Article published online: 2022-12-13
THIEME
Original Article
Eating Behavior and Caries Experience in
Children with Growth Stunting
Regina Puspita Sari1
Laili Rahayuwati2
Arlette Suzy Setiawan3
1 Faculty of Dentistry, Universitas Padjadjaran, Jatinangor, Indonesia
2 Department of Community Nursing, Faculty of Nursing, Universitas
Padjadjaran, Jatinangor, Indonesia
3 Department of Pediatric Dentistry, Faculty of Dentistry, Universitas
Address for correspondence Arlette Suzy Setiawan, Department of
Pediatric Dentistry, Faculty of Dentistry, Universitas Padjadjaran, Jl.
Sekeloa Selatan 1, Bandung 40132, Indonesia
(e-mail: arlette.puspa@unpad.ac.id).
Padjadjaran, Bandung, Indonesia
Eur J Dent
Abstract
Keywords
►
►
►
►
caries experience
eating behavior
preschool
stunting
Objective Stunting is the impaired growth and development children experience
from chronic malnutrition and repeated infection that cause long-term damage.
Malnutrition for a long time will affect the shape and composition of bones and teeth,
making children more vulnerable to dental health problems. Preschoolers with
sufficiently active consumption can choose the food they like delightful foods so
that it can increase the risk of caries. Based on data from the Bandung City Health Office
in 2019, 161 toddlers (25.43%) in Sukawarna Village experienced stunting. This study
analyzed the relationship between eating behavior and caries experience in stunting
children in Sukawarna Village, Sukajadi District.
Materials and Methods This study uses a quantitative descriptive research method
with a secondary data analysis approach from the documentation of the Universitas
Padjadjaran Academic Leadership Grant data with the title “Aspects of jaw growthdevelopment and family approach in early detection and prevention of stunting.”
Sampling used purposive sampling specifically for preschool children with a sample size
of 80 respondents. The data obtained will be processed and then analyzed using the
Spearman Rank correlation statistical test.
Results Sixty-three percent of respondents have poor eating behavior, and the
majority (80.35%) have cavities due to caries (decay). Spearman Rank correlation
coefficient is 0.145 and significance is 0.0983.
Conclusion Overall eating behavior is related to the caries experience in stunting
children. Consumption of cariogenic foods influences the caries experience.
Introduction
Malnutrition is a common problem in some developing
countries and includes being underweight, stunting, wasting, and micronutrient deficiencies.1 Growth stunting is
caused by chronic malnutrition and recurrent disease that
causes long-lasting damage leading to children growing
shorter than the standard height for their age. Prolonged
DOI https://doi.org/
10.1055/s-0042-1758069.
ISSN 1305-7456.
nutrition deficiency will cause irreversible physical and
cognitive abnormality, metabolic disorders that increase
the risk of children experiencing obesity and diabetes, and
dental health problems.2,3 Growth stunting starts in the first
1,000 days of a child’s life, intrauterine until approximately
2 years old. Indonesia is included in the second-highest
prevalence of stunting in the Southeast Asia Region after
© 2022. The Author(s).
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Eating Behavior and Caries Experience in Children with Growth Stunting
Cambodia. The prevalence of stunting in Indonesia in 2018
was 30.8%, then in 2021 it was reported that the prevalence
of stunting was 24.4%. Although it is decreasing, the figure is
still high because the World Health Organization (WHO)
target is 20%.4–6
The preschool age period (3–5 years) is the initial period
for developing children’s abilities. Children will learn about
behavior, eating habits, and food during this period.7 According to the Minister of Health of the Republic of Indonesia No.
41 of 2014, eating behavior is an essential aspect of life as it
can affect long-term health because the quality and quantity
of food and drinks consumed will affect nutritional status.
The nutritional status of children under 5 is an integral part
of health indicators. If there is a nutritional problem in this
golden age, it is difficult to return it even though the
following nutritional needs are met.8 Inadequate nutritional
status in children will affect the shape and composition of
bones and teeth. Chronic undernutrition has been associated
with disturbed dental development, including enamel hypoplasia and delayed eruption, so children are more susceptible
to demineralization and caries.9,10 Preschoolers, as sufficiently active consumers, can choose the food, they like,
especially sweet foods so that it can increase the risk of
caries.2
Dental health is one of the most important things
because it is the first entry point for food. Caries is a dental
health problem that often occurs in children. Caries occurs
because food residue is attached to the teeth, which causes
cavities.11 Indonesian health research data in 2018 showed
that the prevalence of dental and oral problems in
Indonesia has increased compared with 2013, from 25.9%
in 2013 to 57.6% in 2018. The prevalence of dental and oral
problems in Bandung City is 50.02%.12,13 In children who
experience growth stunting, there is a decrease in the
salivary flow because of the atrophy of salivary glands; it
affects self-cleaning abilities and increases the risk of
caries.9,10 Dental health, nutritional intake, and eating
behavior are closely related to the growth and development
phase in children. A balanced nutritional intake plays a role
in supporting dental health, and dental health plays a vital
role in adequate nutritional intake.14–16 Based on the
Decree of the Mayor of Bandung in 2020, Sukawarna Village
is the village with the fourth-highest risk of stunting
in Bandung City.17 Therefore, this study aimed to analyze
the relationship between eating behavior and caries experience in stunting children in Sukawarna Village, Sukajadi
District.
Materials and Methods
Study Design
A quantitative descriptive study with a secondary data
analysis approach was conducted from September 2020 to
March 2021. The secondary data were collected from the
modified WHO food frequency questionnaire and Decayed,
Missing, Filled Teeth Index (DMFT) scores from the documentation of the Universitas Padjadjaran Academic Leadership Grant data.
European Journal of Dentistry
© 2022. The Author(s).
Sari et al.
Eligibility Criteria
The population of this study was 164 data of children aged
under 5 years recorded to have growth stunting. Sampling
was performed using a purposive sampling method leading
to the minimal sample size of 80.18 Data from children aged
up to 3 years were excluded from this study.
The secondary data that were reanalyzed were data on eating
behavior and caries experience. The eating behavior was modified from the National Health and Nutrition Examination Survey
(NHANES) food frequency questionnaire containing 23 questions, including carbohydrates, protein, fat, fast food, fiber, and
snacks, coded 1 to 4 for each answer.19 Eating behavior is the
suitability of eating in children that can affect meal times, amount
of food intake, food preferences, and food choices involving
carbohydrates, protein, fat, fast food, fiber, and snacks. Eating
behavior was assessed through a modified WHO food frequency
questionnaire. The score is categorized into poor eating behavior
if the score is less than population mean and eating behavior is
good if the score more than population average.
The DMFT score is used to measure the caries experience
of primary teeth by summing up cavities due to caries
(decay), teeth extracted due to caries (missing), and teeth
filled due to caries (filling).20 Caries experience is a dental
health status that has experienced caries and is assessed
using the DMFT scores that were categorized into very low
(0–1.1), low (1.2–2.6), moderate (2.7–4.4), high (4.5–6.5),
and very high (>6.6).
Data Analysis
The data were not normally distributed. Data analysis used
Spearman Rank correlation test using SPSS v25.0 software
with a p-value less than 0.05.
Ethical Aspects
The research has been reviewed and passed the ethical
clearance from the Universitas Padjadjaran Research Ethics
Commission with document number 172/UN6.KEP/EC/2022.
Results
The secondary data collected and analyzed for this study are
presented in tabular form. The characteristics of the respondents in the secondary data are shown in ►Table 1, where the
Table 1 Distribution of respondent characteristics by gender
and age
Characteristic
n
%
Male
41
51.25
Female
39
48.75
3 years
45
56
4 years
35
44
1. Gender
2. Age
5 years
Total
0
0
80
100.00
Eating Behavior and Caries Experience in Children with Growth Stunting
number of boys (51.25) is more than that of girls. Respondents aged 3 years recorded the most compared with other
ages (56%). Meanwhile, the response data for the NHANES
food questionnaire are collected in ►Table 2. It can be seen
that most children consume rice, chicken, tempeh/tofu,
whole cream milk, vegetable oil, fruit and vegetables, and
snacks. The grouping of eating behavior and DMFT score is
shown in the same table, namely ►Table 3, which shows 63%
of respondents have poor eating behavior and also that the
majority of respondents have cavities due to caries (decay)
80.35%. Caries is more prevalent in female respondents, 54%,
and most caries occur in children aged 3 years
(56.47%; ►Table 4). All data are then analyzed and presented
in ►Table 5.
Sari et al.
Discussion
Eating behavior is related to eating habits, food selection, and
the amount of food eaten.21 Children of preschool age have
the potential to experience psychological development and
become toddlers who are independent and can express the
emotions they feel. Preschoolers have an active consumption
trait. Children can determine what food they want to eat.
However, the problem is that children cannot determine
which foods are suitable for consumption to meet their
nutritional needs.22
According to Loka, preschoolers can eat with a frequency
of three main meals: morning, afternoon, and evening, and
are given two small snacks.23 Based on the questionnaire
Table 2 Distribution of modified food frequency questionnaire results
Category
Often
Rarely
4–6x/week
(3)
>1x/day
(4)
Never
(1)
<1–3x/week
(2)
n
%
n
%
n
%
n
%
80
100
0
0
0
0
0
0
1. Carbohydrates
Rice
Noodles
0
0
0
0
29
36
51
64
Bread
0
0
1
1
77
96
2
3
Cow
0
0
0
0
29
36
51
64
Goat
0
0
0
0
0
0
80
100
Chicken
39
49
41
51
0
0
0
0
Fish
0
0
1
1
29
36
50
63
Tempe/tofu
75
94
5
6
0
0
0
0
Nuts
0
0
0
0
29
36
51
64
2. Protein
3. Fat
Full cream milk
80
100
0
0
0
0
0
0
Vegetable oil
80
100
0
0
0
0
0
0
Innards
0
0
0
0
0
0
80
100
Cheese
0
0
1
1
29
36
50
63
Butter
0
0
1
1
29
36
50
63
Coconut cream
0
0
0
0
29
36
51
64
Fast food
0
0
3
4
27
34
50
63
Soft drink
0
0
1
1
28
35
51
64
Fried food
1
1
1
1
28
35
50
63
Fruit
38
48
42
53
0
0
0
0
Vegetable
36
45
44
55
0
0
0
0
Candy
80
100
0
0
0
0
0
0
Sweet biscuits
80
100
0
0
0
0
0
0
Sweet drink
80
100
0
0
0
0
0
0
4. Fast food
5. Fiber
6. Snack
European Journal of Dentistry
© 2022. The Author(s).
Eating Behavior and Caries Experience in Children with Growth Stunting
Table 3 Eating behavior and DMFT score
Table 4 Distribution of DMFT scores based on characteristics
No
Category
n
%
Characteristic
1
Good eating behavior
30
37
1. Gender
2
Poor eating behavior
50
63
80
100.00
Total
Sari et al.
DMFT score
F
%
Male
Decay
185
46
Female
Decay
217
54
No
Category
F
%
1
Decay
323
80.35
3 years
Decay
227
56.47
2
Missing
79
19.65
4 years
Decay
175
43.53
3
Filling
5 years
Decay
0
0
402
100,00
Total
0
0
402
100.00
2. Age
Total
Abbreviation: DMFT, Decayed, Missing, Filled Teeth Index.
Abbreviation: DMFT, Decayed, Missing, Filled Teeth Index.
Table 5 The results of statistical analysis of the relationship between eating behavior and caries experience in stunting children in
Sukawarna Village, Sukajadi District using Spearman Rank
Eating behavior
Spearman’s rho
Eating behavior
Caries experience
Correlation coefficient
1.000
Sig.(2-tailed)
–
n
80
Correlation coefficient
© 2022. The Author(s).
0.145
0.0983
0.145
80
1.000
Sig. (2-tailed)
0.0983
–
n
80
80
results, it was found that children always consumed a
carbohydrate source in the form of rice more than once a
day. This is in line with Febriyani and Mexitalia, children
never refuse carbohydrates, and Karyani et al conducted in
two kindergartens, found that preschoolers always consume
carbohydrates.22,24 Children always consume protein sources, vegetable, and animal products such as tofu, tempeh, and
chicken, while beef, goat, fish, and nuts are rarely consumed.
Preschool children need protein to support growth and
development.25 Fat is needed by the body to absorb fatsoluble vitamins, and fat is a crucial source for growth, but if
the amount is excessive for a long time will cause excess fat
accumulation in the body and the risk of obesity.25 All
children consumed fat in the form of whole cream milk
and vegetable oil more than once a day. The questionnaire
results found that children rarely consume fast food, soft
drinks, and fried foods. This is not in line with Hermina’s
research at a kindergarten in South Jakarta, which states that
there is a tendency for fast food to be consumed by preschool-aged children.26 The results also show that respondents have a habit of frequently consuming fruits and
vegetables every day. This is not in line with the research
of Has et al on preschool children in urban areas and Karyani
et al conducted in two kindergartens that preschool children
rarely consume vegetables and fruit.22,27 According to
Febriyani and Mexitalia, children usually do not like vegetables because there is a bitter taste in them.24
According to the results of the researcher’s analysis, many
children’s eating behavior is not good because the food
European Journal of Dentistry
Caries experience
consumption of each child is less diverse. According to
Scaglioni et al, parents’ eating habits and feeding patterns
are the most dominant factors in children’s eating behavior
and food choices.28 Parents’ income levels and mothers’
education levels play a role in influencing children’s consumption quality. The higher income of the parents will
improve eating behavior because of the various foods. A
mother’s education level can be the basis for making decisions and actions to provide and regulate daily food portions
to meet nutritional adequacy.29
Caries Experience
From the study results, most children had cavities due to caries
(80.35%) compared with teeth extracted due to caries (19.65%),
and no teeth were filled. These results are in line with Nabila’s
research which reported that the most components found in
preschool children were decay, missing, and filling.30
Several factors influenced the high rate of decay: oral
hygiene, composition and frequency of food, socioeconomic
status, salivary flow rate, and use of fluoride.10 Saliva contains secretory immunoglobulin A, which protects teeth
against caries-causing bacteria.30 In children, stunting may
affect salivary gland atrophy, which causes the decrease of
salivary function as a protector; it can make the teeth more
susceptible to caries.30 The absence of filling teeth can be
caused by parents’ wrong perception regarding replacing
primary teeth with permanent ones.30
Based on Blum’s theory, individual oral and dental health
is influenced by heredity, environment, behavior, and health
Eating Behavior and Caries Experience in Children with Growth Stunting
services. In Blum’s theory, the behavior in maintaining health
is influenced by knowledge, attitudes, and actions.31 This is
in line with research conducted by Afrinis et al that there is a
significant relationship between a mother’s knowledge
about dental and oral health and the incidence of caries.
The leading cause of caries is an unhealthy lifestyle related to
teeth brushing habits.32 This is in line with the research of
Afrinis et al, which said there was a relationship between
brushing habits and the incidence of dental caries.32
Based on the study’s results, as stated in ►Table 5, caries in
women are higher (54%) than in men (46%). This is in line
with research conducted by Malaka et al (in Amiqoh) which
states that men and women have the same tendency to get
caries, but in women, teeth erupt more quickly, causing the
teeth to stay longer in the mouth and take longer to have
intercourse with caries risk factors.33 This is not in line with
the chi-square analysis conducted by Kali, which states that
there is no significant relationship between gender and
dental caries.34
From the study results, most caries occurred at the age of
3 years, which was 56.47%, while at the age of 4 years, it was
43.53%. These results are directly proportional to the chisquare analysis by Ruslan that there is a significant relationship between the child’s age and the incidence of caries. This is
not in line with research conducted by Pindobilowo (in Ruslan)
which states that the younger the child is, the lower the risk of
developing caries and Prakash et al (in Ruslan), which states
that caries increases with age because of many eruptions of the
teeth and consumption of cariogenic foods.35
Relationship between Eating Behavior and Caries
Experience
Based on the results of the Spearman Rank analysis, the value
of p ¼ 0.0983 (ρ <0.05). This is because the eating behavior in
this study is the current eating behavior of preschool-aged
children. Stunting is a state of malnutrition for a long time.
Conditions of nutritional status in 1,000 days of life start
from when the child is in the womb and continues until at
least the first 2 years of postnatal life. These 1,000 days of life
can affect the occurrence of stunting because this period is a
critical window period for children.36 At this time, adequate
nutritional intake is needed for both mother and child
because the growth and development of children occur
significantly. Health and maternal conditions are prenatal
factors that can cause stunting, while postnatal factors can be
caused by infection, environment, and nutrition.37 Stunting
can occur in normal-born babies if their nutritional intake is
inadequate.30 According to Krisnana et al, pregnancy is a
prenatal factor related to stunting, while the postnatal factor
is exclusive breastfeeding for toddlers.36 Ramadhandi et al, as
stated by Ariati, said there was a significant relationship
between food intake, mother’s knowledge of complementary
foods and the nutritional status of stunting toddlers. This is
in line with Ariati, who said that maternal nutrition status
during pregnancy, history of exclusive breastfeeding, and
protein intake cause stunting.38
Caries is a multifactorial disease.39 The hosts that are
closely related to the occurrence of caries are tooth structure
Sari et al.
and saliva. In children, stunting is a host factor related to
dental structural abnormalities, enamel hypoplasia, and
delayed tooth eruption, so children are more susceptible to
demineralization and caries.30,40 Deficiency of vitamins D
and A and protein-energy malnutrition can cause enamel
hypoplasia and salivary gland atrophy.41 Salivary gland
atrophy causes decreased saliva production and interfere
with its function as a buffer, cleanser, and antibacterial,
which will increase the risk of caries.42 This is in line with
research by Achmad et al that there is a relationship between
stunting in children with oral health conditions, including
the incidence of caries, delayed eruption of permanent teeth,
and affecting the rate of salivary flow. Stunting in children
and dental health conditions are interconnected.10
Aviva et al, in their research, stated that stunting children
had a higher caries rate in primary teeth than normal
children.43 In Nabila’s study, stunting children had an average caries experience score of two times higher than the
control group.30 Rahman and Adhani in their research stated
that the mean DMFT scores in stunting children are almost
three times higher than in normal children.42 Stunting
children have a 3.4 times higher chance of experiencing
caries than normal nutritional children. The results of the
study contained in ►Table 2 show that respondents always
consume sweet snacks and sweet drinks with a frequency of
more than once a day, and this is following the research of
Karyani et al which states that children generally like sweet
foods.22 Dental caries in preschool children is because children have a habit of consuming cariogenic foods, and if left
for a long time, will cause caries.32
Cariogenic foods contain fermented carbohydrates that
can cause plaque pH to drop to 5.5 or less and can encourage
caries.44 The chi-squared test analysis conducted by Ismail
said there was a significant relationship between the consumption of cariogenic foods and the incidence of dental
caries.34 These results are in line with Afrinis et al who stated
that there is a significant relationship between sweet foods
and the occurrence of dental caries.32 From the study results,
the effect of eating behavior on the caries experience in
stunting children is 2.1%, or it can be concluded that they
have a nonsignificant relationship. At the same time, the
remaining 97.9% is influenced by other factors, for example,
host factors, economic status, fluoride use, mother’s efforts
to maintain the child’s dental health, and how to brush teeth
correctly by mother.
Conclusion
Consumption of cariogenic foods influences the caries
experience. Although, statistically, eating behavior has no
relationship with caries experience, overall, eating behavior
has a relationship with caries experience in stunting children. In this study, there were no respondents aged 5 years.
The data used is secondary data from the modified WHO
food frequency questionnaire, so that researchers cannot
know the daily consumption portion of the type of food
consumed. Further research needs to be conducted with a
broader scope regarding the eating behavior of stunting
European Journal of Dentistry
© 2022. The Author(s).
Eating Behavior and Caries Experience in Children with Growth Stunting
children of preschool age, for example, eating behavior and
tooth brushing behavior with caries experience in stunting
children.
Authors’ Contributions
RPS collects data analyses and makes the first draft; ASS
generates ideas and designs, drafts the first draft, reviews
the first draft, and completes the final draft; LR reviews
the first draft.
Conflict of Interest
None declared.
15 Omer Muhammad N, Ali Al-Obaidi D, Mohammad Amen D.
16
17
18
19
Acknowledgments
The authors wish to thank Universitas Padjadjaran Academic Leadership Grant for the data. We also thank Dr. Sri
Susilawati, Dr. Felisha Balafif, and Dr. Anggun Rafisa for
the constructive review during mini-thesis defense.
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