll Sushi,California,roll,restaurant style n/a Hard candy (werthers orig) Sugar confectionery,hard varieties n/a 28 g based on 1 slice of Devon/fritz,processed Headcheese (Braun) Headcheese (Braun) luncheon meat Healthy Choice Chicken Cabanara Healthy Choice Chicken Cabanara 1 x healthy choice in as 1 serve. Herb, nfs Mixed herbs,fresh 1 tb= 12.6g (Using parsley 1 tb). 1 cup = 31.5g Highland Oatcakes Biscuit,sweet,oatmeal n/a

Hommus Dip,hommus (hoummous/hummous),Lebanese style n/a Honey, nfs Honey n/a Bar,honeycomb centre,chocolate-coated Bar,honeycomb centre,chocolate-coated 1 piece = 12g according to Calorie King Chicken, battered w lemon/honey sauce, Chinese Chicken, honey restaurant style n/a Beverage,drinking chocolate,from chocolate powder & Hot chocolate nfs liquid,nfs n/a Hot cross bun Bun/scroll,with dried fruit,iced Use no of scrolls

Ice block Ice confection,stick,frozen,water-based,flavoured 1 stick

Ice cream,regular fat,neopolitan flavour 1L =550g, Using 'Ice cream,reduced fat,vanilla Ice cream, nfs (vanilla,strawberry & chocolate) & other non-chocolate flavours' Use 1 stick; Woolworth's Choc Coated Ice Ice cream, choc coated Ice cream,stick,vanilla,chocolate coated Cream Bar Icrecream, Golden Gaytime STREETS GOLDEN GAYTIME 1 serving

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Manual for nutritional data entry – Sheet 1: List of foods

Ice cream,regular fat,vanilla,w fruit based ice Ice cream with fruit base (Weis or Fruttare) confection Look at packaging or look up. Ice cream,reduced fat,neopolitan flavour Ice cream, light/reduced fat (vanilla,strawberry & chocolate) n/a

Ice cream, low fat/low sugar Ice cream,reduced fat,vanilla,low carbohydrate (~ 5%) 1 large scoop = 46g

Ice cream, vanilla, light/reduced fat Ice cream,reduced fat,vanilla,low carbohydrate (~ 5%) n/a Ice cream, with cone Ice cream,vanilla,regular fat,with wafer cone n/a Ice confection,non-dairy (soy),regular Ice cream, Soy fat,chocolate,added vitamins & minerals Use no. of scoops Indian takeaway nfs Chicken,curry,tandoori,Indian restaurant style n/a Italian takeaway nfs Pasta bolognese,Italian restaurant style n/a Jam, nfs Jam,all flavours,intense sweetened n/a Jam, unsweetened Jam,all flavours,reduced sugar n/a Jelly prepared Jelly,made up,all flavours,sugar sweetened n/a 1 cup = 265g (based on 1 cup of Jelly made up, all Jelly Lite Jelly lite flavours, sugar sweetened).

Jelly, with fruit Jelly,made up,all flavours,sugar sweetened,w fruit n/a

Juice , lemon, sweet Juice,lemon,home squeezed,added water & sugar n/a Juice, Charlie's Old Fashioned Lemonade Charlie's Old Fashioned Lemonade Honest Quencher Honest Quencher Chilled Chilled 100ml = 100g according to Coles website Juice, lemon Juice,lemon n/a Juice nfs Juice,orange,home squeezed n/a Juice, apple Juice,apple,home squeezed n/a juice, aloe vera, ready to drink juice, aloe vera, ready to drink Using 1 cup = 250ml, 1g ~ 1ml (liquid)

Juice, apple & mango Fruit drink,20% apple & 5% mango juice n/a Juice, apple and blackcurrant Juice,94% apple & 6% blackcurrant n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Juice, apple and pear BERRI JUICE APPLE PEAR n/a Juice, blackcurrant Juice,blackcurrant n/a Juice, cranberry Fruit drink,cranberry juice n/a Juice, grape Juice, grape n/a juice, grapefruit, nfs juice, grapefruit Juice, mango nfs (enter half of serve recorded and half of water) Mango,pulp,canned n/a Juice, Mango Nectar GOLDEN CIRCLE JUICE MANGO NECTAR n/a Juice, orange & mango COLES JUICE ORANGE & MANGO n/a Juice, orange nfs Juice,orange,home squeezed n/a Juice, Fruit drink,25% orange juice Fruit drink,25% orange juice n/a Juice, pineapple Juice,pineapple,home squeezed,added water n/a Juice, Tomato, nfs Juice,tomato,salted,sweetened Prune, juice Juice,prune n/a V8 JUICE FRUIT VEGETABLE APPLE CARROT Vegetable and fruit juice, nfs GINGER Juice,tropical (pineapple,orange,apple,pear & Juice, tropical passionfruit juices) n/a Just Juice JUST JUICE ORANGE 100% NAS n/a 0.5 cup = 68.5g based on weight of cooked Kale,raw Kale,raw kale Kangaroo, nfs Kangaroo,loin fillet,grilled n/a Kangaroo, sausage Sausage,cooked,nfs n/a Doner kebab,chicken in flat white bread w Kebab, doner /souvlaki lettuce,tomato,onion & sauce n/a Kelloggs cereal nfs KELLOGGS CORN FLAKES n/a KFC,CHICKEN wrap, TWISTER REGULAR (247 G) KFC,CHICKEN,TWISTER REGULAR (247 G) 1 wrap = 247g as per food works database entry

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Manual for nutritional data entry – Sheet 1: List of foods

1 round Kibbeh = 43g (based on wt of 1 Falafel ball, 5 cm in diameter). For flat kibbeh use meat loaf or Kibbeh Kibbeh mince patty models. Kidney,Lamb Kidney, All types, Stewed/Braised Kiwi Kiwifruit,unpeeled,raw n/a Casserole, lamb Lamb,stewed/casseroled,nfs n/a Lamb,stew/casserole,tomato sauce,vegetables Lamb stew with vegetables including potato n/a Lamb, nfs Lamb,cooked,nfs n/a Lamb, rissole Chicken,breast,lean,baked n/a lamb fritters Lamb fritters Enter as 1 serve = 277g 1 small Chop = 30 g, Medium Chop = 45g, Large chop = 60g (bone removed). Use the steak model to help determine the size of the Lamb, chop Lamb,loin chop,lean,grilled chop. Lamb, chump chop Lamb,chump chop,lean,grilled n/a Lamb,crumber Lamb, crumbed Lamb, cutlet Lamb,frenched cutlet/rack,lean,grilled see lamb chop Lamb,forequarter chop Lamb,forequarter chop,lean,grilled 1 large chop bone removed = 94g Lamb, fry Lamb,trim lamb,stir-fry strips,lean,stir fried n/a Lamb, leg Lamb,leg roast,lean,baked/roasted n/a lamb liver Lamb,liver,fried,butter 1 liver is about 225g Lamb, roasted Lamb,trim lamb,mini roast,lean,baked/roasted n/a Lamb, semi-trimmed, cutlet Lamb,frenched cutlet/rack,semi-trimmed,grilled n/a 1= 94g (using lamb,forequarter chop,lean,grilled, large chop(94g, bone Lamb, shank Lamb,easy carve shoulder,lean,baked/roasted removed. lamb, steak Lamb,trim lamb,steaks,lean,grilled n/a Lamb, stewed Lamb,stew/casserole,gravy & onion n/a

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Manual for nutritional data entry – Sheet 1: List of foods

1 cup =253g (Using beef stir fry and veg to Lamb, stir-fry, with vegetable Lamb,stir fry,plum & oyster sauces,mixed vegetables estimate) If unknown 1 slice = 250 g based on 1 serving Lasagne nfs Lasagne,beef,frozen,baked from pack. Lasagne,vegetarian,homemade Lasagne,vegetarian,homemade Use lasagne dish 400g to estimate 1 serve = 22g (as researched by serving sizes of individual packets sold in bulk at woolworths and Le Snack Le Snack coles). Lean Cuisine chicken and pasta Lean Cuisine Creamy Chicken Pasta Bake Ready to eat meal, Lean Cuisine, Atlatic Salmon with Lean cuisine atlantic salmon with pasta pasta Lean Cuisine Spaghetti Bolognaise Lean Cuisine Spaghetti Bolognaise Recipe: So 1 cuisine = 1 serve Le Rice Pudding,rice,vanilla flavoured n/a Lamb,sausage (kafta/kofta),w herbs,Lebanese Lebanese takeaway restaurant style n/a Leek Leek,raw n/a Legumes, nfs Beans,cooked,nfs 1/2 cup =95g based on beans, cooked Lemon sorbet WEIS SORBET LEMON n/a lemon tart Pie,lemon,baked 0.5 cup= 98.5g (using apple pie) Lemon, lime and bitters Soft drink,lemon flavour n/a Lemonade Soft drink,lemonade n/a Chinotto (Italian Soft Drink) Chinotto (Italian Soft Drink) 260 g = 250 mL based on 250 mL of lemonade Lentils nfs Lentil,dried,soaked,boiled,drained n/a Lettuce Lettuce,raw,nfs n/a Lettuce Cooked Lettuce Boiled 0.5 cup = 75g based on 0.5 cup of boiled cabbage Liquorice, Allsorts Licorice,allsorts Use no. of piece (nfs)

Liquorice, licorice Licorice,plain 1 piece (2cm long) Liquor, Clear based Liquor, Clear based 30 mL (1 nip) = 28.5 g based on 30 mL of whisky Lemon liqueur (limoncello) Liquor, Clear based see above

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Manual for nutritional data entry – Sheet 1: List of foods

Breakfast cereal,mixed grain (wheat,corn,oat),clusters,nuts,added vitamins B1,B2 Light n tasty, macadamia & folate & Fe n/a Lite n Easy Roast Beef Lite n Easy Roast Beef Enter as 1 serve = 479g Lite n easy Hearty Beef Casserole Lite n easy Hearty Beef Casserole Enter as 1 serve Lite n Easy Lasagne Lite n Easy Lasagne Enter as 1 serve = 427g Lite n Easy Baked Turkey Lite n Easy Baked Turkey Enter as 1 serve = 468g Lite n easy Butter Chicken Lite n easy Butter Chicken Enter as 1 serve =425g Lite n Easy Chargrilled Steak and Pepper Sauce Lite n Easy Chargrilled Steak and Pepper Sauce Enter as 1 serve = 448g Lite n Easy Chicken Dijon Lite n Easy Chicken Dijon Enter as 1 serve = 435g Lite n Easy Chicken in Sweet and Sour Sauce Lite n Easy Chicken in Sweet and Sour Sauce Enter as 1 serve = 440g Lite n Easy Malay Beef Curry Lite n Easy Malay Beef Curry Enter as 1 serve = 420g Lite n Easy Roast Lamb Lite n Easy Roast Lamb Enter as 1 serve = 426g Lite n Easy Spaghetti Marinara Lite n Easy Spaghetti Marinara Enter as 1 serve = 403g Lite n Easy Mac & Cheese Lite n Easy Mac & Cheese 1 Serve = 1 meal Lite n Easy Honey Soy Chicken Lite n Easy Honey Soy Chicken 1 Serve = 1 Meal Lite n Easy Fried Rice and BBQ Chicken Lite n Easy Fried Rice and BBQ Chicken 1 serve = meal Lite n Easy Nasi Goreng with Chicken balls. Lite n Easy Nasi Goreng with Chicken balls. 1 Serve = 1 Meal Lite n Easy Chicken in Satay Sauce Lite n Easy Chicken in Satay Sauce 1 Serve = 1 Meal Lite n Easy Sausages with Onion Gravy Lite n Easy Sausages with Onion Gravy 1 Serve = 1 Meal Lite n Easy Sausages with Onion Gravy Lite n Easy Sausages with Onion Gravy 1 Serve = 1 Meal Use medium size (unless can give weight, cups, tb lobster Lobster,purchased steamed/boiled etc). 1 piece = 3.8g based on 1 piece of Sugar Lolly, soft, sugar free Lolly, soft, sugar free confectionery,jelly varieties

Macaroni cheese Macaroni cheese,homemade from basic ingredients n/a Magnum mini STREETS MAGNUM CLASSIC MINI SIZE Use "1 stick mini" (48g) Magnum mini or normal sized STREETS MAGNUM CLASSIC MINI SIZE Use "1 stick mini" (48g) 1 large = 91g Malt Beverage base,malted milk powder,unfortified n/a Mandarin Mandarin (imperial),peeled,raw n/a

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Mandarin canned Mandarin, canned in syrup, drained n/a Mango Mango,peeled,raw Use no. of mangoes

Mango, canned in light syrup Mango, canned in light syrup AUSNUT (all foods) Mango pudding Pudding,rice,with mango n/a Margarine , logical MEADOW LEA LOGICOL SPREAD n/a Margarine nfs Margarine spread,nfs n/a Margarine, canola HOMEBRAND MARG CANOLA n/a Margarine, canola (flora) FLORA SPREAD CANOLA n/a Margarine, flora nfs FLORA SPREAD ORIGINAL n/a Margarine Light FLORA SPREAD LIGHT (40% LESS FAT) n/a Heart plus Maragarine FLORA PRO ACTIV MARG Margarine, meadow lea, reduced fat MEADOW LEA MARG LITE RED FAT n/a Margarine, meadowlea nfs MEADOW LEA MARG n/a Margarine, olive nfs OLIVE GROVE MARG OLIVE OIL n/a Margarine, polyunsaturated Margarine spread,polyunsaturated,nfs n/a Margarine, pro active FLORA PRO ACTIV MARG n/a Margarine, reduced salt Margarine spread,reduced salt,nfs n/a Margarine, sunflower FLORA MARG SUNFLOWER LIGHT n/a margarine light and salted reduced Margarine spread,regular fat & salt,nfs n/a Marmalade, nfs Marmalade,orange,preserve n/a

Mars bar Bar,nougat & caramel centre,milk chocolate-coated Fun size = 18g Marshmallow,plain/flavoured Marshmallow,plain/flavoured 1 piece = 5g according to Calorie King Mayonnese nfs Mayonnaise,commercial,nfs n/a Mayonnese, light/ reduced fat Mayonnaise,low fat,commercial n/a

Mayonnaise homemade from condensed milk Mayonnaise,condensed milk-based,homemade n/a

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Manual for nutritional data entry – Sheet 1: List of foods

McCains Healthy Choice Apricot Chicken McCains Healthy Choice Apricot Chicken 1 serve = 350g Mccain Butter chicken Mccain Butter chicken 1 serve Mccain Roast Chicken Mccain Roast Chicken 1 serve = 320g

Beef,stew/casserole,gravy + Vegetarian protein,stew/casserole,in tomato sauce,w vegetables McCain Steak diane (including potato) + Rice,white,boiled with added salt Total= 320g ie 107g of each McCain Lamb cutlet and gravy (find in New recipe Always put in as 1 Serve (unless they have more McCain Lamb cutlet and gravy (Recipe) folder) than 1 pre-packed meal) Always put in as 1 Serve (unless they have more McCain Veal Cordon Bleu (Recipe) McCain Veal Cordon Bleu (find in New Recipe folder) than 1 pre-packed meal) McCain Roast Beef (Recipe) McCain Roast Beef Recipe McCains Roast lamb (Recipe) McCains Roast lamb Use 1 Serve

McCain Chicken Parmagiana McCain Chicken Parmagiana Recipe McCain Roast Turkey Dinner McCain Roast Turkey Dinner 1 meal = 320g McDonalds Crispy Chicken Salad McDonalds Crispy Chicken Salad 1 salad serve = 341g according to the website McDonalds Grand Angus Burger McDonalds Grand Angus Burger 1 burger = 260g MCDONALDS,BURGER,BIG MAC (201 G) MCDONALDS,BURGER,BIG MAC (201 G) 1 burger; McDonalds Burger Big Mac MCDONALDS,BURGER,CHEESEBURGER (110 G) MCDONALDS,BURGER,CHEESEBURGER (110 G) 1 burger; McDonalds Burger Cheeseburger MCDONALDS,FRENCH FRIES,SMALL (72 G) MCDONALDS,FRENCH FRIES,SMALL (72 G) 1 serving; small, McDonalds French Fries MCDONALDS,BURGER,QUARTER MCDONALDS,BURGER,QUARTER POUNDER (205 POUNDER (205 G) G) 1 burger = 205g Meal replacement, Isagenix Isagenix Isalean Pro Meat Brawn Brawn,processed meat Use model. It looks like spam or processed meat. Meat bun (Asian) Dumpling,meat filled,Chinese style n/a Bun, Pork Bun, Pork CalorieKing estimates 1 bun = 100g Meat with vegetables soup/chunky canned Soup,meat (beef/lamb/pork),w vegetables,prepared w soup water n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Meat, minced nfs Meat (beef,chicken,lamb,pork),mince,cooked,nfs n/a Meat, red nfs Beef,rump steak,lean,grilled n/a Meat, roast nfs Meat,baked,nfs n/a 2 meatball = 86g. Based on 2 meatball with Meatballs nfs Meatballs,beef,fried,ns oil,nfs sauce Meatloaf nfs Meatloaf,beef,with breadcrumbs & vegetables Melon, honey dew Melon,honey dew,white skin,peeled,raw 1 wedge (1/8 of 13cm dia melon) Melon, nfs Melon,rockmelon (cantaloupe),peeled,raw 1 medium slice Meringue, lemon Pie,lemon meringue,baked n/a Milk, A2, Light A2 FRESH LITE MILK n/a milk, almond Almond milk,with linseed oil & water Milk, powder Milk,powder,cow,regular n/a Milk, powder, skim Milk,powder,cow,skim n/a Milk, chocolate flavoured or flavoured nfs Milk,cow,fluid,flavoured,chocolate,regular fat n/a Milk, condensed nfs Milk,canned,sweetened,condensed,regular n/a Milk, dairy famers, light white DAIRY FARMERS LITE WHITE FRESH n/a milk, goat, nfs Milk,goat,fluid Milk, lactose free, nfs ZYMIL LACTOSE FREE LOW FAT FRESH n/a Milk, light/reduced fat Milk,cow,fluid,reduced fat (~1%) n/a Milk, regular Milk,cow,fluid,regular fat (~3.5%) n/a Milk, semi skim DEVONDALE SEMI SKIM 2% FAT FRESH n/a Milk, skim Milk,cow,fluid,skim (~0.15% fat) n/a Milk, smart nfs PAULS SMARTER WHITE MILK n/a Milk, soy, light/ reduced fat/skim SOY LIFE FRESH SOY LOW FAT FRESH n/a Milk, soy, regular SOY LIFE MILK FRESH NATURAL FRESH n/a milk,farmers best, omega 3 FARMERS BEST OMEGA 3 FRESH n/a Milk, Heart Active PURA HEART ACTIVE MILK 99% FAT FREE n/a

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Milkshake,home made,chocolate flavour,regular fat 1 serve = 300ml - based on Milkshake,cafe Milkshake cow milk style,chocolate flavour,regular fat cow milk Millet meal Millet,raw n/a Milo NESTLE MILO n/a

Mince, curry Meat (beef,chicken,lamb,pork),mince,cooked,nfs n/a Mince, reduced fat Beef,mince,low fat,dry fried n/a Mineral water Water,mineral,natural,unflavoured n/a

Mint jelly Sauce,mint n/a Mentos tube is 37.5g (14 in a pack = 2.7g each), mint, lolly, nfs Sugar confectionery,mint flavoured,hard & chewy Minties are 6.7g per piece 1 cup = 253g (using beef stir fry with veges to Mixed Seafood StirFry Mixed Seafood StirFry estimate). Mongolian Lamb Lamb, stiry fry Black bean sauce 1 cup = 253g money bags spring rolls

Mortadella nfs or bologna Mortadella,processed meat n/a

Mousse, chocolate Mousse,chocolate,homemade 1 tub= 62g (Based on Nestle choc mouse 1 tub) Lamb,mince & eggplant,w white sauce Use Lasagne dish (400g) to estimate or 1 cup = Moussaka (Greek Lasagne) (moussaka),Greek restaurant style 170g Muesli bar, choc flavour Bar,muesli,chocolate chip n/a Muesli flakes UNCLE TOBYS MUESLI FLAKES PLUS n/a

Muesli nfs Muesli,commercial,toasted,unfortified n/a Muesli,homemade/commercial,bircher Muesli,homemade/commercial,bircher n/a Carman's musei (cereal) CARMANS NATURAL BLEND MUESLI Muesli,commercial,untoasted/natural style,unfortified Muesli, Untoasted

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Muesli, bar, nfs Bar,muesli,uncoated,nfs n/a

Muesli, bar, fruit, chocolate coated Bar,muesli,plain/with dried fruit,chocolate-coated n/a UNCLE TOBYS CRUNCHY MUESLI BAR ORIGINAL Muesli, bar, Uncle tobys (20G) n/a MORNING SUN MUESLI NATURAL APRICOT Muesli, Morning sun nfs ALMOND n/a Muesli,homemade,toasted,added nuts,seeds & dried Muesli, w dried fruit and nuts fruit n/a Muffin nfs Muffin,cake/American style,plain,homemade n/a Muffin, bran Muffin,cake/American style,with bran,uniced n/a Muffin, cheese and bacon Muffin,savoury,with cheese & ham,homemade n/a 1 muffin (2 halves) = approx 62g according to Muffin, English, White Muffin,English-style,from white flour,toasted Calorie King Muffin,cake/American style,w chocolate Muffin, choc chip chips,uniced,homemade n/a Blueberry muffin Muffin,cake/American style,with fruit Fish, mullet Mullet,yelloweye,baked/grilled n/a Fish, mulloway/jewfish Mulloway,fried,ns butter n/a Mushroom, raw Mushroom,common,raw Use no. of medium option Mushroom, steamed Mushroom,common,boiled/steamed n/a Mushrooms, canned in butter sauce Mushroom,common,stir-fried,butter 1 Tbspn = 20 g based on 1 Tbspn of Cream,regular Mushroom Sauce Mushroom Sauce thickened,35% fat Mushroom, in breakfast dish Mushroom,common,stir-fried without oil n/a Mussel Mussel,green,steamed/boiled n/a Mustard Mustard,cream-style,condiment Mustard, horseradish Horseradish,raw n/a Nectarine Nectarine,unpeeled,raw Use medium Nesquik, beverage base NESTLE DAIRY NESQUIK CHOC MILK n/a

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Nestle drumstick NESTLE DRUMSTICK VANILLA 1 drumstick = approx 120 g cup= 136g based on weight of 1 cup of Noodle,wheat,instant,boiled w flavour Noodle nfs Noodle,boiled,nfs sachet,drained Noodle, egg Noodle,wheat,Asian style n/a

Noodles, crunchy, non flavoured Noodle,wheat,instant,uncooked,no flavour sachet n/a Noodles, fried Noodle,wheat,Asian style,fried in ns oil n/a

Noodles, Instant Noodle,wheat,instant,boiled w flavour sachet,drained 85g dry packet Noodles,rice,w prawns & vegetables (pad Thai),Thai Pad Thai restaurant style 1 cup = 253g (based on 1 cup of beef curry). Chicken,stir fry,soy based sauce,hokkien noodle & Chicken noodle (with vegetables) mixed vegetables 1 cup = 253g Beef,stir fry,soy based sauce,hokkien noodle & mixed Beef noodles (with vegetables) vegetables 1 cup = 253g Stir-fry,mixed vegetable (capsicum,carrot,snow pea,bok choy & onion),w wheat noodles & soy-based vegetables and noodles sauce 1 cup = 253g Nougat Nougat,honey & almond n/a Nut, almond Nut,almond,with skin,dry roasted n/a WOOLWORTHS NATURA BAR NUT DELIGHT Nut, bar (50G) n/a Nut, Brazil Nut,brazil,raw/blanched n/a Nut, cashew Nut,cashew,roasted,salted n/a Nut, chestnut roasted Nut,chestnut,roasted Use no. of chestnuts Nut, hazelnut Nut,hazelnut,raw n/a fox nuts mixed nuts n/a Nut, macadamia Nut,macadamia n/a 1 packet nfs: 250g (based on a woolworths Nut, mixed Nuts,mixed (peanut,cashew,hazelnut,brazil nut) packet of nuts)

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Nut, peanut nfs Nut,peanut,no skin,roasted,with oil,unsalted n/a Nut, peanut, salted Nut,peanut,no skin,roasted,with oil,salted n/a Nut, Pecan Nut,pecan,unsalted n/a Nut, pinenut Nut,pine,raw n/a Nut, walnut Nut,walnut,raw n/a NUTRI-GRAIN KELLOGGS NUTRI-GRAIN n/a Nuts nfs Nuts,mixed (peanut,cashew,hazelnut,brazil nut) n/a NUTMEAT Nutrients manually entered NUTOLENE Nutrients manually entered Nuttelex NUTTELEX MARG POLYUNSAT 500G n/a Oat bran Oats,bran,unprocessed n/a Oat flakes UNCLE TOBYS OAT FLAKES n/a Oats nfs Porridge,rolled oats,nfs 1 tb = 7.6 g (raw) Oats, Uncle tobys UNCLE TOBYS TRADITIONAL OATS 40g makes 1c of porridge Octopus Squid/calamari,baked/grilled n/a Oil, nfs Oil,nfs n/a Avocado oil Avocado oil 1 tb = 18.2g. 1ml - 0.91g (based on olive oil). oil,almond Oil,monounsaturated,nfs oil,cotton Soybean oil Oil, Coconut Oil, Coconut Base quantities off olive oil pure 1tb = 18.2g Oil, olive nfs Oil,olive,pure n/a Oil, grapeseed Oil,grapeseed n/a Oil, vegetable Oil,blended,polyunsaturated vegetable oils n/a Oil, linseed/flaxseed Oil,linseed/flaxseed n/a Oil, mustard seed Oil,blended,polyunsaturated vegetable oils n/a Oil, palm Oil,palm n/a Oil, peanut Oil,peanut n/a Oil,sesame Oil,sesame Use measurements from database

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Manual for nutritional data entry – Sheet 1: List of foods

Oil, sunflower Oil,sunflower n/a Olives, nfs Olive,green/black,drained Use no. of olives or measurements (cups etc) Olive,green,pimento stuffed,drained Olive,green,pimento stuffed,drained Use no of Olives Okra, boiled, drained Okra,boiled,drained Use measurements from database Omelette nfs or potato omelette Omelette,chicken egg,cooked with fat n/a Onion Onion,mature,white skinned,peeled,raw n/a Onion rings , fried Onion,bhaji,deep-fried n/a Onion, roasted/baked Onion,mature,peeled,baked,nfs Use no. of onions Onion, red Onion,mature,peeled,raw,nfs n/a Onion, spring Onion,spring,raw n/a Onion,mature,peeled,stir-fried Onion,mature,peeled,stir-fried without oil,nfs n/a Optifast- milkshake Nutrients manually entered (chocolate) Optifast, mixed veg soup Nutrients manually entered Orange Orange,navel (all varieties),peeled,raw n/a Osso Bucco (veal) Veal,leg steak,untrimmed,stewed/casseroled n/a Ouzo (Greek Spirit) Ouzo (Greek Spirit) 30 mL (1 nip) = 28.5 g based on 30 mL of whisky Beverage base,chocolate flavour,added iron & Ovaltine, beverage base vitamins (Ovaltine brand) n/a ox tail beef tails simmered n/a Oyster, nfs Oyster,baked/grilled n/a Oyster, raw Oyster,raw n/a Paddle pop nfs STREETS PADDLEPOP CHOCOLATE 1 Stick Pancake nfs Pancake,plain,homemade 1 medium Tubs from coles are 150g each or 0.5cup = 130g Pannacotta, nfs Pannacotta, nfs (based on Greek yoghurt/natural 10%) Pappadum Pappadam,microwaved without oil/salt no. of pappadums Pappadum from restaurant Pappadam fried no. of pappadums Parsley nfs Parsley,curly,raw n/a Parsnip Parsnip,peeled,boiled,drained 82.5g=1/2cup as per potato

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Manual for nutritional data entry – Sheet 1: List of foods

Pasta dish, nfs Pasta bolognese,Italian restaurant style n/a Pasta,white wheat flour based,boiled from dry,w Pasta nfs added salt n/a 1 cup = 150g (based on weight of 1 cup of white Pasta, Gluten Free Gluten Free Pasta pasta cooked). Pasta, low GI Pasta, low GI 1 cup = 148g based on 1 cup of white pasta boiled Pasta/noodles,buckwheat flour,boiled without added Pasta, noodles, rice, buckwheat based, boiled salt 1 cup of buckwheat cooked = 168g 1 cup =150g (based on 1 cup of cooked white Pasta in a pesto sauce Pasta in a pesto sauce pasta). Pasta sauce, white Sauce,pasta,cream-based,commercial n/a 1 cup = 280g based on pasta sauce, cream based Pasta sauce, cream based with seafood Pasta sauce, cream based with seafood with added chicken. Pasta with cheese sauce Pasta bake,cheese sauce,cheese-topped n/a 1 cup = 262 g based on 1 cup of Pasta Creamy Chicken Pasta Creamy Chicken Pasta bolognese,Italian restaurant style 1 cup = 150g (based on weight of 1 cup of white Pasta in cream based sauce Pasta in cream based sauce pasta cooked). 1 cup =150g (based on one cup of cooked white Pasta, cream based with vegetables pasta, cream based with vegetables pasta. Pasta, white wheat flour based, boiled from dry, w added salt + Sauce,pasta,tomato- Pasta+ tomato sauce based,commercial,heated n/a 1 cup = 150g (based on weight of 1 cup of white Pasta in oil, garlic and parsley Pasta with oil, garlic, parsley and parmesan pasta cooked). 1 cup = 150g (based on weight of 1 cup of white Pasta with seafood in oil based sauce Pasta with seafood in oil based sauce pasta cooked). Pastie, nfs Pastie,vegetable,baked n/a Pastry,spinach & cheese filling (spanakopita),Greek Pastizzi, spinach and cheese style,RTE n/a Pastrami nfs Beef,corned,canned n/a Pastry (savoury) nfs Pastry,fillo (phyllo),baked n/a

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Manual for nutritional data entry – Sheet 1: List of foods

1 roll =140g ( based on weight of one sausage Pastry roll, spinach and cheese Pastry. spinach & cheese filling,RTE roll). Scroll, (pastry) with custard and fruit Bun/scroll,with dried fruit & custard,iced Use no of scrolls Pate, nfs Pate,liverwurst n/a 1 piece = 42g based on a Woolworths 500g Pavlova Pavlova,plain,cream-topped pavlova cake that serves 12. 1 slice= 37g - based on 1 medium slice of Paw paw, nfs Pawpaw (papaya),peeled,raw melon Peach Peach,fresh,unpeeled,raw Peach, canned Peach,canned in light syrup,drained 1 can =825g (SPC)

Peanut butter Peanut butter,smooth & crunchy,sweetened,salted n/a 1 piece ~ 15g based on peanut nut snap (golden Confectionary, Peanut brittle Confectionary, Peanut brittle days) indiv packs Pear Pear,unpeeled,raw,nfs 1 medium (6-7cm dia base) Pear, peeled Pear,peeled,raw,nfs 1 medium (6-7cm dia base) Pear, stewed/canned Pear,canned in syrup,drained 1 cup =240g Peas/ frozen peas Pea,green,fresh,boiled,drained n/a Pepper, nfs Pepper,ground,black/white Perch / Fish nfs Silver perch,aquacultured,baked/grilled n/a Persimmon Persimmon,peeled,raw n/a Pickles Gherkin,pickled,drained,commercial n/a Mustard pickles pickles,mustard,sweet,commercial n/a pickled onion onion,pickled,commercial,drained

Pie, fish Pie,mixed seafood in creamy sauce,individual size n/a Pie, fruit mince pie Pie,apple,commercial,family size,RTE 1 individual = 60g usually If you do not have a value 1 indivdual pie = Pie, meat Pie,meat 175g

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Manual for nutritional data entry – Sheet 1: List of foods

Pie, Weight watchers cottage pie Weight Watchers Cottage Pie 1 serve = 320g 1 small slice/pie = 125g based of 1 individual apple Pie,pumpkin,sweet,home prepared Pie,pumpkin,sweet,home prepared pie Pie,vegetable Pie,vegetable Indivdiual pie approx 150g 174 g = 1 indivdiual pie based on 1 indivdual meat Chicken and vegetable pie Chicken and vegetable pie pie Pikelet Pikelet/drop scone,commercial put in a pikelet. Pineapple Pineapple (cayenne),fresh,peeled,raw n/a Pineapple, canned Pineapple,canned in water,drained n/a Pistachio Nut,pistachio,roasted,with oil,salted n/a

Pizza nfs / pizza mini Pizza,cheese topping,tomato sauce,homemade n/a

Pizza, bacon MCCAIN PIZZA SLICE CHEESE&BACON (100G) n/a 1 pizza = 632g based on 8 slices in 1 pizza and 1 slice of pizza = 79 g. Derived from Pizza, Ham and pineapple Pizza Ham and Pineapple 'Pizza,supreme topping,tomato sauce,take away style' 1 slice = 79g.

Pizza Margarita DOMINO'S CLASSIC,MARGARITA,SLICE (69 G) Can use slice option. 1 pizza = 632g based on 8 slices in 1 pizza and 1 slice of pizza = 79 g. Derived from Pizza,meat & vegetable topping,tomato 'Pizza,supreme topping,tomato sauce,take Pizza, meat and veg sauce,homemade away style' 1 slice = 79g

Pizza, meatlovers Pizza,meat & cheese topping,BBQ sauce,homemade n/a

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Manual for nutritional data entry – Sheet 1: List of foods

1 pizza = 632g based on 8 slices in 1 pizza and 1 slice of pizza = 79 g. Derived from Pizza,seafood topping (calamari & prawns),tomato 'Pizza,supreme topping,tomato sauce,take Pizza,seafood sauce,homemade away style' 1 slice = 79g 1 pizza = 632g based on 8 slices in 1 pizza and 1 slice of pizza = 79 g. Derived from 'Pizza,supreme topping,tomato sauce,take Pizza, supreme Pizza,supreme topping,tomato sauce,take away style away style' 1 slice = 79g

Pizza, vegetarian Pizza,vegetarian topping,tomato sauce,homemade n/a 1 pizza = 632g based on 8 slices in 1 pizza and 1 slice of pizza = 79 g. Derived from 'Pizza,supreme Pizza,chicken & vegetable topping,tomato topping,tomato sauce,take away style' 1 slice = pizza chicken sauce,frozen & baked 79g. Beverage base,chocolate flavour,unfortified (Nesquik Plain chocolate beverage base brand) Plum Plum,unpeeled,raw,nfs Use 5cm dial option 1 cup =210g (based on 1 cup of peach, canned in Plum, canned Plum,dark,canned in syrup,drained light syrup, drained 1 cup =210g (based on 1 cup of peach, canned in Plum, stewed Plum,dark,canned in syrup,drained light syrup, drained Cornmeal (polenta),cooked in unsalted water without Polenta fat n/a Pork, belly Pork,crackling,baked/roasted n/a Pork, fillet Pork,fillets,lean,fried,olive oil n/a Pork,forequarter shoulder roast,untrimmed,BBQ (pork neck) Pork,forequarter shoulder roast,untrimmed,BBQ n/a Pork, mince Pork,mince,stir-fried without oil n/a Pork, nfs Pork,cooked,nfs n/a Pork, rissole Patty/meatball,pork,plain,fried,ns oil n/a Pork, roll Pork,cooked,nfs n/a

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Pork, boiled Pork,leg,diced,lean,boiled/simmered n/a Casserole, pork Pork,stewed/casseroled,nfs n/a Pork, chop Pork,loin chop,lean,grilled n/a Pork, cutlet Pork,loin chop,lean,grilled n/a Pork knuckle Pork knuckle 1 pork knuckle = 250g Pork, medallion Pork,medallion steak,lean,grilled n/a Pork, pickled Pork,pickled,nfs n/a Pork, ribs Pork,spare ribs,lean & fat,grilled/BBQ n/a Pork, roasted Pork,leg roast,trimmed,roasted n/a 1 cup=253 g as per pork stirfry sweet & sour Pork, satay pork,kebab,marinated,satay sauce, grilled/BBQ Chinese restaurant style Pork, schnitzel Pork,leg schnitzel,lean,dry fried n/a Pork,butterfly steak,lean,grilled Pork,butterfly steak,lean,grilled Use model Pork, steak Pork,leg steak,lean,grilled n/a Pork, stir-fried Pork,leg strips,lean,stir-fried n/a Pork,stir fry,sweet & sour sauce,Chinese restaurant Pork, sweet & sour style 1 cup= 253g - based on beef curry, 1 cup Pork,stew/casserole,sweet & sour sauce,mixed pork stew with vegetables vegetables Porridge (variety pack/quick) UNCLE TOBYS PORRIDGE QUICK OATS Individual packets are 35g. Porridge nfs Porridge,rolled oats,nfs n/a Porridge/oats raw Oats,rolled,raw n/a Port nfs Port (fortified wine) n/a Potato bake Potato,scalloped/bake,nfs n/a 1 cup = 239g (based on 1 cup of Potato, potato bake with cream and cheese Potato,scalloped/bake,with cream & Cheese scalloped/bake,nfs) 1 potato = 122g (based on weight of 1 potato, boiled, drained nfs). Small chat potato = 60g Potato, baked (in the oven) Potato,baked without oil,nfs according to Calorie King

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Manual for nutritional data entry – Sheet 1: List of foods

Potato, fried, nfs Potato,hash brown,fresh/frozen,fried,ns oil Use no. of patty,nfs

Potato,other varieties (e.g. Potato, gem gems,smiles,nuggets),fresh/frozen,baked without oil 48.5g =½ cup Potato, nfs Potato,boiled,drained,nfs 1/2 cup =82.5g Potato,wedges,homemade - fresh/frozen,fried,ns Potato, wedges oil,nfs n/a

Potato, chips - take away /club Potato,chips,homemade - fresh/frozen,fried,ns oil n/a Potato,chips,homemade - fresh/frozen,baked without 1 cup = 113g (based on weight of Potato chips, Potato chips, home-baked oil homemade - fresh/frozen, fried, ns oil 1 cup). Potato, hash brown Potato,hash brown,fresh/frozen,cooked,nfs n/a Potato, mashed Potato,peeled,boiled,mashed,nfs n/a 1/2 cup = 82.5g based on potato peeled boiled Potato low GI Carisma Potato Low GI drained 1 potato = 122g (based on weight of 1 potato, Potato, roast, nfs BIRDS EYE OVEN ROAST POTATO TRADITIONAL boiled, drained nfs)

Potato, scallop Potato,scallop,battered,deep-fried,take-away outlet 1 scallop is 70g according to Calorie King Potato, sweet, chips Sweet potato,orange flesh,chips,fried,ns oil n/a

Potato, sweet Sweet potato,orange flesh,peeled,boiled,drained n/a

Sweet potato,orange flesh,peeled,boiled,mashed,ns 0.5 cup = 130g, (based on potato peeled boiled Sweet potato mash milk & table spread mashed nfs) 1 tb = 20.8g 0.5 cup = 130g, (based on potato peeled boiled Potato mashed, with butter Potato,peeled,boiled,mashed,ns butter,nfs mashed nfs) 1 tb = 20.8g Prawns, nfs Prawn,king (large size),baked/grilled Use no. of prawns Prawn,king (large size),battered,deep fried,canola Prawns, battered/honey T/A style oil,home prepared Use no. of prazwns or T/A container

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Manual for nutritional data entry – Sheet 1: List of foods

1 cutlet = 16g, based on Prawn,King, crumbed Prawn Cutlet (T/A) prawn cutlet baked weight of one prawn 1 cup =253g (Using beef stir fry and veg to Prawn Chow Mein Prawn Chow Mein estimate) profiteroles, cream puff profiteroles Average each = 35g based on Calorie King 1 ball = 32g (Based on weight of Boost Juice Protein ball Protein Ball nfs Protein ball in calorie king). Psyllium husk Psyllium husk 1 tb: 5g (based on tb of Kellogs All Bran). Pretzels,snack food Pretzels,snack food Use packet size or no. of pretzels Prickly Pear Prickly Pear 1 Prickly pear = 40g (based on size of small fig). Pringles (chips) PRINGLES (FLAVOUR NOT REQUIRED) 1 can = 150g Prune Prune (dried plum) Use no. of prunes Prune, juice Juice,prune n/a Pudding ,christmas Pudding,nfs 1 individual = 60g usually 1 cup = 211g (based on 1 cup of bread and butter Chocolate pudding Chocolate pudding pudding). 1 cup = 211 g based on 1 cup of bread and Pudding nfs or pudding, ginger Pudding,nfs butter pudding. Pudding, bread and butter Pudding,bread & butter,baked n/a Pudding, rice pudding/ creamed rice Pudding,rice n/a Pudding, sticky date/caramel Pudding,sticky date,homemade n/a Pumpkin, nfs Pumpkin,peeled,cooked,nfs n/a Pumpkin,peeled,baked without oil,nfs Pumpkin,peeled,baked without oil,nfs n/a 1 butternut pumpkin = 1.8kg or 1 cup = 215g (based on weight of 1 cup,nfs of pumpkin, peeled pumpkin, butternut. Pumpkin,butternut,peeled,boiled,drained boiled cooked, drained) Pureed fruit/blended fruit Fruit, puree apple & blackberry n/a Puttu Puttu Use 1 Serve or lasagna model Quiche Quiche,nfs n/a Vegetable slice/frittata Quiche,zucchini & tomato,homemade Use Lasagne dish (400g) to estimate

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1 tb = 16.5g (based on 1 tb of wt Rice brown, boiled with added salt). 1 cup = 206g based on the same Quinoa Quinoa, cooked in water method as above. Rabbit Casserole Rabbit Casserole 1 cup = 300g using pork casserole Radicchio Chicory,boiled,drained n/a Radicchio/Chicory raw Chicory,raw 0.5 cup= 72.5g- based on wt of boiled chicory Radish Radish,white skinned,peeled,raw 0.5 cup =87.5g- based on wt of white onion 1 raisin=1.4g- based on Foodworks sultana Raisin Currant,dried weight Ranch, dressing Dressing,thousand island,regular,commercial n/a rapini 1/2 Broccoli,fresh,boiled,drained and 1/2 endives Ravioli/angloti meat Pasta,meat filled,boiled,no sauce n/a Pasta,cheese & vegetable filled,no sauce,fast food Ravioli/angloti veg+cheese style n/a Ravioli, Vegetable Ravioli, Vegetable 1 cup = 264g relish Relish,corn Resource 2.0 + Fibre Resource 2.0 + Fibre 1 serve or whole bottle is 200ml/200g. Rhubarb,stalk,stewed,sugar sweetened + Berries,mixed (strawberry,raspberry,blueberry,blackberry,canned,dr Rhubarb + berries stewed ained) n/a Rhubarb, stewed Rhubarb,stalk,stewed n/a Rice bran oil/spread Margarine spread,rice bran oil based n/a Rice bran oil Rice bran,extruded/low processed n/a

Rice, bubbles KELLOGGS RICE BUBBLES n/a Rice cracker, seaweed SAKATA RICE CRACKER SEAWEED Rice, cake, savoury Biscuit,savoury cake,rice,salted n/a Rice, cake, sweet KELLOGG'S LCMS RICE BUBBLES (22G) 1 bar = 22g

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Manual for nutritional data entry – Sheet 1: List of foods

Rice, nfs Rice, white, boiled with added salt n/a Rice, brown Rice,brown,boiled without added salt n/a 1 cup = 120g based on 1 cup of white flour weight Rice, glutinous, white Rice, glutinous, white on google Noodle, rice Noodle,rice,boiled without added salt n/a Rice, fried Rice,fried,with mixed vegetables,ns oil n/a Rice paper Rice paper 1 sheet = 14.3g serving size = 230g = 2 rolls, based on (ausnut rice paper spring rolls prawn only Rice paper rolls,Asian style,with prawn 2013 database) Rice paper rolls, chicken/meat and vegetable Rice Paper rolls, chicken and vegetable. 1 roll = 120g (Ausnut). Rice, Pilaf with spices Pilaf Rice with spices 1 cup = 190g based on 1 cup of cooked white rice. 1 cup =280g- Wt based on 1 c of Risotto Risotto,chicken,with parmesan cheese Sauce,pasta,cream-based,added chicken Risotto with prawns, fish or seafood Risotto,seafood 1 cup = 280g Risotto, pumpkin and cheese Risotto, pumpkin and cheese 1 cup = 280g based on above Risotto,bacon,with parmesan cheese Risotto,bacon,with parmesan cheese 1 cup = 280g based on above Rissoles Hamburger patty,frozen,grilled n/a Ritz crackers RITZ CRACKERS PLAIN (3G) n/a Rock cake, homemade Rock cake,homemade n/a Rocket/ ruccola Spinach,English,raw n/a Rockmelon/melon Melon,rockmelon (cantaloupe),peeled,raw 0.5 cup (diced) Roti/naan bread Bread,naan,Indian restaurant style n/a Rum, nfs Rum,dark & light coloured n/a Rusk (biscuit) Biscuit,savoury,melba toast n/a Ryvita, nfs RYVITA CRISP BREAD ORIGINAL RYE n/a Salad dressing, reduced fat Dressing,french,reduced fat,commercial n/a Salad dressing, vinigarete Dressing,salad,oil & vinegar,homemade n/a Salad, caesar Salad,caesar,with dressing n/a 0.5 cups = 84.5g (based on Chicken salad Chicken caesar salad MCDONALDS,DELI CHOICE,CHICKEN CAESAR measurements).

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Salad,green (lettuce,capsicum,snowpeas,cucumber,avocado),w chicken salad chicken,no dressing 0.5cups = 84.5g Salad, coleslaw Salad,coleslaw,commercial n/a Salad, greek Salad,greek,no dressing 1 cup = 169g (using tabouli 1 cup to estimate) Salad,green (lettuce,capsicum,snowpeas,cucumber,avocado),no 0.5 cup = 84.5g- based on wt of Salad, green nfs dressing Salad,tabouleh,Lebanese restaurant style Salad, pasta Pasta,salad,with vegetables 1 cup = 170g (based on one cup of pasta) Salad, potato Salad,potato,commercial n/a 1 cup = 200 g based on 1 cup of Coleslaw Salad, seafood,nfs Seafood,mixed,poached,w creamy dressing & lettuce commercial. Salami, nfs Salami,nfs n/a Salt, nfs Salt,nfs 1 tsp = 6g 1 piece = 145g (samosa, vegetable, indian Meat samosa Meat samosa restaurant style 1 piece)

Sandwich roll,white roll,ham w salad Sandwich, ham and salad (lettuce,tomato,carrot,onion,capsicum),fast food n/a

Sandwich, egg & lettuce Sandwich,wholemeal bread,tablespread,egg & lettuce 1 sandwich Sandwich,white bread,tablespread,ham & Sandwich, toasted, Ham and Cheese cheese,toasted No. of sandwich Sandwich tuna Sandwich tuna 1 sandwich = 96g. Sandwich,white bread,tablespread,ham,cheese & Sandwich,ham,cheese & tomato tomato 1 sandwich

Sandwich, nfs Sandwich,white bread,with cheese & tomato,toasted n/a

Sandwich, cheese, tomato Sandwich,white bread,with cheese & tomato,toasted n/a Sandwich,white bread,tablespread & chicken sandwich chickent toasted roll,toasted sandwich

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Manual for nutritional data entry – Sheet 1: List of foods

Sandwich roll,white roll,salad (lettuce,tomato,carrot,cucumber,onion,capsicum,olive Sandwich, salad ),fast food n/a Salmon and Onion sandwich salmon and onion sandwich Recipe: 1 serve = 1 sandwich (1 Roll = 266g based on Sandwich roll,white Sandwich roll with roast beef or lamb and roll,marinated chicken breast w salad salad Sandwich roll with roast beef or lamb and salad (lettuce,tomato,carrot,onion,capsicum),fast food) Sanitarium Light n Tasty nfs SANITARIUM LIGHT N TASTY BERRY n/a Sao Arnotts sao original biscuit; Sao Sara Lee Dessert, nfs SARA LEE STICKY DATE PUDDING (85G) n/a

Sara Lee Pie SARA LEE RASPBERRY FLAN (1 SLICE = 80G) n/a Sashimi, nfs Salmon,Atlantic,fillet,raw n/a Sauce,nfs Sauce,nfs n/a Sauce simmer, chicken tonight Sauce,simmer for chicken,commercial n/a Sauce, apple Apple,peeled,stewed,nfs n/a Sauce, apricot Apricot,fresh,stewed n/a sauce, bbq Sauce,barbecue,commercial Sauce,basil pesto,pasta style,commercial Sauce,basil pesto,pasta style,commercial using units as per database paste, bean paste, bean 1 tb ~25g Sauce, Calabrese for Pasta (salami, tomato, mushroom and olive) Calabrese Pasta Sauce 1 cup = 170g based off 1 cup of bolognaise sauce Sauce, carbonara Sauce,pasta,cream-based,added beef & ham n/a Sauce,cheese,made with butter & milk,home- Sauce, cheese prepared n/a Sauce,cranberry Sauce,cranberry,commercial n/a Sauce, paste, Curry, nfs Paste,green curry,Asian style,commercial Sauce, gravy/diane sauce Gravy,commercial,prepared n/a sauce, fish, nfs Sauce,fish,Asian,commercial

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Manual for nutritional data entry – Sheet 1: List of foods

Sauce, Hoi sin Sauce,hoi sin,Asian,commercial n/a Sauce, hollandaise Sauce,hollandaise,home-prepared 1tb = 21g Sauce, HP BBQ sauce n/a Sauce, korma TAYLORS ROYAL KORMA n/a Sauce, oyster Sauce,oyster,Asian,commercial n/a Sauce, pepper, gravy Sauce,pepper with gravy n/a Sauce, plum Sauce,plum,Asian,commercial n/a Sauce, salsa, tomato based Sauce,salsa,tomato-based n/a Sauce, soy Sauce,soy,commercial n/a Sauce,satay,Asian,commercial Sauce,satay,Asian,commercial using measurements already in foodworks Sauce, sweet and sour Sauce,sweet & sour,Asian,commercial n/a Sauce, Chilli, nfs Sauce,chilli,Asian,commercial Sauce, sweet chilli Sauce,sweet & sour,Asian,commercial n/a sauce, A1 steak A1 Steak Sauce 1 tbs = 17g Sauce, Tartar Sauce,tartar,commercial n/a Sauce, Teriyaki Chicken, Masterfoods Sauce, Teriyaki Chicken, Masterfoods 1 pack = 175g? Sauce, tomato Sauce,tomato,commercial n/a Sauce, tomato (for pasta) Sauce,pasta,tomato-based,commercial,heated n/a Sauce, white (eg. for pasta ) Sauce,white,home-prepared n/a Sauce, white creamy Sauce,white,home-prepared n/a Sauce, worcestershire or holbrook sauce,worcestershire,commercial n/a Sauerkraut Sauerkraut,canned in brine,drained n/a Sausage, nfs Sausage,cooked,nfs n/a Sausage, roll Sausage roll,individual size,commercial,RTE n/a Sausage, beef Sausage,beef,cooked,nfs n/a 1 sausage = 58g based on 1 sausage (nfs) beef Sausage,beef, low fat, nfs Sausage,beef, low fat, nfs cooked Sausage, Black pudding Black pudding,raw 1 serving size = 50g (calorieking)

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Manual for nutritional data entry – Sheet 1: List of foods

Sausage, chicken Sausage,chicken,grilled/BBQ n/a Sausage, Chinese Sausage,pork,cooked,nfs Use no. of thick or thin Sausage, frankfurt Frankfurt/cheerios,fresh,simmered Enter as no. of Frankfurts Sausage, Italian/chipolata Sausage,pork,cooked,nfs n/a 1 sausage = 58g based on weight of 1 Sausage, kransky Sausage,curry,made with curry powder Italian/chipolata sausage. Lamb,sausage (kafta/kofta),w herbs,Lebanese 1 thin= 44g- based on sausage cookned nfs (1 Sausage, Lamb restaurant style thin) Sausage, pork Sausage,pork,cooked,nfs n/a Sausage,stew/casserole,gravy,capsicum,onion & sauage stew potato 253g = 1 cup Scampi Lobster,purchased steamed/boiled n/a Schnitzel, nfs INGHAMS CHICKEN SCHNITZELS (200G) n/a Chicken, scnitzels INGHAMS CHICKEN SCHNITZELS (200G) n/a Scone, nfs Scone,white flour,plain Use regular option Scotch finger ARNOTTS SCOTCH FINGER 18g/biscuit

Scotch and soda Scotch & Soda 120 ml = 114 g based on whisky.

Seafood in pasta Sauce,pasta,tomato-based,added seafood n/a Marinara mix,w fish & Seafood marinara shellfish,fresh,poached/steamed n/a Seafood Sauce seafood sauce 1 Tbsn = 20g, based on weight of mayonaise. Seafood, Scallop Scallop,boiled,unsalted water n/a Seaweed, Poached Seaweed,nori,poached n/a Seaweed, Dried Seaweed,nori,dried n/a Seed, chia Seed,linseed/flaxseed 1 tb = 11.2g (using seseme seeds 1tb) Seed,poppy Seed,poppy n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Seed, pumpkin Seed,pumpkin,hulled & dried 1 tb = 11.2g (using seseme seeds 1tb) Seed,sunflower Seed,sunflower n/a Seed,sesame,white Seed,sesame,white n/a sesame seed, powder, black sesame seed white n/a Seed,mixed (linseed,sunflower seed & almond Linseed, sunflower seed and almond (LSA) mixture),LSA n/a Semolina Semolina,made with water n/a Shallot, cooked Shallot,peeled,cooked,nfs Use weight of spring onion as example Shallot, raw Shallot,peeled,raw n/a Shepherds pie Pie,meat,with potato topping 1 cup = 152g Sherry (fortified wine),sweet style (approximately 11% Sherry, nfs sugars) n/a Silverbeet Silverbeet,boiled,drained n/a

Slice, apple Pie,fruit (apple/apricot),commercial,family size,RTE n/a Slice, caramel/cherry/vanilla slice Slice,sweet,nfs n/a Slice, coconut Slice,coconut filling n/a Slice,muesli,w oats,apricots,sultanas & Slice Muesli almonds,homemade Smoothie, fruit and yoghurt Smoothie,mango,banana & yoghurt n/a Snowpea Snowpea, raw n/a 1 tb =26.8g- baed on wt of 1tb of regular frozen So Good, Frozen Yoghurt SO GOOD BLISS CREAMY VANILLA yoghurt Soft candy/gummy lollies Sugar confectionery,jelly varieties 1 snake lollie is 13g (CK) Soft drink, nfs Soft drink,nfs 1= 375ML (NFS)

Soft drink, diet MCDONALDS,SOFT DRINK,DIET COKE,MEDIUM 1= 375ML (NFS) Solo/lift/soft drink lemon flavour Soft drink,lemon flavour n/a Soup, Asparagus Soup, Asparagus 1 cup = 265g based on 1 up of mushroom soup

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Manual for nutritional data entry – Sheet 1: List of foods

Soup, bean/lentil Soup,vegetable & lentil,homemade n/a Soup,meat (beef/lamb/pork,w vegetables & Soup, beef noodle noodles,prepared w milk & water n/a Soup, canned nfs Soup,meat & vegetable,canned,RTE,heated Large can = 430g, Small =290g- campbells soup Soup, Cauliflower Soup, Cauliflower 1 cup = 252g based on 1 cup of pumpkin soup Soup,Celery Soup,cream of celery,canned,condensed 1 cup = 252g based on 1 cup of pumpkin soup Soup Carrot Soup Carrot 1 cup = 252g based on 1 cup of pumpkin soup Soup,chicken & vegetable,homemade,prepared w Soup, chicken water n/a Soup, chicken noodle or pasta Soup,chicken noodle,made with water n/a

Soup, Chicken and rice or noodle Soup,chicken noodle,w vegetables,prepared w water n/a Soup, chicken, canned Soup,chicken,broth style,condensed,canned n/a Soup, chicken, creamy Soup,cream of chicken,condensed,canned n/a Soup,chicken & corn chowder Soup,chicken & corn chowder Soup, chickpea Soup,vegetable & lentil,homemade n/a Soup, creamy vegetable Soup,cream of vegetables,condensed,canned n/a Soup French Onion Soup French Onion 1 cup = 257g based on 1 cup of minestrone soup Soup, instant soup e.g cup a soup Soup,cream variety,instant dry mix 1 serve = 200ml Soup, laksa Soup,chicken laksa n/a Soup, lentil Soup,vegetable & lentil,homemade n/a 1 cup = 255g (based on weight of 1 cup of Soup,meat (beef/lamb/pork,w vegetables & Soup, Pho Pho noodles,prepared w milk & water) Soup,meat (beef/lamb/pork),w pasta,prepared w Soup, meat and pasta water n/a Soup,meat (beef/lamb/pork),w vegetables & Soup, meat, vegetables, legumes legumes,prepared w water n/a Soup, minestrone Soup,minestrone,homemade n/a Soup,miso Soup,miso,with radish n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Soup, mushroom Soup,mushroom,cream style,condensed,canned n/a Soup, nfs Soup,vegetable,homemade n/a Soup,Asian style,w noodles,instant dry mix,cup Soup, noodle, asian style,reconstituted w water n/a Soup,meat (beef/lamb/pork,w vegetables & Soup, noodle with meat and vege noodles,prepared w milk & water Soup,pea & ham,w vegetables,homemade,prepared Soup, pea and ham w water n/a Soup,pea & ham,canned Soup,pea & ham,condensed,canned,reconstituted w water n/a Soup, potato and leek Soup, potato & leek, homemade n/a Soup, pumpkin Soup,pumpkin,homemade n/a Soup,pumpkin & carrot,canned Soup,pumpkin & carrot,condensed,canned n/a

Soup, seafood Soup,seafood/fish,w vegetables,made with water n/a Soup, short Soup,wonton in chicken broth n/a Soup,tomato,condensed,canned,reconstituted w Soup, tomato water n/a Soup, vegetable Soup,vegetable,homemade n/a Soup, wonton Soup,wonton in chicken broth n/a Souvenaid, Nutricia Souvenaid, Nutricia 1 bottle = 125ml, using 1g =1ml Souvlaki nfs Lamb,kebab,grilled/BBQ n/a Spagetti, canned Spaghetti in meat sauce,canned 1 CUP= 265G Spam, can Spam,canned 1 can = 340g (6 serves in a can - 56g per serve) Spanakorizo (Greek Rice Dish) 1 cup rice, 0.5 cup spinach, juice of 1 lemon Recipe is equal to 1 cup Sparkling, apple juice APPLEMAID JUICE APPLE SPARKLING n/a spatchcock Chicken,baked/roasted,nfs approximately 450g for a whole spatchcock. Speck Ham,prosciutto/parma style,raw use ham or roast meat model. Special K KELLOGGS SPECIAL K n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Spinach Spinach,English,raw n/a Spinach, cooked Spinach,English,boiled,drained Use if specifies as cooked Size=1 pastry; Bakers Del Danish Square Spinach Spinach, roll Pastry. spinach & cheese filling,RTE & Feta Splice Streets splice berry n/a Split pea Pea,split,dried,soaked,boiled,drained n/a Cheese, spread Cheese spread,cheddar cheese-based n/a Spreadable tuna/fish paste/fish dip Fish paste/spread n/a Spread, chocolate, nutella Spread,hazelnut & chocolate flavoured Use measurements from database Spread, vegetable & yeast extract, promite Spread, vegetable & yeast extract, promite Measurements copied from vegemite Spring roll, chinese t/a Spring roll,deep fried,take away style n/a Squash Squash,button,boiled,drained 1cup=222g Steak, chuck nfs Beef,chuck steak,trimmed,casseroled n/a steak, porterhouse Beef,sirloin steak,lean,grilled n/a Steak, semi-trimmed Beef,rump steak,semi-trimmed,grilled n/a Stir fry, beef or stir fry nfs Beef,stir-fry strips,lean,fried,ns oil n/a 1 cup = 253g (using beef,curry,prepared with Stir fry, beef with vegetable nfs Beef,stir fry,mixed vegetables curry powder,onions and stock) Stir fry, chicken nfs Chicken,breast,lean,stir-fried n/a 1 cup = 253g (using beef,curry,prepared with Stir fry, chicken with vegetable Chicken,stir fry,soy based sauce,mixed vegetables curry powder,onions and stock)

Chicken,stir fry,chop suey (chicken & 1 cup = 253g (using beef,curry,prepared with Stir fry, Chinese vegetables),Chinese restaurant style curry powder,onions and stock) Stir fry, lamb Lamb,trim lamb,stir-fry strips,lean,stir fried n/a Chicken,stir fry,chow mein (chicken & 1 cup =253g (Using beef stir fry and veg to Stir fry, Noodle, asian meal based on noodles noodles),Chinese restaurant style estimate)

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Manual for nutritional data entry – Sheet 1: List of foods

Pork,stir fry,sweet & sour sauce,Chinese restaurant 1 cup =253g (Using beef stir fry and veg to style Stir fry, pork, takeaway estimate)

Pork,stir fry, with vegetables Pork,stir fry,plum & oyster sauce,mixed vegetables 1 cup = 253g Stir fry, prawns Prawn,stir fry,soy based sauce,asparagus n/a

Stir-fry,mixed vegetable (capsicum,carrot,snow Stir fry vegetables (mixed) pea,bok choy & onion),w soy-based sauce,no oil 1 cup = 253g (from 1 cup of stir fried beef). Stock nfs Stock,liquid,commercial,nfs n/a Stock, powder, boullion, nfs Stock,powder,dry 1 cube ~ 5g Strawberry Strawberry,fresh,raw n/a

Beef,stroganoff (steak,mushroom & sour cream 1 cup = 253 g based on 1 cup of Stroganoff, beef casserole) Beef,stew/casserole,gravy SUBWAY,CHICKEN FILLET SUBWAY,CHICKEN FILLET 1 roll; Subway 6" SUBWAY,ITALIAN,B.M.T. HOT/COLD SUBWAY,ITALIAN,B.M.T. HOT/COLD 1 roll; Subway 6" SUBWAY,ITALIAN,MEAT BALL SUBWAY,ITALIAN,MEAT BALL 1 roll; Subway 6" SUBWAY,SANDWICH,CLASSIC TUNA SUBWAY,SANDWICH,CLASSIC TUNA 1 roll; subway 6 inch SUBWAY,VEGGIE DELITE SUBWAY,VEGGIE DELITE 1 roll; subway 6 inch SUBWAY,SANDWICH,HAM SUBWAY,SANDWICH,HAM 1 roll; Subway 6" SUBWAY,SANDWICH,SAVOURY TURKEY SUBWAY,SANDWICH,SAVOURY TURKEY 1 roll; Subway 6" Sugar, nfs Sugar,white,granulated/lump n/a sugar, brown Sugar,brown n/a from Coles Barley Sugar entry, 1 pc = 6g (calorie sugar, barley, lolly sugar, barley, confectionary king) Base quantities off Sugar,white,granulated/lump, Sugar, low GI Sugar, low GI 1tsp = 4.2g, Tb = 16.8g Sultana Sultana,dried n/a SULTANA BRAN KELLOGGS SULTANA BRAN n/a Sushi, tuna and avocado Sushi,California roll,restaurant style n/a

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Manual for nutritional data entry – Sheet 1: List of foods

from Coles Barley Sugar entry, 1 pc = 6g Sushi,nfs Sushi,vegetarian (calorie king) Beverage,formulated supplementary,chocolate Sustagen RTD flavour,purchased RTD (Sustagen brand) 1 Tetra pack is 250 mL 1 scoop of sustagen is 20 g which = 1 Beverage base,chocolate flavour,added calcium,iron tablespoon (according to household Sustagen, powder & vitamins A,B1,B2 & C (Milo brand) measures). 10 g = 1 teaspoon. 1 scoop of sustagen is 20 g which = 1 Nestle Nutrition Hospital Formula Sustagen tablespoon (according to household Plus Fibre Vanilla Flavour Sustagen powder nfs measures). 10 g = 1 teaspoon. Swede Swede,peeled,boiled,drained n/a Sweet bread/tripe/other offal Beef,kidney,simmered n/a Sweetcorn, creamed Sweetcorn,creamed,canned,heated n/a Sweetener, powder Sweetener, powder, nfs 1 sachet usually = 1g Sweetener, tablet Sweetener,tablet,nfs 1 tablet usually = 0.6 g Syrup,maple Syrup,maple,pure n/a Syrup, Ribena/ blackcurrant RIBENA BLACKCURRANT SYRUP n/a Tabouleh Salad,tabouleh,Lebanese restaurant style n/a Taro Taro,peeled,boiled,drained 1/2 c= 102g Tart, sweet, nfs Tart,jam n/a Tart,citrus Slice,lemon/orange custard filling n/a 1 large tart = 480g (as per woolworths large custard Tart, Custard Tart,Custard tart) Large size = 480g, individual size =120g, and mini Fruit tart Fruit Tart = 40g (based on coles tarts sizes and weights). portuguese tart Tart, custard 40g Tarte Tatin Cake,apple,uniced,homemade n/a Tea, green Tea,herbal other than chamomile,no milk n/a Tea, nfs Tea,regular,no milk,brewed from leaf/teabags n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Thai curry/takeaway nfs Chicken,curry,green,Thai restaurant style 1 cup = 253 g based on 1 cup of beef curry Tim Tam ARNOTTS TIM TAM ORIGINAL n/a Tip top 9 grain nfs TIP TOP BREAD 9 GRAIN MEDIUM n/a 1 cup= 210g (using bread and butter pudding 1 Tiramisu Pudding,nfs cup) Tiramisu Coles Tiramisu As above TLC Beef in Red Wine Casserole TLC Beef in Red Wine Casserole Enter as 1 serve = 380g TLC Spinach & Ricotta Cannelloni TLC Spinach & Ricotta Cannelloni Enter as 1 serve=380g TLC Grilled Steak and Mushroom Sauce TLC Grilled Steak and Mushroom Sauce Enter as 1 serve = 370g TLC Lamb Steak with Rosemary TLC Lamb Steak with Rosemary Enter as 1 serve = 350g TLC Moroccan Lamb TLC Moroccan Lamb Enter as 1 serve = 370g TLC Pork Steaks in Plum Sauce TLC Pork Steaks in Plum Sauce Enter as 1 serve = 370g TLC Sweet and Sour Chicken TLC Sweet and Sour Chicken Enter as 1 serve = 390g TLC Sweet and Sour Fish TLC Sweet and Sour Fish Enter as 1 serve = 370g TLC Vegetable Lasagne TLC Vegetable Lasagne Enter as 1 serve=370g TLC Beef Goulash TLC Beef Goulash Enter as 1 serve TLC Chicken Parmigiana TLC Chicken Parmigiana Enter as 1 serve TLC Chicken Stroganoff TLC chicken Stroganoff Enter as 1 serve TLC lamb casserole TLC lamb casserole Enter as 1 serve TLC silverside and white sauce TLC silverside and white sauce Enter as 1 serve Toffee Sugar confectionery,hard varieties n/a Tofu, firm Tofu (soy bean curd),firm,baked without oil n/a Tofu, fried Tofu (soy bean curd),firm,stir-fried,no oil n/a Tofu, silken Tofu (soy bean curd),silken/soft,as purchased n/a Based on 1 small tomato (<3cm dial) or 4 cherry sized tomatoes = 45g. 1 Cup salsa tomatoes = Tomatillo (Green tomato) Tomatillo (Green tomato) 275g.

Tomato, canned Tomato,canned in tomato juice,nfs 1 can = 400g Tomato, nfs Tomato,common,raw Use medium option

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Manual for nutritional data entry – Sheet 1: List of foods

4.5 slices = 1 medium tomato. Based on 1 medium tomato = 167g and 4.5 slices of fried tomato = Tomato,stir-fried Tomato,common,stir-fried without oil 162g. Tomato, sun-dried Tomato,sun-dried,in canola oil n/a Tomato, paste Tomato paste,with added salt n/a 1 cup = 267g (based on weight of 1 cup of Sauce,pasta,tomato-based,added eggplant & Tomato and Vege Pasta sauce Tomato and Vege Pasta sauce parmesan cheese). Or Or 1 tb = 21.2g Topping/Sauce chocolate commercial Topping,chocolate,commercial n/a Tortilla Tortilla,from wheat flour 1 medium Fish,pasta bake,tuna mornay w cheese & Tuna, bake breadcrumbs 1 serve= 296 Turkey, leg Turkey,hindquarter,lean,baked n/a Turkey, breast Turkey,breast,lean,baked n/a Turkey, cold Turkey,processed luncheon meat n/a Turkey, roast Turkey,breast,lean,baked n/a 1 Pide = 450g (112.5g per slice/section of bread, 4 slices in a pack). Rolls = 120g each. Turkish Pide BAZAAR TURKISH PIDE According to website. Turnip Turnip,white,peeled,boiled,drained 1cup=240g

Two fruits (pear and peach) Mixed fruit,peach & pear,canned in light syrup,drained n/a TwoCal HN TwoCal HN Cereal, Healthwise For heart Circulatory System Uncle Toby's Healthwise Breakfast Cereal n/a Uncle tobys plus range UNCLE TOBYS PLUS FIBRE PLUS n/a Uncle tobys, Oatbrits UNCLE TOBYS VITA BRITS n/a 1 cup = 43g (Using UNCLE TOBYS MUESLI Uncle tobys Plus omega 3 Uncle tobys Plus omega 3 FLAKES PLUS 1 cup). Vanilla,artificial,extract,alcohol free, essence Vanilla,artificial,extract,alcohol free 1 tsp = 5ml

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Manual for nutritional data entry – Sheet 1: List of foods

Veal, chop Veal,loin chop,lean,grilled n/a Veal, cutlet Veal,loin chop,lean,grilled n/a Veal, nfs Veal,cooked,nfs n/a Veal, pan fried Veal,leg steak,lean,fried,ns oil n/a Veal, Schnitzel Veal,leg steak,crumbed,fried,ns oil n/a Veal, stew nfs Veal,leg steak,untrimmed,stewed/casseroled n/a Beef,stew/casserole,tomato sauce & vegetables veal stew with vegetables and potato including potato 1 cup = 253g Veal,steak Veal,leg steak,lean,grilled n/a VEGE juice nfs V8 JUICE VEGETABLE 100% n/a Vegemite Spread,yeast,vegemite n/a Vegetable, mint Mint,raw n/a

Vegetable, mixed , frozen Mixed vegetables,frozen,boiled/microwaved,drained n/a Vinegar Vinegar n/a 1 Tablespoon = 20g based on 1 tablespoon of Vinegar, Balsamic Balsamic vinegar vinegar VITA BRITS UNCLE TOBYS VITA BRITS 1 cup =60g Waffle Waffle,plain,homemade waffle;square Watercress Lettuce,raw,nfs n/a Watermelon Melon,watermelon,peeled,raw 1 pc = 1 wedge (~1/16 whole) Weaten, chocolate HOME BRAND CHOCOLATE WHEATS n/a Enter as no. of biscuits. (Unless they specify Weet-Bix SANITARIUM WEET-BIX otherwise, 1C = 60g) Weetbix mini/bites SANITARIUM WEET-BIX FRUITY APRICOT n/a WEETIES UNCLE TOBYS WEETIES VITA ORIGINAL n/a Weis bar WEIS BARS MANGO n/a Weight Watcher Chicken and Mushroom Fettucine Weight Watcher Chicken and Mushroom Fettucine 1 serve = 300g

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Manual for nutritional data entry – Sheet 1: List of foods

Weight Watchers Beef and Tomato Bolognese Weight Watchers Beef and Tomato Bolognese 1 serve = 225g Weight Watchers Thai Chicken Curry Weight Watchers Thai Chicken Curry 1 serve = 320g Weight Watchers Beef Lasagne Weight Watchers Beef Lasagne 1 serve = 300g Wheat, bran Wheat bran,unprocessed n/a Wheat, germ Wheat germ n/a Wheat, meal ARNOTTS SHREDDED WHEATMEAL n/a Whey powder Milk,powder,cow,whey n/a Whisky, nfs Whisky n/a Wine, nfs Wine, nfs n/a Wine, red Wine, red n/a Wine,white,medium dry style (approximately 1% Wine, white sugars) n/a Wombok Cabbage,bok choy,raw n/a Yakult YAKULT FERMENTED MILK DRINK 65ml/ bottle Yoghurt, flavoured nfs Yoghurt,flavoured,nfs n/a Yoghurt, frozen,nfs Yoghurt,frozen,regular fat,fruit flavoured n/a Yoghurt, fruit Yoghurt,regular fat (~3%),fruit pulp/juice,nfs n/a yoghurt full fat vanilla Yoghurt,regular fat (~3%),vanilla flavoured Yoghurt, Greek nfs Yoghurt,Greek style,natural/plain,nfs n/a Yoghurt, greek, low fat Yoghurt,Greek style (~6% fat),plain/flavoured n/a

Yoghurt, Greek, Fruit, Full fat Yoghurt,Greek style (~6% fat),added mixed berries n/a Yoghurt, Jalna, nfs JALNA WHOLE MILK NATURAL n/a Yoghurt, Jalna, creamy, vanilla JALNA PREMIUM CREAMY VANILLA n/a Yoghurt, kafir Yoghurt,Greek style,natural/plain,nfs n/a Yoghurt, lactose free VAALIA NATURAL LACTOSE FREE n/a

Yoghurt, light/ reduced fat Yoghurt,natural,reduced fat (~2%) n/a Yoghurt,reduced fat (~2%),tropical fruit Yoghurt, light/reduced fat, fruit pieces/flavoured n/a

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Manual for nutritional data entry – Sheet 1: List of foods

Yoghurt, low fat/low sugar Yoghurt,low fat/no fat (<0.5%),intense sweetened,nfs n/a Yoghurt, nfs Yoghurt,natural,regular fat (~4%) n/a Yoghurt, no fat Yoghurt,low fat/no fat (<0.5%),nfs n/a Yoghurt, no fat/diet varieties nfs Yoghurt,low fat/no fat (<0.5%),nfs n/a Yoghurt, ski activ SKI D/LITE FAVOURITES n/a Yoghurt, ski d'lite SKI D/LITE FAVOURITES n/a Yoghurt, ski, nfs SKI DIVINE VANILLA CREME n/a

Yoghurt, soy Soy yoghurt,regular fat (~3%),nfs n/a Yoghurt, Vaalia, nfs VAALIA NATURAL LOW FAT n/a 160g singles, 2 x 175g twin packs, 4 x 150g four Yoghurt Vaalia Low fat flavoured VAALIA FRENCH VANILLA LOW FAT packs, 12 x 100g and 900g tubs Yoghurt, Vaalia, fruit, low fat VAALIA APRICOT MANGO PEACH LOW FAT n/a Yoghurt vanilla Yoghurt,low fat/no fat (<0.5%),vanilla flavoured n/a Yoplait for me nfs/no fat YOPLAIT FRNCH VANILLA NO FAT n/a Yoplait for me light YOPLAIT PASSIONFRUIT LIGHT n/a Yorkshire pudding Yorkshire pudding,homemade with oil 1 pudding = 30g according to calorie king Za'atar spice Za'atar spice 1 Tb = 10g, 1 tsp = 2.5g. Based off mixed spice. Zucchini flower nfs Zucchini,green skin,boiled,drained n/a Zucchini nfs Zucchini,green skin,boiled,drained cup(nfs), 1 cup=190g Zucchini,green skin,baked without oil Zucchini,green skin,baked without oil n/a

475 Manual for nutritional data entry – Sheet 2: Food Models

Sheet 2: Food Models List with weight FOOD MODELS WEIGHT 1 dsp 2 tsp 1cup (aus) 250ml/ 12.5tb 1tb (aus) 20ml/2ds/4ts Apple 1 medium Apple Sauce 1/2 cup Banana 1 medium Beans, Baked 1/3 cup Baked Beans in Can 220g Beans, Green, Canned 1/2 cup Beef, Roast 85g Bologna/davon 30g Bread, White Spread W/ Peanut Butter 1 slice w/ 2 tbsp peanut butter Broccoli 1/2 cup Cake 1.5 slice (large) Carrots, cooked or canned 1/2 cup Cereal, Bran Flakes 1/2 cup Cereal, Raisin Bran 1 cup Cheese 30g (3 cubes) Chicken Drumstick 85g Chicken Thigh, Fried 85g Corn Flakes, Dry Cereal 3/4 cup Corn, Whole Kernel, Canned 1/2 cup Butter/cream cheese 1 tbsp Cup of coffee/tea 180ml or tea/coffee cup Fish/Breast Chicken 85g

476 Manual for nutritional data entry – Sheet 2: Food Models

Fried rice 1 cup Grapes serve nfs 84g (15 grapes) Ham Slices Model 60g (7 slices, 8.6g each) Hamburger patty Large 115g Hamburger patty Small 85g Ice Cream 1 scoop/1/2 cup Jello 120 mL (0.5 cup) Lasagna dish 400g Margarine/Jam/ spreads in general- Big Dab 1 tbsp Meat Loaf used for cake slice 1 slice (small) Meat Loaf 85g Milk 240mL NfS sugar for coffee/tea 1 tsp Oil 1 tbsp Orange Juice 120mL 2 halves (110g: based pear,canned in pear juice, drained 2 Pear canned halves). Peas, Frozen 1/2 cup Pineapple Slices 80g (2.25 slices) Pizza 1 slice Potatoes, French Fried 1/2 cup Potatoes, Mashed 1/2 cup Rice, White Cooked 1/3 cup Rice, White, Cooked 1/2 cup Spaghetti +Meatballs 240g (1/2 pasta +1/2 sauce) Steak Strip/Steak 225g

477 Manual for nutritional data entry – Sheet 2: Food Models

Sweet Potatoes/Pumpkin 1/2 cup Whole chicken 1.2Kg= Whole spring chicken Fruit in general use medium size or one unit (eg mandarin) Meals on Wheels serve 360g (with 1 cup of vegetable (142g) included ) 8 year rule: MOW now appear to be 400g. Use the 1 cup of vegetable rule, and then get an idea of the carbohydrate size (e.g. 1/2 cup mashed potato), and leftover weight will be the weight of the protein. Does not need to be entered as recipe. Always use cup or cup nfs when refering to cup except for pasta, rice, porridge, beans in which case you should use cup (cooked)

Always use g (only) for beef, chicken, fish etc - Don't use g (bone removed, raw) for example.

Tuna/Salmon are expressed as sml/lrg can not in grams (95g=small, 100-120g large can)

Always select the grilled option if available for meat, as we enter the amount of oil used separetely.

Food Models we don't have: Bread roll 70g Cocoa mix 2 tbs Cornetto 120g Cucumber for sandwish 6 slices

478 Manual for nutritional data entry – Sheet 2: Food Models

Handful of nuts 30g Herring n/a in FW Silver perch,aquacultured,baked/grilled Loaf of bread 700g Mixed veggies pack 1kg Onion 1/2 cup (120mL) Salad 2 cups Tomato in sandwich nfs 1/2 cup Chop 225g

479 Manual for nutritional data entry – Sheet 3: Formulas

To calculate what is consumed from leftover: 1- Determine amount: E.g. same as dinner or 1/3 of serve of dinner, etc. 2- Determine how often leftover is being consumed: E.g. once a week or 5 days a week, etc. 3- Calculate frequency: E.g. 1 /7 (one day a week)* number of days leftover is being consumed. E.g.: Rosie eats chicken from her leftovers 3 times a week, 1/3 of dinner serve Chicken serve is 85g-> 85/3=28.3g 1/7*3= 0.428 ~0.43 -> this is equivalent to 3 days in a week. 0.43*28.3=12.13g of chicken in amount, 1D OR 28.3G of chicken, 0.43D in frequency. Warning: Always multiply amount by how often food is being consumed to obtain total amount consumed. How to calculate the frequency that a food is being consumed when participant consumes leftover from main meal on specific days, but does not specify which food i.e. anything from a range of options: Follow the same procedures as above, however, at the end you will have to use the formula bellow:

E.g.: Rosie consumes leftover from dinner 3 times a week and there are 7 options for dinner.

1/7*3=0.43 or 43% of the time-> here is how often Rosie consumes leftovers 0.43/7(options)= 0.06 (6%) a week Only the frequency will change because the portion size is the same as dinner unless otherwise specified. You can also calculate it as percentage: e.g.: I have chicken twice a week, beef three times a week, pork twice a week and leftover three times a week. First you should determine how often (%) I consume leftovers (in this example ~43%), then you will multiply the percentage by how often I consume each alternative i.e chicken = 2 x 0.43= 0.86/w; beef= 3 x 0.43=1.29/w; pork= 2 x 0.43= 0.86/w

To determine how much is consumed a day when several options are available:

E.g.: 2 fruits per meal; 4 options provided; 3 times a week

Calculation: 2/4x3 = 1.5 ( g/kg/cup/serves/fruit - as reported by participant) per week

To determine how much is consumed a week ( and to make sure the above calculation is right): 1 item (fruit in the above example) x 3 days a week = weekly weight/ 7 days (week)= daily weight

480 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

Sheet 4: New food entries in FoodWorks at 4th Wave Food FoodWorks food name Source Alcoholic Ale Beer, Ale AusNut (Allfoods) 1mL:1g 1tb:6g or 1 cup:75g (based on cocnut, grated and Almond meal Almond meal AusFoods 2012 desicated) Beer, stout Beer, stout Ausnut (Allfoods) 1mL:1g Ensure Ensure Abbott products 1mL:1g Ensure Plus Ensure Plus Abbott products 1mL:1g Ginger beer Bundaberg ginger Beer AusBrands 2012 1mL:1g Kidney,Lamb Kidney, All types, Stewed/Braised AusNut (Allfoods) Use meat models Lamb, Chop, NS cut, Home Lamb,crumber crumbed, Fried/Baked, Lean&Fat AusNut (Allfoods) use meat models Lean Cuisine chicken and Lean Cuisine Creamy Chicken pasta Pasta Bake AusBrands 2012 serves are 300g Lean cuisine atlantic salmon Ready to eat meal, Lean Cuisine, with pasta Atlatic Salmon with pasta AusFoods 2012 serves are 300g Mackerel, Canned in Brine, Three quarters of the meatloaf model makes up Mackerel,nfs Drained AusNut (Allfoods) 75g of mackerel steak (based on THIS=THAT) http://www.sanitarium.com.au/ 1 can is 415g, or 1 tb = 14g (based on NUTMEAT Nutrients manually entered products/vegetarian/vegie-delights-canned/nutmeat pate,liverwurst) http://www.sanitarium.com.au/ 1 can is 415g, or 1 tb = 14g (based on NUTOLENE Nutrients manually entered products/vegetarian/vegie-delights-canned/nutolene pate,liverwurst) Optifast- Nutrients manually entered http://www.optifast.com.au/Products/Shakes/Shake- milkshake (chocolate) chocolate#nutrition-table 1 serving is 54g (added to 200mL cold water) Optifast, mixed http://www.optifast.com.au/ veg soup Nutrients manually entered Products/Soups/Vegetable-soup 1 serving is 54g (added to 200mL hot water) Psyllium husk Psyllium husk AusFoods 2012 1 tb: 5g (based on tb of Kellogs All Bran). Rock cake, 45g per cake (cookie style), based on 1/2 medium homemade Rock Cake, homemade AusNut (Allfoods) scone (THIS = THAT) Scotch & Soda Whisky, Scotch&Soda,NFS AusNut (Allfoods) 1mL:1g Nestle Nutrition Hospital Sustagen powder nf AusBrands 2012 Enter as 1 scoop = 20g per scoop.

481 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

Formula Sustagen Plus Fibre Vanilla Flavour 1 cup = 180g (based on the weight of 1 cup of Tiramisu Coles Tiramisu AusBrands 2012 Mousse, chocolate, homemade) TwoCal HN TwoCal HN Abbott products either 1 mL:1g Uncly Toby's healthwise Breakfast Cereal, Healthwise For heart 1 cup = 120g (based on KELLOGGS ALL BRAN Cereal Circulatory System AusFoods 2012 FRUIT AND OAT) Prawn Cutlet 1 cutlet = 16g, based on Prawn,King, crumbed (T/A) Prawn Cutlet Prawn, King, Deep Fried, crumbed - AUSFOODS 2012 baked weight of one prawn seafood sauce seafood sauce Sauce, seafood cocktail - AusNut (All foods). 1 tb = 20g (1 tbspn of mayonnaise). McCain Lamb cutlet and McCain Lamb cutlet and gravy Always put in as 1 Serve (unless they have more gravy (Recipe) (find in New recipe folder) Changed to new recipes than 1 pre-packed meal) McCain Veal Cordon Bleu McCain Veal Cordon Bleu (find in Always put in as 1 Serve (unless they have more (Recipe) New Recipe folder) Changed to new recipes than 1 pre-packed meal) 1 cup = 150g (based on weight of 1 cup of white alfredo pasta Alfredo Pasta Continental Pasta & Sauce Alfredo - AusBrands 2012 pasta cooked). Tomato and pasta sauce, with vegetables, 1 cup = 267g (based on weight of 1 cup of Vege Pasta tomato based sauce,packaged, regular salt Sauce,pasta,tomato-based,added eggplant & sauce Tomato and Vege Pasta sauce - Ausfoods 2012 parmesan cheese). Or Or 1 tb = 21.2g Pasta in oil, garlic and pasta, pasta dish, other pasta dish, plain, 1 cup = 150g (based on weight of 1 cup of white parsley Pasta in oil, garlic and parsley oil based sauce, homemade - Ausfoods 2012 pasta cooked). Dry Bean Casserole,lentil, with tomato based sauce, Casserole Dry Bean casserole homemade - Ausfoods 2012. 1 cup= 253g- based on beef curry, 1 cup Japanese Rice 0.5 cup = 32g, based on THIS = THAT book, 1 Crackers Japanese rice crackers Snappy mixed rice crackers - AusBrands 2012 cracker = 1.8g as per calorieking McDonalds Crispy Chicken Mcdonalds, Salad, Crispy Classic Chicken Salad Salad McDonalds Crispy Chicken Salad - AusFoods 2012 1 salad serve= 341g accordng to the website.

482 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

Mushroom 1 Tbspn = 20 g based on 1 Tbspn of Sauce Mushroom Sauce Sauce, Mushroom - Ausnut 2007 Foods Cream,regular thickened,35% fat 1 pizza = 632g based on 8 slices in 1 pizza and Pizza, Ham Pizza, ham & pineapple topping, tomato sauce 1 slice of pizza = 79 g. Derived from Pizza Ham and Pineapple and pineapple , frozen & baked - Ausnut 2007 Foods 'Pizza,supreme topping,tomato sauce,take away style' 1 slice = 79g Prawn Chow Prawn Chow Mein (with noodles & vegetables), 1 cup =253g (Using beef stir fry and veg to Mein Prawn Chow Mein chinese restaurant style - NUTTAB 2010 estimate) Rabbit Casserole Rabbit Casserole Rabbit, casseroled- AusFoods 2012 1 cup = 300g using pork casserole Lean Cuisine Spaghetti Lean Cuisine Spaghetti Bolognaise Bolognaise Recipe Put 1 x lean cuisine in as 1 serve 1 serve = 22g (as researched by serving sizes of individual packets sold in bulk at woolworths and Le Snack Le Snack Snack, Le snack, cheddar cheese - Ausfoods 2012 coles). stir fry, seafood, with soy based sauce Mixed Seafood with vegetables, no noodles or rice, homemade 1 cup = 253g (using beef stir fry with veges to StirFry Mixed Seafood StirFry - Ausfoods 2012 estimate). Beetroot and Almond dip Beetroot and Almond dip Dip,beetroot, homemade - Ausfoods2012 1 tb = 21g (based on wt of 1 tb of hummus) Gluten Free 1 cup = 150g (based on weight of 1 cup of white Pasta Gluten Free Pasta Pasta, plain boiled pasta, gluten free -Ausfoods 2012 pasta cooked). Healthy Choice Chicken Healthy Choice Chicken Cabanara Cabanara Recipe 1 x healthy choice in as 1 serve. Pasta with seafood in oil Pasta with seafood in oil based pasta,pasta dish, other pasta dish, with seafood, 1 cup = 150g (based on weight of 1 cup of white based sauce sauce in oil based sauce, homemade -Ausfoods 2012 pasta cooked). Bruschetta Bruschetta Bruschetta - Ausfoods 2012 1 slice = 138 g based on Calorie King estimate. Creamy Sauce, pasta, cream-based, added chicken- Ausnut 1 cup = 262 g based on 1 cup of Pasta Chicken Pasta Creamy Chicken Pasta 2007 Foods bolognese,Italian restaurant style McCain Chicken Parmagiana McCain Chicken Parmagiana Recipe 1 x McCains in as 1 serve

483 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

Chicken and Pie,savoury, chicken & vegetable, 174 g = 1 indivdiual pie based on 1 indivdual meat vegetable pie Chicken and vegetable pie 1 pastry crust only, homemade - AusFoods 2012 pie McCain Roast Beef McCain Roast Beef Recipe 1 x McCains in as 1 serve Jelly made up from crystals, diet, 1 cup = 265g (based on 1 cup of Jelly made up, all Jelly Lite Jelly lite without food added - AusFoods 2012 flavours, sugar sweetened). Lite n Easy Roast Beef Lite n Easy Roast Beef Recipe Enter as 1 serve = 479g Lite n Easy Lasagne Lite n Easy Lasagne Recipe Enter as 1 serve = 427g Large size = 480g, individual size =120g, and mini Fruit tart Fruit Tart Tart, fruit only, homemade - Ausfoods 2012 = 40g Goji berries Goji Berries Morlife Goji Berries - Ausbrands 2012 1 tsp = 3.22g

Brioche Brioche Brioche - Ausnut (Allfoods) 1 slice = 30g (based on one slice if white bread). Capsicum 1 stuffed capsicum = 400g (not a whole capsicum, stuffed nfs Capsicum stuffed nfs Stuffed capsicum - Ausfoods 2012 not half). Capsicum stuffed with Capsicum Stuffed with Meat and Capsicum Stuffed with Meat and Rice 1 stuffed capsicum = 400g (not a whole capsicum, meat and rice Rice - Ausfoods 2012 not half). Herring, pickled - AusNut(AllFoods) Fish, Herring, and AUSNUT 2011-13 food nutrient Pickled, tinned Fish, Herring, Pickled, Tinned database used to fill in missing values 1 tin = 110g 1 round Kibbeh = 43g (based on wt of 1 Falafel lamb, kibbi (meat & Burghul), fried, ball, 5 cm in diameter). For flat kibbeh use meat Kibbeh Kibbeh lebanese restaurant style - Nuttab 2010 loaf or mince patty models. Kippers Kippers Kipper, canned (Ausnut Allfoods 1 tin = 200g arancini Arancini Arancini, homemade - Ausfoods 2012 1 piece = 50g, (based on 1 dim sim piece). 1 slice = 73g (1/4 of Bakers deligjht turkish bread, Focaccia based on focaccia /turkish style bread, savoury,w Mediterranean Focaccia Mediterranen Focaccia Olive&Tomato - AusNut (All foods) cheese toasted). TLC Beef in Red Wine Casserole TLC Beef in Red Wine Casserole Recipe Enter as 1 serve = 380g

484 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

TLC Grilled Steak and Mushroom TLC Grilled Steak and Mushroom Sauce Sauce Recipe Enter as 1 serve = 370g TLC Lamb Steak with Rosemary TLC Lamb Steak with Rosemary Recipe Enter as 1 serve = 350g TLC Moroccan Lamb TLC Moroccan Lamb Recipe Enter as 1 serve = 370g TLC Pork Steaks in Plum Sauce TLC Pork Steaks in Plum Sauce Recipe Enter as 1 serve = 370g TLC Sweet and Sour Chicken TLC Sweet and Sour Chicken Recipe Enter as 1 serve = 390g TLC Sweet and Sour Fish TLC Sweet and Sour Fish Recipe Enter as 1 serve = 370g Lite n Easy Baked Turkey Lite n Easy Baked Turkey Recipe Enter as 1 serve = 468g Lite n Easy Chargrilled Steak and Lite n Easy Chargrilled Steak and Pepper Sauce Pepper Sauce Recipe Enter as 1 serve = 448g Lite n Easy Chicken Dijon Lite n Easy Chicken Dijon Recipe Enter as 1 serve = 435g Lite n Easy Chicken in Sweet and Lite n Easy Chicken in Sweet and Sour Sauce Sour Sauce Recipe Enter as 1 serve = 440g Lite n Easy Malay Beef Curry Lite n Easy Malay Beef Curry Recipe Enter as 1 serve = 420g Lite n Easy Roast Lamb Lite n Easy Roast Lamb Recipe Enter as 1 serve = 426g Lite n Easy Spaghetti Marinara Lite n Easy Spaghetti Marinara Recipe Enter as 1 serve = 403g chinese soft flour cake Chinese Soft flour cake Recipe Enter as 1 serve = 48g

485 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

Pasta, pasta dish, ravioli, Ravioli, vegetables with no sauce, homemade Vegetable Ravioli, Vegetable - Ausfoods 2012 1 cup = 264g Isagenix Isagenix Isa lean Shake Natural Creamy Vanilla Isaslean pro Isagenix Isalean Pro - AusBrands 2012 1 packet = 68g Fortisip, Nutricia Fortisip, Nutricia Nutricia Fortisip Vanilla - Nutricia 2012 1 bottle = 200ml Sauce, Calabrese for Pasta (salami, tomato, mushroom and olive) Calabrese Pasta Sauce Recipe 1 cup = 170g based off 1 cup of bolognaise sauce Online facesheet, https://www.souvenaid.com.au/uploadedFiles/ souvenaid_australia/Content/Souvenaid/ Souvenaid_Information_Sheet Souvenaid, /Souvenaid%20fact%20sheet% Nutricia Souvenaid, Nutricia 20-%20consumer.pdf 1 bottle = 125ml Rice paper Rice paper Rice Paper Ausfoods 2012 1 sheet = 14.3g Pork Bun, steamed, without added salt Bun, Pork Bun, Pork - Ausnut (all foods) CalorieKing estimates 1 bun = 100g Caro, Nestle (powder), caffeine free, coffee substitute Caro, Nestle (powder) Caro Powder - Ausfood 2012 CalorieCount estimates 1 tsp = 2.5g Agnolotti Leggo's Large Agnolotti Semi-Dried sundried Tomato with tomato Agnolotti Sundried Tomato Basil and Mozzarella - Ausbrands 2012 1 cup = 264g cabbage roll stuffed with Cabbage roll stuffed with vegetables vegetables Cabbage roll, stuffed with tomato&rice - AUSNUT2013 1 cabbage roll = 130g lamb fritters Lamb fritters Recipe Enter as 1 serve = 277g cabbage, preserved, kimchi cabbage, preserved, kimchi Kim Chee - Pacific Islands 2004 1 cup ~ 76g

486 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

paste, bean paste, bean bean, paste - AUSNUT 2013 1 tb ~25g profiteroles, cream puff profiteroles Coles profiteroles - Ausbrands 2012 Average each = 35g based on Calorie King sardines, canned in oil Sardines, canned in oil sardine canned in oil, drained - AusFoods 2012 1 small tin = 95g Novartis Resourse Plus - Novartis. Override values with correct values from Resource 2.0 + http://www.nestlehealthscience.com.au/ Fibre Resource 2.0 + Fibre products/resource%C2%AE-2-fibre 1 serve or whole bottle is 200ml/200g. Recipe based on nutrition information panel from Beneprotein https://www.nestlehealthscience.us/ powder Nestle Beneprotein powder Nestle products/beneprotein%C2%AE 1 level scoop (1.5 Tblspn) = 7 g or 1 sachet = 7g 1 cup = 255g (based on weight of 1 cup of Soup,meat (beef/lamb/pork,w vegetables & Pho Pho Soup,broth with meat & noodles - AUSNUT2013 noodles,prepared w milk & water) Lite n Easy Mac & Cheese Lite n Easy Mac & Cheese Recipe 1 Serve = 1 meal Lite n Easy Honey Soy Chicken Lite n Easy Honey Soy Chicken Recipe 1 Serve = 1 meal Lite n Easy Fried Rice and Lite n Easy Fried Rice and BBQ BBQ Chicken Chicken Recipe 1 Serve = 1 meal Lite n Easy Nasi Goreng with Chicken Lite n Easy Nasi Goreng with balls. Chicken balls. Recipe 1 Serve = 1 meal Lite n Easy Chicken in Lite n Easy Chicken in Satay Satay Sauce Sauce Recipe 1 Serve = 1 meal Lite n Easy Sausages with Lite n Easy Sausages with Onion Onion Gravy Gravy Recipe 1 Serve = 1 meal Lite n Easy Sausages with Lite n Easy Sausages with Onion Onion Gravy Gravy Recipe 1 Serve = 1 meal

487 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

1 cup = 190g based on beans, cooked. Note 0.5 cup Curry, legume (dhal), Indian restaurant style is Ful Medames Ful Medames Recipe a very similar amount). McDonalds Grand Angus Burger McDonalds Grand Angus Burger McDonalds, Grand Angus Burger - AusFoods 2012 1 burger = 260g 150ml = one standard drink. Assume 150g = Champagne Champagne Champagne - AusFoods 2012 150ml Cannoli filled Cannoli Filled with vanilla, ricotta & cream cheese filling 1 serve = 150g based on estimation from Calorie with ricotta Cannoli filled with ricotta - AUSNUT2013 King Benefibre Powder Novartis Benefibre Powder Novartis Novartis Benefiber Powder - Novartis 3g = 2 teaspoons Chicken Chicken, breast, flesh, canned Chicken canned canned in water, drained - AUSNUT2013 Based on canned goods. Standard can is 85g. Chicken, feet, boiled, casseroled, microwaved, poached or steamed, 1 chicken feet = 45g (estimated from a range 35- Chicken feet Chicken feet with or without added fat - AUSNUT 2013 55kg) Pork knuckle Pork knuckle Pork Knucle grilled - Ausfoods 2012 1 pork knuckle = 250g Buckwheat, 1 cup of cooked buckwheat = 168g (estimated groats, cooked, Buckwheat, groats, cooked, no from http://nutritiondata.self.com/facts/cereal- no added salt added salt - AUSNUT2013 grains-and-pasta/5683/2) Chicken, boiled/steamed Chicken breast, boiled/steamed, with skin skin eaten Chicken, breast, boiled, skin eaten - AusFoods 2012 Use food model Based on 1 small tomato (<3cm dial) or 4 cherry Tomatillo Tomatillos, raw – sized tomatoes = 45g. 1 Cup salsa tomatoes = (Green tomato) Tomatillo (Green tomato) USDA National Nutrient Database SR24 275g. Ouzo (Greek Spirit) Ouzo (Greek Spirit) Ouzo - AUSNUT2013 30 mL (1 nip) = 28.5 g based on 30 mL of whisky

Based on ingredients list and NIP from Coles On The Menu website: Frozen Meals On The Menu Frozen Meals http://shop.coles.com.au/online/mobile/national/on- Prawn Alfredo Prawn Alfredo Recipe the-menu-pasta-prawn-alfredo. 1 Serve = 260g

488 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

On the Menu Based on ingredient list and NIP from Coles Frozen Meals website: Spaghetti and On the Menu Frozen Meals http://shop.coles.com.au/online/mobile/national/on- Meatballs Spaghetti and Meatballs Recipe the-menu-spaghetti-meatballs. 1 Serve = 260g Liquor, Clear based Liquor, Clear based Liqueur, clear, based - AusFoods 2012 30 mL (1 nip) = 28.5 g based on 30 mL of whisky Sauce, Teriyaki Chicken, Sauce, Teriyaki Chicken, Masterfoods stir fry teriyaki chicken recipe Base Masterfoods Masterfoods - AusBrands 2012 1 pack = 175g A1 Steak sauce Sauce, Steak, A1 sauce A1 Steak sauce - AusBrands 2012 1 tb = 17g Dip, capsicum, commercial regular Dip, Capsicum Dip, Capsicum - AUSNUT 2013 1 cup = 260g (using hommus 1 cup) Dip, Chilli and Dip, chilli & nut, commercial, regular nut Dip, Chilli and nut - AUSNUT 2013 1 cup = 260g (using hommus 1 cup) Based on ingredient list and NIP from Coles On the Menu website: Frozen Meals On the Menu Frozen Meals Beef http://shop.coles.com.au/online/national/on-the- Beef Lasagne Lasagne Recipe menu-beef-lasagne. 1 Serve = 260g juice, aloe vera, juice, aloe vera, ready to drink ready to drink juice, aloe vera, ready to drink - AusFoods 2012 Using 1 cup = 250ml, 1g ~ 1ml (liquid) Goat Casserole/Stew Stew, Goat, with tomato based 1 cup = 253g (using beef, stew/casserole, gravy 1 nfs sauce, Homemade Goat casserole/stew nfs - AusFoods 2012 cup = 253g). sugar, barley, from Coles Barley Sugar entry, 1 pc = 6g (calorie lolly sugar, barley, confectionary Coles barley sugar - AusBrands 2012 king) Uncle tobys 1 cup = 43g (Using UNCLE TOBYS MUESLI Plus omega 3 Uncle tobys Plus omega 3 Uncle tobys Plus omega 3 AusBrands - 2012 FLAKES PLUS 1 cup). Walnut/Pecan cake Walnut/Pecan cake cake,walnut,not iced,homemade AusBrands - 2012 Use chocolate cake model. McCains Roast lamb McCains Roast lamb Recipe Use 1 Serve Chinotto (Italian Soft Drink) Chinotto (Italian Soft Drink) Chinotto (italian soft drink) - AusNut 1999 Brands 260 g = 250 mL based on 250 mL of lemonade Average fillet weight 150g according to Calorie Fish, sword Fish, sword Fish, sword - AusFoods 2012 King

489 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

McCain Roast Turkey Dinner McCain Roast Turkey Dinner McCain Roast Turkey Dinner - Ausbrands 2012 1 meal = 320g McCains Based on ingredient list and NIP from McCains Healthy Choice McCains Healthy Choice Apricot http://mccain.com.au/product/healthy-choice- Apricot Chicken Chicken Recipe apricot-chicken-350g/ 1 serve = 350g Custard apple, african, pride, peeled raw 1 whole custard apple edible portion is 288 g Custard Apple Custard Apple - AUSTNUT 2013 according to calorie king Weight Watchers Cottage Pie Weight Watchers Cottage Pie Weight Watchers cottage Pie - Ausbrands 2012 1 serve = 320g 1 piece = 145g (samosa, vegetable, indian Meat samosa Meat samosa samosa,meat filling,baked,homemade - 2012 restaurant style 1 piece) Abalone Abalone Abalone, raw - AusNut (Allfoods) 1 Abalone is 85g Rice paper rolls, chicken/meat Rice Paper rolls, chicken and Spring roll or rice paper roll chicken & and vegetable vegetable. vegetable filling, fresh - Ausnut 2013 1 roll = 120g (Ausnut). Confectionary, 1 piece ~ 15g based on peanut nut snap (golden Peanut brittle Confectionary, Peanut brittle AUSNUT 2013 days) indiv packs Sausage,beef, 1 sausage = 58g based on 1 sausage (nfs) beef low fat, nfs Sausage,beef, low fat, nfs AUSNUT 2014 cooked Spread, vegetable & yeast extract, Spread, vegetable & yeast 1 tsp = 4g, 1 tb = 24g, copying measures from promite extract, promite AUSNUT 2013 Vegemite entry Cheese Fruit and Nut Cheese fruit and nut Coles Fruit and Nut cheese - Ausbrands 2012 1tb = 20.2g Pasta in a Pasta,pasta dish, other pasta dish, 1 cup =150g (based on 1 cup of cooked white pesto sauce Pasta in a pesto sauce plain,basil,pesto,homemade - Ausfoods 2012 pasta). Chocolate 1 cup = 211g (based on 1 cup of bread and butter pudding Chocolate pudding Pudding,chocolate,homemade- Ausfoods 2012 pudding). Salmon and Onion sandwich salmon and onion sandwich Recipe 1 serve = 1 sandwich

490 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

Lite n easy Hearty Beef Lite n easy Hearty Beef Casserole Casserole Recipe 1 serve Cashew, Almond, Hazelnut and 1 tbs approximately 5g (based on Breakfast Coconut cereal,mixed grain Cluster, Be Cashew, Almond, Hazelnut and (wheat,corn,oat),clusters,nuts,added vitamins Natural Coconut Cluster, Be Natural B1,B2 & folate & Fe, entry) Chicken and Cashew Nut Chicken & cashew nut stir fry 1 cup = 253g (based on weight of 1 cup of beef stir stir fry Chicken and cashew nut stir fry ~ restaurant ~ café - Ausfood 2012 fried with veges). Weight Watcher Chicken and Mushroom Weight Watcher Chicken and Weight Watcher Chicken and Fettucine Mushroom Fettucine Mushroom Fettucine - Ausbrand 2012 1 serve = 300g Weight Watchers Beef and Tomato Weight Watchers Beef and Weight Watchers Beef and Bolognese Tomato Bolognese Tomato Bolognese - Ausbrand 2012 1 serve = 225g Weight Watchers Thai Weight Watchers Thai Chicken Weight Watchers Chicken Curry Curry Thai Chicken Curry - Ausbrand - 2012 1 serve = 320g Weight Watchers Beef Lasagne Weight Watchers Beef Lasagne Weight Watchers Beef Lasagne - AusBrand 2012 1 serve = 300g Pasta in cream Pasta, pasta dish, other pasta dish, plain, 1 cup = 150g (based on weight of 1 cup of white based sauce Pasta in cream based sauce cream based sauce, homemade - Ausfoods 2012 pasta cooked). Cherry Ripe Cherry Ripe cadbury Cherry Ripe - Ausbrands 2012 1 individual bar is approx 55g

Puttu Puttu Recipe Use 1 Serve or lasagna model Dessert, apple turnover Turnover, Apple AUSNUT 2013 1 medium ~120g, based on calorieKing Lollie, soft, 1 piece = 3.8g based on 1 piece of Sugar sugar free Lollie, soft, sugar free AusFoods 2012 confectionery,jelly varieties

491 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

Sandwich roll with roast beef Sandwich or roll, filled with (1 Roll = 266g based on Sandwich roll,white or lamb and Sandwich roll with roast beef or roast beef or lamb & salad roll,marinated chicken breast w salad salad lamb and salad - Ausnut 2013 (lettuce,tomato,carrot,onion,capsicum),fast food) Mccain Butter chicken Mccain Butter chicken Recipe 1 serve Tubs from coles are 150g each: http://shop.coles.com.au/online/national/wicked- Pannacotta, nfs Pannacotta, nfs AusFoods 2012 sister-mango-passionfruit-panna-cotta-2-pack Mango, canned in light syrup Mango, canned in light syrup AUSNUT (all foods) 1 cup = 250g (calorie king) Dip, Taramasalata Dip, Taramasalata AUSNUT 2013 1 commercial Tub of dip = 250g or use Tb Soup, Cauliflower Soup, Cauliflower AusFoods 2012 1 cup = 252g based on 1 cup of pumpkin soup Dumpling, no filling Dumpling, no filling AusFoods 2012 1 bread dumpling = 100g according to calorie king

Lettuce Boiled Lettuce Boiled AUSNUT 2013 0.5 cup = 75g based on 0.5 cup of boiled cabbage Mixture is dried thyme (60%), sesame seeds (20%) and sumac (used cumin as an alternative) (20%). Recipe: 9g dried thyme (based on 0.6 cup dried parsley/oregano), Za'atar spice Za'atar spice 0.2 cup sesame seeds (28g), 0.2 cup cumin (22.65g) 1 Tb = 10g, 1 tsp = 2.5g. Based off mixed spice. Rice, Pilaf with spices Pilaf Rice with spices 1 cup = 190g based on 1 cup of cooked white rice. Rice, glutinous, 1 cup = 120g based on white Rice, glutinous, white 1 cup of white flour weight on google Bread, cooked 1 slice = 35g based on one slice of bread with with olives Bread, cooked with olives AusFoods 2012 grains Risotto, pumpkin and cheese Risotto, pumpkin and cheese AUSNUT 2013 1 cup = 280g based on other risotto Pasta, low carbohydrate Pasta, low GI AusFoods 2012 1 cup = 148g based on 1 cup of white pasta boiled

492 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

Pasta, cream pasta, pasta dish, other pasta dish, based with pasta, cream based with with vegetables, creamed based sauce 1 cup =150g (based on one cup of cooked white vegetables vegetables home made - Ausfoods 2012 pasta. Soup, Asparagus Soup, Asparagus AusFoods 2012 1 cup = 265g based on 1 up of mushroom soup Juice, Charlie's Old Fashioned Lemonade Honest Charlie's Old Fashioned Quencher Lemonade Honest Quencher Chilled Chilled AusBrands 2012 100ml = 100g according to website Soup French Onion Soup French Onion AUSTNUT2013 1 cup = 257g based on 1 cup of minestrone soup Soup Carrot Soup Carrot AusFoods 2012 1 cup = 252g based on 1 cup of pumpkin soup Cereal beverage powder Ecco Ecco Instant Cereal beverage 1 teaspoon = 5g, 1 Tablespoon = 20g based on Nestle Nestle AusBrands 2012 intant coffee 1/2 cup = 82.5g based on potato peeled Potato low GI Carisma Potato Low GI AusBrands 2012 boiled drained Fried White 1 stick = 110g (based on 1 Doughnut,dusted with Bread Fried White bread Bread, white, fried - Ausnut (All foods) cinnamon & sugar (bar 14 x 7 x 4cm) Oil, Coconut Oil, Coconut AusFoods 2012 Base quantities off olive oil pure TLC Spinach & Ricotta TLC Spinach & Ricotta Cannelloni Cannelloni Recipe Enter as 1 serve=380g TLC Vegetable Lasagne TLC Vegetable Lasagne Recipe Enter as 1 serve=370g Sugar, low GI Sugar, low GI AUSTNUT2013 Base quantities off Sugar,white,granulated/lump Cake, coffee, iced Cake, coffee, iced AUSTNUT2013 1 slice = 88g using food model Glucose Powder Glucose Powder AustNut (AllFoods) 1 Tb = 11g based on 1 Tb of Sugar,white,icing Chocolate 1 piece = 6.6g (based on 1 piece coated ginger Chocolate coated ginger confectionery, ginger, chocolate-coated - AUSNUT 2013 Chocolate,milk,with dried fruit & nut).

493 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

Mccain Roast Chicken Mccain Roast Chicken Recipe Enter as 1 serve = 320g

Prickly Pear Prickly Pear Prickly pear, peeled, raw - AUSNUT 2013 1 Prickly pear = 40g (based on size of small fig). Chickpeas, roasted, salted Chic Nuts AusBrands 2012 Individual packet = 25g = approx 0.25 cup cider, apple, alcoholic, not further defined, - AUSNUT Cider Alcoholic Cider Alcoholic 2013 1ml = 1g (based on Cider, apple non alcoholic) chocolate rum Cadbury Old Jamaican Dark Chocolate 1 piece = 6.6g (based on 1 piece and raisin chocolate rum and raisin Rum 'N' Raisin block - Ausbrand 2012 Chocolate,milk,with dried fruit & nut). Avocado oil Avocado oil Oil Avocado - Ausfood 2012 1 tb = 18.2g. 1ml - 0.91g (based on olive oil). Bounce Natural energy Ball Almond 1 ball = 32g (Based on weight of Boost Juice Protein ball Protein Ball nfs Protein Hit - AusBrands 2012 Protein ball in calorie king). 30 mL (1 nip) = 28.5 g based on 30 mL of whisky Bitters Bitters Bitters - AUSNUT 2013 or 1 tb = 19g (based on 1 tb of whisky) Pasta sauce, cream based Pasta sauce, cream based with Pasta sauce, with seafood, cream based 1 cup = 280g based on pasta sauce, cream based with seafood seafood sauce, homemade - Ausfood 2012 with added chicken. Tuna, smoked, Canned in oil, Drained use fish model or tin, (base weight on Tuna Smoked Tuna Smoked Tuna - AusNut (All Foods). canned in oil, drained. Cereal, Goodness Superfood Cereal, Goodness Superfood 0.5 cup = 50g according to website. Use cereal Heart Heart AusFoods 2012 model Sandwich tuna Sandwich tuna Sandwich or roll, filled with tuna - AUSNUT 2013 1 sandwich = 96g. TLC Beef Goulash TLC Beef Goulash Recipe Enter as 1 serve TLC Chicken Parmigiana TLC Chicken Parmigiana Recipe Enter as 1 serve TLC Chicken Stroganoff TLC chicken Stroganoff Recipe Enter as 1 serve TLC lamb casserole TLC lamb casserole Recipe Enter as 1 serve TLC silverside and white sauce TLC silverside and white sauce Recipe Enter as 1 serve

494 Manual for nutritional data entry – Sheet 4: New Food Entries at 4th Wave

Cake,cupcake or muffin, ornage Cake, poppy & poppyseed, prepared from dry seed mix,undefined fat,uniced AUSNUT 2013 1 slice 88 g Soup,cream of Soup,Celery celery,canned,condensed USDA National Nutrient Database SR24 1 cup = 252g based on 1 cup of pumpkin soup Enprocal Enprocal Recipe based on 100g. 1 serve is 35g. Lite n easy Butter Chicken Lite n easy Butter Chicken Recipe Enter as 1 serve Magyaros Spenotfozelek 1 cup english spinach cooked, 1 (Hungarian cup cream thick, 1 garlic clove = (Left in this spreadsheet, incase needs to be dish) 2 cups. Plus 1 fried egg on top. Recipe is equal to 2 cups. referred to again.) 0.75 cup minced meat, 0.5 onion, Bobotie 2 eggs, 333ml light milk Recipe is equal to 1 cup Chilaquiles Verdes O'Rojos Corn (Mexican dish) chip,toasted,unflavoured,unsalted 2 cup Serves 1 Chicken breast, boiled/steamed, skin eaten 170g Cream,regular thickened,35% fat 150mL Tomatillos (Green tomatoes) 275g Cheese,feta (fetta),sheep & cows milk 0.5 cup

495 Manual for nutritional data entry – Sheet 5: New Food Entries at 4th Wave

Sheet 5: Additional Rules at 4th Wave.

Food Rule Notes

Unspecified takeaway fish: flake Shark (flake),skinless fillet,baked/grilled (or crumbed) Unspecified home white fish whiting Whiting,king george,flesh only,steamed Decimal places max of 2 Chicken, Baked/Roasted,nfs (unless they specify wing or leg Whole chicken 1.2Kg= Whole spring chicken etc) NfS sugar for coffee/tea 1 tsp Handful of nuts 30g Cup of coffee/tea 180ml or tea/coffee cup Grain waves 1 cup = 20g kraft slice (21.3g) cheese,cheddar,reduced fat (~15%) add 1/2 teaspoon of vegemite for vegemite slices. if specified no fat removed put as untrimmed, no trimmed etc. Still remain as grilled as fat from cooking counted in oil or Meat margarine. (same for chicken and skin). extra small packs 45g, small packs 90g, Chips/crisps large packs 180g. pringles (10) = 20g Meat loaf is considered 1 slice, the In regards to cake slices chocolate cake is 1.5 slices. lamb rib 117g (based on weight of 1 pork rib) dip 21g (based on tb of hommous). Eggs Enter as medium Frankfurt Enter as no. of frankfurts Sausages Enter as thin or thick For combination chinese Chicken,stir fry,chow mein (chicken & meals use Chow Mein noodles),Chinese restaurant style

496 Manual for nutritional data entry – Sheet 5: New Food Entries at 4th Wave

Whenever using a recipe we have created for a Ready Made Meal always put it in as 1 Serve. For other recipes, refer to the New Ready Made Meal Recipes foods in foodworks section. Depends on the type…if unsure use Wurst sausage frankfurt. put in as omelette,chicken egg, cooked with Omelette with green fat + 0.25cups of chosen vegetables (e.g. veggies mixed or spinach).

497 APPENDIX I: ORAL HEALTH AND AGEING ORAL HEALTH QUESTIONNAIRE

498 CHAMP ID:

Oral Health and Ageing

Oral Health Clinic Questionnaire

Chief Investigators

Professor Robert Cumming Professor Fredrick A C Wright Dr Vasant Hirani

A/Professor Vasi Naganathan A/Professor Fiona Blyth Dr Jane Harford

Professor David Handelsman Professor David Le Couteur

Professor Markus Seibel Dr Louise Waite

499 CHAMP ID: CHAMP ID:

CHAMP ORAL HEALTH QUESTIONNAIRE

500 CHAMP ID:

Section 1 – Pain

1. In the past month, have you had pain (or discomfort) in your face, jaw, temple, in front of your ear or in the ear?

Yes No

1a. If yes, how long have you had this pain (discomfort)? s day

2. In the past month, have you had pain (or discomfort) in your mouth, teeth, gums or tongue?

Yes No

2a. If yes, how long have you had this pain (discomfort)? s day

2b. Has this pain (discomfort) been associated with dentures or filled teeth?

Yes No

3. In the past month, has the pain in your face, jaw, mouth or teeth kept you from any of your usual activities (work, going out)?

Yes No

3a. If yes, how many days has it affected your activities? s day

CHAMP ORAL HEALTH QUESTIONNAIRE 1 501 CHAMP ID:

4. Has pain or discomfort from your face, mouth, jaw or teeth prevented or limited you from doing any of the following activities:

4a. Chewing? Yes No N/A

4b. Drinking? Yes No N/A

4c. Exercising? Yes No N/A

4d. Eating hard foods? Yes No N/A

4e. Eating soft foods? Yes No N/A

4f. Smiling or laughing? Yes No N/A

4g. Swallowing? Yes No N/A

4h. Cleaning your teeth/face? Yes No N/A

4i. Yawning? Yes No N/A

4j. Kissing? Yes No N/A

4k. Talking? Yes No N/A

4l. Having a good night's sleep? Yes No N/A

502 CHAMP ID:

Section 2 – Dental Care

1. How often do you brush your natural teeth? Twice per day or more

Once per day

Four to six times per week

One to three times per week

Less than once per week

Intermittently or hardly ever

Never Go to Question 5

2. How difficult do you find it to clean your teeth and/or your dentures?

I don't have any problems

I occasionally have problems

I often have problems

I require assistance to clean my teeth/dentures

Someone cleans my teeth/dentures for me

3. What type of toothpaste do you use to help clean your teeth and mouth? (research officer to check)

No fluoride (<1000ppm) Name Standard (fluoride 1000-1500ppm) Brand High fluoride (5000ppm)

4. About how often do you change (buy a new) toothbrush?

About once per month (12 brushes per year)

About once every 3 - 4 Months (3-4 brushes per year)

About every six months (2 brushes per year)

Every two or three years

Once per year

Every three years or more CHAMP ORAL HEALTH QUESTIONNAIRE 3 503 CHAMP ID:

5. How often do you use dental floss to help you clean your teeth?

Twice per day or more

Once per day

Four to six times per week

One to three times per week

Less than once per week

Intermittently or hardly ever

Never

6. How often do you use tooth picks to help you clean your teeth?

Twice per day or more

Once per day

Four to six times per week

One to three times per week

Less than once per week

Intermittently or hardly ever

Never

7. How often do you use a mouth-rinse or gargle to help you clean your teeth and mouth?

Twice per day or more

Once per day

Four to six times per week

One to three times per week

Less than once per week

Intermittently or hardly ever

Never

504 CHAMP ID:

Section 3 – Mouth Assessment

1. Date of oral examination / / day month year

2. Time of day : hrs

EXTRA-ORAL CONDITION 3. Does the participant have facial asymmetry? Yes No

3b. Does the participant have mandibular lymphadenopathy? Yes No

4. Does the participant have a maxillary denture? Yes No Go to Question 5

4a. Does the participant have a full or partial maxillary denture? Full maxillary denture Partial maxillary denture 4b. What is the condition of the maxillary denture? (Mark all that apply) Retentive Stained/ small defects Stable Large defects Occlusive Attributable to pathology

5. Does the participant have a mandibular denture? Yes No Go to Question 6

5a. Does the participant have a full or partial mandibular denture? Full mandibular denture Partial mandibular denture

5b. What is the condition of the mandibular denture? (Mark all that apply) Retentive Stained/ small defects Stable Large defects Occlusive Attributable to pathology

505 CHAMP ID:

INTRA-ORAL CONDITION

6. General Mucosal Pathology Scoring 1 = Suspected malignant tumour (oral cancer) 2 = Ulcerated lesions (aphthous, herpetic, traumatic) SCORE 3 = Any other oral mucosal lesions X = none of the above

7. Tongue Coating

1 = No visible coating SCORE 2 = Thin coating – papilla visible 3 = Thick coating – papilla no visible

8. Mouth Dryness

1 = Saliva droplets within 30 seconds SCORE 2 = Saliva droplets within 30-60 seconds 3 = No droplets after 60 seconds

9. Biochemistry of the oral cavity 9a. What time did you eat or drink anything other than water? : (hours : minutes)

9b. Salivary pH

SCORE

9c. Salivary Buffering Capacity

SCORE

506 CHAMP ID:

10. Tooth Presence (insert score)

All teeth are missing

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

SCORE

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

SCORE

Scoring 1 = Present permanent tooth 2 = Implant 3 = Missing & replaced 4 = Missing & NOT replaced 5 = Root fragment decayed 6 = Root fragment NOT decayed

11. Functional Tooth Units (insert number) Right Posterior 11a. Natural FTUs 11b. Total FTUs

Left Posterior 11c. Natural FTUs 11b. Total FTUs

507 CHAMP ID:

Section 4 – Periodontal Assessment

Medical History Review Say to the participant: “Now I am going to have a look at your gums. To start with I need to ask you a few questions.”

Has a doctor or dentist ever told you that you must ALWAYS take antibiotics (for example, penicillin) before you go to the dentist? Yes No Have you ever had rheumatic fever? Yes No Do you have kidney disease requiring renal dialysis? Yes No Do you have haemophilia? Yes No Do you have a pacemaker or automatic defibrillator? Yes No Do you have artificial material in your heart, vein or arteries? Yes No Do you have a hipbone or joint replacement that has been Yes No inserted during the last three months?

Do you have any transplanted organs (for example, kidney Yes No transplant)? Has a doctor ever told you that you have a heart murmur? Yes No Have you ever had bacterial endocarditis? Yes No Do you have congenital heart disease? Yes No Has a doctor ever told you that you have heart valve problems? Yes No

If the participant answers YES to any of these questions, DO NOT proceed with the periodontal examination.

Answer Question 1a – No. Unable to attempt due to medical reasons.

1. Was the Periodontal assessment completed? Yes (Complete Q1a and then No (Continue) go to Section 5)

1a. If not why not? Participant did not understand instructions

Unable to attempt due to medical reasons

Did not attempt/ refused

508 CHAMP ID:

Scoring 0 = Nil present Gingivitis 1 = Slight change but no bleeding after pressure with periodontal probe (assessor to circle) 2 = Inflammation with bleeding after pressure with periodontal probe 3 = Marked inflammation; Spontaneous bleeding

0 = Nil present Plaque 1 = A film of plaque found after scraping the surface (assessor to circle) 2 = Visible soft deposits 3 = Abundance of soft matter

Right Maxilla (X Missing teeth)

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

17 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

16 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

15 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

14 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

509 CHAMP ID:

Anterior Maxilla (X Missing teeth) Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

13 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

12 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

11 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

21 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

22 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

23 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

510 CHAMP ID:

Left Maxilla (X Missing teeth) Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

24 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

25 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

26 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

27 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Move to Mandible

511 CHAMP ID:

Left Mandible (X Missing teeth)

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

37 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

36 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

35 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

34 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

33 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

512 CHAMP ID:

Left Mandible (X Missing teeth)

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

32 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

31 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

41 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

42 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

43 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

513 CHAMP ID:

Left Mandible (X Missing teeth)

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

44 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

45 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

46 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

Site Recession Pocket Depth Gingivitis Plaque Calculus

m/b mm mm 0 1 2 3 0 1 2 3 Y N

47 Buccal mm mm 0 1 2 3 0 1 2 3

d/b mm mm 0 1 2 3 0 1 2 3

514 CHAMP ID:

Section 5 – Dental Assessment Decay Experience – Maxilla

Scoring 0 = Sound 3 = Filled - unsatisfactory X = Missing 1 = Decayed 4 = Filled ok 2 = Recurrent caries 5 = No visible root surface

o m b d l o m b d l

Coronal Coronal 18 28 Root Root

o m b d l o m b d l

Coronal Coronal 17 27 Root Root

o m b d l o m b d l

Coronal Coronal 16 26 Root Root

o m b d l o m b d l

Coronal Coronal 15 25 Root Root

o m b d l o m b d l

Coronal Coronal 14 24 Root Root

i m b d l i m b d l

Coronal Coronal 13 23 Root Root

i m b d l i m b d l

Coronal Coronal 12 22 Root Root

i m b d l i m b d l

Coronal Coronal 11 21 Root Root

515 CHAMP ID:

Decay Experience – Mandible

Scoring 0 = Sound 3 = Filled - unsatisfactory X = Missing 1 = Decayed 4 = Filled ok 2 = Recurrent caries 5 = No visible root surface

o m b d l o m b d l

Coronal Coronal 38 48 Root Root

o m b d l o m b d l

Coronal Coronal 37 47 Root Root

o m b d l o m b d l

Coronal Coronal 36 46 Root Root

o m b d l o m b d l

Coronal Coronal 35 45 Root Root

o m b d l o m b d l

Coronal Coronal 34 44 Root Root

i m b d l i m b d l

Coronal Coronal 33 43 Root Root

i m b d l i m b d l

Coronal Coronal 32 42 Root Root

i m b d l i m b d l

Coronal Coronal 31 41 Root Root

516 CHAMP ID:

2. Tooth Wear

Scoring 0 = No exposure of dentine Incisal wear 1 = Some dentine and some enamel visible (assessor to circle) 2 = Complete loss of enamel exposing dentine X = Tooth missing / Restored edge / not assessed

0 = Tooth worn to level of CEJ or apical to it Incisor height 1-12 = whole mm from CEJ (assessor to circle) X = Tooth missing / Restored edge / not assessed

13 12 11 21 22 23 Wear 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2

Height mm mm mm mm mm mm

43 42 41 31 32 33

Wear 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2

Height mm mm mm mm mm mm

517 Postal address: CHAMP, Reply Paid 72908, Concord Repatriation Hospital NSW 2139 Freecall: 1800 174 287 Phone: (02) 9767 7269 Fax: (02) 9767 5419 Email: [email protected]

518