Tooth loss and dietary intake

Abstract

Several studies have reported that impaired dentition status is associated with poor nutritional intake. However, most of these studies are cross-sectional and thus are unable to clarify the temporal sequence.
We assessed the longitudinal relation between tooth loss and changes in consumption of fruits and vegetables and of nutrients important for general health among 31,813 eligible male health professionals.
Subjects who lost five or more teeth had a significantly smaller reduction in consumption of dietary cholesterol and vitamin B12, greater reduction in consumption of polyunsaturated fat and smaller increase in consumption of dietary fiber and whole fruit than did subjects who had lost no teeth. Men who had lost teeth also were more likely to stop eating apples, pears and raw carrots.
The results support the temporal association between tooth loss and detrimental changes in dietary intakes, which could contribute to increased risk of developing chronic diseases.
Dietary evaluation and recommendations can be incorporated into dental visits to provide a greater benefit to patients.

Full text

Background. Several studies have
reported that impaired denti-
tion status is associated
with poor nutritional
intake. However, most of
these studies are cross-
sectional and thus are
unable to clarify the tem-
poral sequence.
Methods. We assessed the
longitudinal relation between tooth loss
and changes in consumption of fruits and
vegetables and of nutrients important for
general health among 31,813 eligible male
health professionals.
Results. Subjects who lost five or more
teeth had a significantly smaller reduction
in consumption of dietary cholesterol and
vitamin B12, greater reduction in consump-
tion of polyunsaturated fat and smaller
increase in consumption of dietary fiber and
whole fruit than did subjects who had lost
no teeth. Men who had lost teeth also were
more likely to stop eating apples, pears and
raw carrots.
Conclusions. The results support the
temporal association between tooth loss and
detrimental changes in dietary intakes,
which could contribute to increased risk of
developing chronic diseases.
Practice Implications. Dietary evalu-
ation and recommendations can be incorpo-
rated into dental visits to provide a greater
benefit to patients.
Tooth loss and dietary
intake
HSIN-CHIA HUNG, D.D.S., Dr.P.H.; WALTER
WILLETT, M.D., Dr.P.H.; ALBERTO ASCHERIO, M.D.,
Dr.P.H.; BERNARD A. ROSNER, Ph.D.; ERIC
RIMM, Sc.D.; KAUMUDI J. JOSHIPURA, B.D.S., Sc.D.
The relationship between tooth loss and nutri-
tional intake is important. Diet has a role in
the cause and prevention of several systemic
diseases such as cardiovascular diseases,1and
detrimental changes in dietary intake caused
by poor dental status are proposed as one of the media-
tors for poor oral health as a risk factor for cardiovas-
cular disease.2-15 Because of the high prevalence of tooth
loss among older adults,16-18 even a small excess risk of
developing chronic diseases owing to dental disease
would have a significant impact.
Tooth loss reduces masticatory ability
and, hence, can alter food selection. The
Veterans Administration Dental Longi-
tudinal Study conducted in Boston
among 1,231 men enrolled between 1963
and 1968 found tooth loss to be associ-
ated with decreases in masticatory per-
formance, perceived ease of chewing and
acceptability of some specific foods.19-21
Several studies also reported an inverse
association between progressively
impaired dentition and intake of several
nutrients and of fruits and vegetables.22-
27 However, many studies did not adjust for total calorie
intake as well as other potential confounders, which lim-
ited the interpretation of the results.23 These studies
also measured dietary intake and dental status at the
same time and were unable to clarify the temporal
sequence.
Joshipura and colleagues23 observed that edentulous
subjects in a cohort of 49,501 men had significantly
lower intake of vegetables, fiber and carotenoids and
higher intake of cholesterol and saturated fat than did
those with 25 or more teeth. The associations were inde-
pendent of age, caloric intake, smoking status, profes-
ABSTRACT
JADA, Vol. 134, September 2003 1185
Dietary
evaluation and
recommendations
can be
incorporated
into dental visits
to provide a
greater benefit
to patients.
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sion and physical activity. Longitudinal
analysis suggested that detrimental
changes in dietary intake followed inci-
dence of tooth loss, but there was insuf-
ficient power to detect significance.
After an extended period of follow-up
with the same cohort, we now have sub-
stantially more power to examine the
relationship between tooth loss and
dietary changes. In this article, we pre-
sent the longitudinal analyses between
tooth loss and the consumption of spe-
cific foods and nutrients that have been
associated with cardiovascular and
other systemic diseases. These specific
foods and nutrients include fruits, veg-
COVER STORY
Copyright ©2003 American Dental Association. All rights reserved.

etables, vitamins B6, B12, C, D and E, carotene,
beta-carotene, folic acid, fiber, flavonoids, potas-
sium, cholesterol and specific types of fat.
SUBJECTS, MATERIALS AND METHODS
Study population. The Health Professionals’
Follow-up Study was designed as a prospective
cohort study initiated in 1986 with 51,529 male
health professionals aged 40 to 75 years: 29,683
dentists, 3,745 optometrists, 4,185 pharmacists,
2,218 osteopathic physicians, 1,600 podiatrists
and 10,098 veterinarians. Study participants
answered detailed mailed questionnaires that
included a comprehensive diet survey, questions
on lifestyle practices and a medical history. The
number of teeth present was
assessed on the 1986 baseline ques-
tionnaire and questions on recent
tooth loss were added to biennial
questionnaires starting from 1988,
which were used to update the
information on potential risk fac-
tors and medical conditions. Semi-
quantitative food frequency ques-
tionnaires, or FFQs, were sent out
in 1986, 1990 and 1994. This study
has been approved by the human
subjects committee of Harvard
School of Public Health, Boston,
and subjects’ completion of self-
administered questionnaires constituted informed
consent.
Assessment of dietary intake. The assess-
ment of dietary intake was described in detail
previously.28 We assessed dietary intake by semi-
quantitative FFQs, in which a commonly used
unit or portion for all items of food was specified
(such as one tomato, one glass of orange juice),
and subjects indicated how often, on average,
they had consumed that food over the past year.
The validity and reproducibility of this FFQ have
been published in previous studies.28,29 The fre-
quencies were reported in nine categories,
ranging from less than once a month to six or
more times per day. We computed nutrient
intakes, excluding supplements, by multiplying
the frequency with which each food was con-
sumed by the nutrient content of the specified
portions,30 and we adjusted for total calorie intake
by the residual method.31
We also calculated the total daily intakes of all
fruits (with or without juice) and vegetables for
each respondent from his reported consumption
frequencies of individual fruits and vegetables.
Compared with one-week diet records and cor-
rected for within-person weekly variation, the
Pearson correlation coefficients ranged from 0.35
for vitamin B12 without supplements to 0.5 for
vegetables, 0.7 for fruits and 0.77 for vitamin C
without supplements.28,31
Exposure measure. In biennial question-
naires, we asked the number of teeth lost in the
previous two years in the categories of zero, one,
two, three, four, five to nine, and 10 or more. We
do not have information on the validity of self-
reported incidence of tooth loss, but self-reported
residual number of teeth was highly correlated
with the actual number of teeth on clinical exami-
nation in the general population
(r= 0.97),32 hence, we expected a
high validity for self-reported inci-
dent tooth loss.
Data analysis. In the analyses,
we only included participants who
answered all four questionnaires
(1988, 1990, 1992 and 1994). We
further excluded participants who
reported an extreme daily energy
intake (< 800 kilocalories or > 4,200
Kcal) or who left blank 70 or more
questions in dietary questionnaires.
Participants who did not report the
baseline number of teeth or infor-
mation on potentially confounding variables were
further excluded. Since baseline number of teeth
was reported in categories of zero, one to 10, 11 to
16, 17 to 24 and 25 to 32 teeth, and men with no
teeth or one to 10 teeth might not have enough
teeth to lose five or more teeth during follow-up,
we included in the analyses only men who had 11
or more teeth at baseline. There were 31,813 eli-
gible participants.
We used SAS software (Version 8, SAS Insti-
tute, Cary, N.C.) for the analyses. We summed
the reported number of teeth lost every two years
from four questionnaires, and categorized it into
three groups of zero, one to four, and five or more
teeth lost during this eight-year period from 1986
to 1994. We computed mean baseline intakes in
1986 and changes (intakes in 1994 minus intakes
in 1986) in specific foods and nutrients of interest.
We computed the least-square means of dietary
change for the three categories of teeth lost using
analysis of covariance with a general linear model
adjusting for change in total energy intake, base-
line dietary intake and number of teeth and age.
1186 JADA, Vol. 134, September 2003
TRENDS
By 1994, all subjects
reduced their intakes
of saturated fat and
cholesterol and
increased their
intakes of most
beneficial nutrients
and fruits and
vegetables.
Copyright ©2003 American Dental Association. All rights reserved.

Since tooth loss and dietary intake both might
be associated with healthy behavior and attitude
and socioeconomic status, we evaluated other
potential confounders, such as smoking, body
mass index, physical activity, diabetes, hyperten-
sion, hypercholestermia, alcohol drinking,
vitamin use and profession. However, adjusting
for some of these factors did not influence the
results appreciably. Hence, the final models only
adjusted for change in total energy intake, base-
line dietary intake, number of teeth, age, smoking
status (current, former or nonsmoker), physical
activity (five categories from lowest quintile to
highest quintile) and profession (dentist or non-
dentist) in the analyses.
For testing the linear trends across number of
teeth lost, we summed number of teeth lost in
each two-year period. For those who indicated
having lost five to nine teeth or 10 or more teeth,
we assumed they lost seven and 10 teeth, respec-
tively. Trends in the change of nutrients and
foods intake across total number of teeth lost in
an eight-year period were tested using an ordinal
variable (zero, one, two, three, four or seven for
five to nine teeth lost and 10 for 10 or more teeth
lost). Since the changes in nutrient and food
intake might not fit the assumption of normality,
we performed similar analyses using the rank-
transformation of the change in calorie-adjusted
nutrients intake and daily intake of fruits and
vegetables. The results showed very similar pat-
terns. Hence, we present results only from para-
metric analyses.
We also examined the percentages of men con-
suming specific fruits and vegetables (bananas,
cantaloupes, apples, pears and carrots) in 1994
among participants who reported consuming
these foods at least once per week in 1986. With
the Mantel-Haenszel test, we evaluated whether
men with more tooth loss would have greater
changes in their intake of harder foods after we
adjusted for confounders.
RESULTS
Table 1 shows the distribution of tooth loss
during an eight-year period by potential con-
founding variables among 31,813 men with at
least 11 teeth in 1986. There were 78.3 percent of
the men without any tooth loss, 18.8 percent who
had lost one to four teeth and 2.8 percent who lost
five or more teeth in the period from 1986
through 1994. Men who had lost more teeth were
older than those who had had no tooth loss (mean
age 52.5 for men who had lost no teeth, 57.3 for
men who had lost one to four teeth and 60.2 for
men who had lost five or more teeth). After
adjusting for age, we found that subjects with
tooth loss appeared to have worse profiles of
potentially confounding variables than those
without tooth loss. Among men who had lost five
or more teeth, approximately 24 percent were cur-
rent smokers, while only 7 percent of men
without tooth loss were smokers in 1986. Number
of teeth at baseline was associated negatively
with tooth loss. Almost one-half of the men with
11 to 16 teeth experienced tooth loss, while only
20 percent of men with 25 to 32 teeth had tooth
loss during the eight years.
Table 2 (page 1189) presents the crude means
of baseline intakes in 1986 and differences in
calorie-adjusted nutrients and fruits and vegeta-
bles from 1994 through 1986 among participants
who had lost zero, one to four and five or more
teeth. The three groups had similar average base-
line dietary intake of these nutrients and fruits
and vegetables. All groups seemed to have
improved their dietary pattern over this eight-
year period. By 1994, they reduced their intakes
of saturated fat and cholesterol and increased
their intakes of most beneficial nutrients and
fruits and vegetables.
In the model adjusting for change in total
energy intake and baseline age, dietary intake
and teeth number (Table 3, page 1190), those who
did not lose any teeth seemed to have greater
improvement in dietary pattern during this eight-
year period compared with men who lost teeth.
There was no difference in the change of total
energy intake. Men without tooth loss had
greater reductions in daily dietary intake of satu-
rated fat, cholesterol and vitamin B12 and greater
increases in dietary fiber, carotene and fruits
compared with men who lost teeth. However,
when we additionally adjusted for smoking
status, physical activity and profession, the
results showed fewer differences among tooth loss
groups. Participants who had lost one to four
teeth were not significantly different from those
without tooth loss in the changes of these dietary
variables except for cholesterol and dietary fiber.
Participants who had lost five or more teeth
appeared to have a smaller reduction in dietary
cholesterol (–36.7 milligrams per day versus
–47.8 mg/day) and vitamin B12 (–0.64 micrograms
per day versus –1.34 μg/day), and more reduction
in polyunsaturated fat (–1.47 grams per day
JADA, Vol. 134, September 2003 1187
TRENDS
Copyright ©2003 American Dental Association. All rights reserved.

versus –1.21 g/day) and vitamin E (–0.54 mg/day
versus –0.14 mg/day) than those without any
teeth lost, but the test for linear trend for vitamin
E across number of lost teeth was of only border-
line significance (P = .07). They also had a
smaller increase in dietary fiber (1.16 g/day) and
solid fruit (0.06 serving per day) than did partici-
pants without tooth loss, who increased dietary
fiber intake by 1.69 g/day
and consumption of whole
fruits by 0.17 serving/day.
Table 4 (page 1191)
shows, by number of teeth
lost, the percentage of
men who had consumed
these specific food items at
least once a week in 1986
and still consumed the
items at least once per
week in 1994. There was
no association between
tooth loss and change in
consumption in bananas
and cantaloupes, which
we considered easy to
chew. For participants
who consumed apples or
pears weekly in 1986,
those who had lost five or
more teeth were signifi-
cantly more likely to stop
eating apples or pears
than were the other two
groups; 79 percent of those
without tooth loss, 78 per-
cent of those who had lost
one to four teeth and 70
percent of those who had
lost five or more teeth
remained frequent con-
sumers. Among those who
ate carrots at least once
per week in 1986, a signif-
icantly higher percentage
of those who lost teeth did
not consume raw carrots
frequently compared with
those who had not lost any
teeth. Although men with
greater tooth loss were
more likely to consume
cooked carrots, the differ-
ence was not significant
after we adjusted for other variables.
DISCUSSION
The results of this study support the detrimental
impact of tooth loss on dietary intake. Although,
in general, participants in these three groups
changed their diet in a healthier manner over this
eight-year period, men who lost five or more teeth
1188 JADA, Vol. 134, September 2003
TRENDS
TABLE 1
AGE STANDARDIZED BASELINE FACTORS BY NUMBER
OF TEETH LOST 1986-1994.
BASELINE FACTOR
Number of Participants (%)
Mean Age in Years (± SD*)
Physical Activity (METs†)
Occupation
Dentist
Nondentist
Total Number of Teeth
11–16
17–24
25–32
Cigarette Smoking Status
Never
Past
Current
Body Mass Index (%)
< 21
21–22.99
23–24.99
25–29.99
30+
Unknown
Alcohol Intake (Grams/Day)
None
> 0–4.99
5–14.99
15–20.99
30+
Regular Dietary Supplement Use
None
Multivitamin
Other supplements
Diabetes
Yes
No
Hypertension
Yes
No
Elevated Cholesterol Level
Yes
No
0 1-4 ≥5
NO. OF TEETH LOST
24,921 (78.3)
52.5 (9.2)
20.7
15,006 (60.9)
9,915 (39.1)
322 (1.6)
2,141 (9.8)
22,458 (88.6)
12,707 (49.5)
10,383 (43.5)
1,832 (7.0)
993 (3.9)
4,067 (16.0)
7,282 (29.1)
10,557 (42.8)
1,542 (6.1)
480 (2.0)
5,421 (21.9)
6,077 (23.9)
7,079 (28.2)
3,486 (14.1)
2,858 (11.9)
10,296 (40.1)
10,495 (42.8)
4,130 (17.0)
493 (2.3)
24,428 (97.7)
4,811 (21.5)
20,110 (78.5)
2,930 (12.7)
21,991 (87.3)
5,992 (18.8)
57.3 (9.2)
19.0
2,973 (49.3)
3,019 (50.7)
237 (3.7)
1,129 (17.7)
4,626 (78.6)
2,326 (39.7)
2,902 (47.2)
764 (13.1)
209 (3.5)
789 (13.2)
1,568 (26.2)
2,754 (45.8)
534 (9.1)
138 (2.2)
1,346 (22.3)
1,438 (24.3)
1,622 (27.1)
793 (13.3)
793 (12.9)
2,513 (42.9)
2,476 (40.7)
1,003 (16.4)
219 (3.4)
5,773 (96.6)
1,524 (23.7)
4,468 (76.3)
865 (13.9)
5,127 (86.1)
900 (2.8)
60.2 (8.6)
15.9
401 (43.6)
499 (56.4)
133 (14.1)
326 (33.6)
441 (52.3)
263 (31.1)
431 (45.0)
206 (23.9)
42 (4.6)
100 (11.3)
212 (23.6)
403 (44.4)
109 (12.6)
34 (3.5)
220 (24.0)
203 (23.2)
236 (26.4)
97 (11.0)
144 (15.3)
353 (41.5)
389 (41.8)
158 (16.7)
47 (4.5)
853 (95.5)
249 (23.7)
651 (76.3)
140 (14.3)
760 (85.7)
* SD: Standard deviation.
† METs: Metabolic equivalents.
Copyright ©2003 American Dental Association. All rights reserved.

changed their dietary intake differently than did
those who had no tooth loss during the eight-year
period. They had greater reductions in intake of
dietary polyunsaturated fat and vitamin E,
smaller reductions in intake of dietary cholesterol
and vitamin B12 and smaller increases in intake
of dietary fiber and whole fruits than did those
who did not lose any teeth. Men who had lost
teeth were more likely to reduce consumption of
apples or pears and raw carrots, which are consid-
ered as hard to chew. We did not find significant
differences in the change of dietary intake
between men who lost one to four teeth and men
who lost no teeth except in intake of dietary
cholesterol.
Our results are consistent with the findings of
several cross-sectional studies that reported that
perceived ease of chewing would be altered only
when severe dentition losses occur.20,21,33 Partici-
pants with tooth loss might increase intake in
foods that do not require a lot of chewing to sub-
stitute for other foods as resources of calories. We
found no differences in change in total calorie
intake among those with or without tooth loss. We
also found that men who had lost more teeth were
more likely to stop eating hard-to-chew foods such
as apples, pears and raw carrots while they main-
tained similar or increased consumption of soft
foods such as bananas, cantaloupes and cooked
carrots.
When compared with our findings, previous
studies have reported substantially stronger
cross-sectional associations after the researchers
controlled for total energy intakes and several
JADA, Vol. 134, September 2003 1189
TRENDS
TABLE 2
NUTRIENTS, FRUITS AND
VEGETABLES CONSUMED
0 (24,921) 1-4 (5,992) ≥5 (990)
NO. OF LOST TEETH (NO. OF PARTICIPANTS)
Mean (± Standard Deviation) Baseline Intake and Difference
Total Calories (Kilocalories)
Carbohydrates (Grams)
Fats
Saturated fat (g)
Trans fat (g)
Monounsaturated fat (g)
Polyunsaturated fat (g)
Cholesterol (milligrams)
Dietary Fiber (g)
Vitamins and Nutrients
Vitamin C (mg)
Carotene (international
units)
Beta-carotene
(micrograms)
Vitamin E (mg)
Vitamin B6(mg)
Vitamin B12 (μg)
Folate (μg)
Potassium (mg)
Flavonoids (mg)
Fruits and Vegetables
Fruits (servings)
Fruits excluding juices
and sauces (servings)
Vegetables (servings)
Baseline
intake
1994 (604)
230 (45)
24.4 (6.0)
2.82 (1.11)
27.2 (6.0)
13.3 (3.5)
299 (106)
21.1 (7.0)
166 (79)
9,659 (7,557)
4,940 (3,386)
8.11 (4.76)
2.23 (0.60)
8.77 (5.34)
359 (118)
3,375 (644)
20.3 (14.5)
2.42 (1.61)
1.62 (1.26)
3.32 (1.83)
Baseline
intake
1,996 (603)
234 (43)
24.5 (6.3)
2.86 (1.17)
27.3 (6.1)
13.1 (3.5)
305 (111)
21.0 (7.0)
167 (83)
9,849 (8,370)
5,056 (3,693)
8.17 (4.87)
2.23 (0.60)
9.00 (5.48)
353 (114)
3,396 (660)
21.1 (15.3)
2.49 (1.75)
1.70 (1.39)
3.33 (1.87)
Baseline
intake
2,015 (624)
235 (42)
25.3 (6.5)
2.92 (1.24)
27.8 (6.5)
12.8 (3.6)
318 (120)
20.2 (7.3)
164 (82)
9,659 (8,641)
4,976 (3,874)
7.98 (4.64)
2.20 (0.62)
9.37 (5.75)
344 (112)
3,383 (692)
21.8 (18.7)
2.42 (1.76)
1.65 (1.41)
3.28 (1.93)
Difference
20.1 (550.7)
22 (44)
−2.69 (5.80)
0.49 (1.35)
−0.85 (6.81)
−1.22 (3.91)
−53.0 (103.7)
2.22 (6.84)
1.14 (76.99)
1,418 (8,323)
116 (3,524)
0.03 (6.79)
0.13 (0.65)
−1.55 (6.48)
14.1 (128.8)
71.8 (606.6)
3.03 (15.6)
0.21 (1.57)
0.19 (1.22)
0.24 (1.89)
Difference
16.3 (571.8)
21 (42)
−2.47 (5.98)
0.52 (1.42)
−0.81 (6.97)
−1.16 (4.02)
−50.5 (113.1)
2.20 (6.84)
1.90 (83.06)
1,419 (9,248)
132 (3,897)
0.03 (6.56)
0.12 (0.65)
−1.35 (6.74)
14.9 (126.4)
64.9 (638.1)
2.45 (16.7)
0.25 (1.88)
0.22 (1.50)
0.22 (1.96)
Difference
7.8 (625.8)
21 (41)
−2.32 (6.22)
0.58 (1.44)
−0.89 (6.92)
−1.19 (3.87)
−47.8 (120.0)
1.98 (7.07)
5.24 (82.08)
1,266 (9,655)
129 (4,264)
−0.22 (5.82)
0.15 (0.63)
−0.76 (7.27)
20.6 (123.7)
94.2 (669.7)
1.86 (19.93)
0.21 (1.80)
0.12 (1.46)
0.13 (2.23)
* In 31,813 men with 11 or more teeth in 1986.
BASELINE (1986) AND DIFFERENCES (1994) FOR DAILY INTAKE OF
CALORIE-ADJUSTED NUTRIENTS, FRUITS AND VEGETABLES BY
NUMBER OF TEETH LOST 1986-1994.*
Copyright ©2003 American Dental Association. All rights reserved.

potential confounding factors.23,27 Healthy
behavior and socioeconomic status may confound
the association between nutrition and oral health,
and their confounding effects are unlikely to
be eliminated completely, especially in cross-
sectional studies. These previous studies indicate
that a change in dietary pattern and oral health
may be affected by not only dentition status, but
also by intake of several nutrients such as vita-
mins A, B6, C and D, calcium, niacin and
thiamin.34 When adjusted for number of teeth and
dietary intake at baseline, and when evaluated
for within-person change, our results would be
less susceptible to these biases. However, we col-
lected data on dietary intake in the past year by
FFQ, which might not be able to reflect the effect
of the tooth loss occurring at the end of the follow-
up period. Also, loss of five or more teeth may not
be severe enough to alter the dietary intake in
this population. Furthermore, since we calculated
change of dietary intake from two measurements
of diet, the attenuation of associations caused by
1190 JADA, Vol. 134, September 2003
TRENDS
TABLE 3
LEAST-SQUARE MEANS OF DIFFERENCES FOR DAILY INTAKE OF
CALORIE-ADJUSTED NUTRIENTS, FRUITS AND VEGETABLES BY
NUMBER OF LOST TEETH 1986-1994.*
NUTRIENTS, FRUITS AND
VEGETABLES CONSUMED
Least-Square Means: Model 1†Least-Square Means: Model 2‡
LEAST-SQUARE MEANS OF DIFFERENCES IN DAILY INTAKE BY NO. OF LOST TEETH
No. of lost teeth Pvalue
for trend
Pvalue for
trend§
No. of lost teeth
Total Calories (Kilocalories)
Carbohydrates (Grams)
Fats
Saturated fat (g)
Trans fat (g)
Monounsaturated fat (g)
Polyunsaturated fat (g)
Cholesterol (milligrams)
Dietary Fiber (g)
Vitamins and Nutrients
Vitamin C (mg)
Carotene (international
units)
Beta-carotene
(micrograms)
Vitamin E (mg)
Vitamin B6(mg)
Vitamin B12 (μg)
Folate (μg)
Potassium (mg)
Flavonoids (mg)
Fruits and Vegetables
Fruits (servings)
Fruits excluding juices
and sauces (servings)
Vegetables (servings)
0
26.4
21.6
−2.51
0.58
−0.79
−1.28
−52.1
2.03
0.10
1,294
70.5
−0.12
0.11
−1.49
8.94
57.2
2.42
0.24
0.21
0.14
1-4
21.9
20.2¶
−2.30#
0.60
−0.65
−1.24
−46.1#
1.72#
−0.98
1,106¶
23.3
−0.23
0.09
−1.38
4.76
40.2
2.22
2.24
0.21
0.12
≥5
19.0
18.3#
−1.93#
0.64
−0.47
−1.43
−36.6#
1.15#
−0.19
775#
−62.3
−0.63
0.10
−0.67#
6.89
63.0
2.16
0.14#
0.08#
0.06
.74
< .001
< .001
< .001
.22
.04
.49
< .001
< .001
.14
.001
.02
.005
.05
< .001
.08
.11
.20
.001
< .001
.09
0
29.2
18.9
−2.19
0.63
−0.45
−1.21
−47.8
1.69
−2.91
1,074
−15.3
−0.14
0.09
−1.34
4.41
37.4
2.15
0.18
0.17
0.11
1-4
20.6
18.7
−2.14
0.62
−0.45
−1.21
−43.6#
1.53
−2.04
1,035
−1.49
−0.19
0.09
−1.28
3.12
29.1
2.11
0.21
0.19
0.11
5
16.4
18.2
−1.96
0.61
−0.49
−1.47#
−36.7#
1.16#
0.94
880
−17.3
−0.54
0.11
−0.64#
8.51
65.4
2.23
0.15
0.06#
0.08
.63
.38
.22
.21
.69
.046
< .001
.004
.12
.27
.83
.07
.81
< .001
.49
.51
.85
.46
.01
.72
* 31,813 men.
† Model 1: Least-square means adjusted for change in total energy intake and for baseline dietary intake, age and number of teeth.
‡ Model 2: Least-square means adjusted for change in total energy intake and for baseline dietary intake, age, number of teeth, smoking status,
physical activity and profession.
§Pvalue for trend across men with zero, one, two, three, four, five to nine, and 10 or more teeth lost.
¶P< .10 for testing differences of least-square means of men with one to four or five or more teeth lost compared with men who had no tooth loss
for dietary variables with Pvalue < .05 for linear trend across number of teeth lost.
# P< .05 for testing differences of least-square means of men with one to four or five or more teeth lost compared with men who had no tooth loss
for dietary variables with Pvalue < .05 for linear trend across number of teeth lost.
Copyright ©2003 American Dental Association. All rights reserved.

nondifferential measure-
ment errors in both FFQs
would be higher than in
cross-sectional studies,
which only use a single
measurement.
The pattern of dietary
change of men with five or
more teeth lost is
unhealthier than that of
men who lost no teeth, even
though the longitudinal
effects of tooth loss were
relatively small in absolute
terms. The combined detri-
mental effects from various
foods and nutrients could
lead to higher risk of devel-
oping chronic diseases. This
cohort of health professionals is less susceptible to
potential confounding owing to their homogeneity
in socioeconomic status and health awareness.
Also, the effect of tooth loss might be smaller, as
these participants would be more likely to seek
dental care to restore their chewing function than
would general populations and also would be more
likely to maintain a healthy consumption in nutri-
ents by modifying food sources thanks to their rela-
tively high socioeconomic status. Compared with
the findings of the Third National Health and
Nutritional Examination Survey, in which only 90
percent of completely edentulous people had both
upper and lower dentures and 81 percent of people
who were edentulous in the lower arch had den-
tures,35 the participants in this cohort who had 17
or fewer teeth all had prostheses. Hence, we expect
that the effect of tooth loss on dietary intake might
be greater in the general population. Also, this
cohort consisted of only men, and the associations
may be different among women. We need further
studies among women.
In our cohort, men with 11 to 16 teeth at base-
line were more likely to lose teeth than men with
25 to 32 teeth. This result might suggest that risk
factors causing initial tooth loss could be associ-
ated with continuing tooth loss. Clinicians need a
better understanding of the factors underlying a
patient’s risk of experiencing oral diseases and
take appropriate preventive strategies to elimi-
nate the risk factors and thus stop continuing
tooth loss.
We did not collect data on the location of teeth
lost and their replacement status in this study.
We expect that most of these health professionals
who lost a substantial number of teeth had
prosthodontic treatment. Previous studies also
have reported only small and inconsistent differ-
ences in dietary intake comparing different types
of prosthetic treatments: implant-supported den-
tures versus conventional mandibular dentures,
or dentures versus no dentures.36-42 Hence, lack of
information of prosthetic treatments is unlikely to
affect our findings significantly.
CONCLUSION
We found significant associations between
changes in dental status and dietary intake of
specific nutrients. Our results suggest that
changes in diet owing to tooth loss could con-
tribute to the increased risk of chronic disease
that has been associated with poor dentition. ■
Dr. Hung is a research fellow, Department of Epidemiology, Harvard
School of Public Health, Boston; a research fellow, Department of Oral
Health Policy and Epidemiology, Harvard School of Dental Medicine,
Boston; and an assistant professor, College of Dental Medicine, Kaoh-
siung Medical University, Kaohsiung, Taiwan.
Dr. Willett is a professor, Department of Epidemiology, Harvard
School of Public Health, Boston; a professor and the chair, Department
of Nutrition, Harvard School of Public Health, Boston; and a professor,
Channing Laboratory, Department of Medicine, Harvard Medical
School and Brigham and Women’s Hospital, Boston.
Dr. Ascherio is an associate professor, Department of Epidemiology,
Harvard School of Public Health, Boston; and an associate professor,
Department of Nutrition, Harvard School of Public Health, Boston.
Dr. Rosner is a professor, Department of Biostatistics, Harvard
School of Public Health, Boston; and a professor, Channing Laboratory,
Department of Medicine, Harvard Medical School and Brigham and
Women’s Hospital, Boston.
Dr. Rimm is an associate professor, Department of Epidemiology,
JADA, Vol. 134, September 2003 1191
TRENDS
TABLE 4
PARTICIPANTS’ CONSUMPTION OF SELECTED FRUIT
AND VEGETABLE ITEMS, 1986 AND 1994.
FRUITS AND
VEGETABLES CONSUMED
TOTAL NO. OF
PARTICIPANTS
CONSUMING SPECIFIED
FOOD ITEMS ONCE PER
WEEK OR MORE IN 1986
% OF THOSE PARTICIPANTS STILL
CONSUMING THOSE FOOD ITEMS IN
1994, BY NO. OF TEETH LOST
0 1-4 ≥5
Banana
Cantaloupe
Apple or Pear*
Cooked Carrot
Raw Carrot*
19,438
8,457
21,376
19,399
19,399
87.0
49.2
79.3
49.7
70.2
86.6
50.7
77.9
53.1
62.5
85.1
49.8
69.9
56.7
55.5
*Pvalue for trend < .05 after adjustment for baseline dietary intake, age, number of teeth, smoking status,
physical activity and profession.
Copyright ©2003 American Dental Association. All rights reserved.

Harvard School of Public Health, Boston; an associate professor,
Department of Nutrition, Harvard School of Public Health, Boston; and
an associate professor, Channing Laboratory, Department of Medicine,
Harvard Medical School and Brigham and Women’s Hospital, Boston.
Dr. Joshipura is an assistant professor, Department of Epidemiology,
Harvard School of Public Health, Boston; and an associate professor,
Department of Oral Health Policy and Epidemiology, Harvard School of
Dental Medicine, 188 Longwood Ave., Boston, Mass. 02115, e-mail
“Kaumudi_Joshipura@hsdm.harvard.edu”. Address reprint requests to
Dr. Joshipura.
This research was supported by grants HL35464, CA 55075 and
DE12102 from the Office of Dietary Supplements, National Institutes
of Health, Bethesda, Md., and by the State of Florida Department of
Citrus, Lake Alfred, Fla.
The authors are indebted to the participants in the Health Profes-
sionals’ Follow-up Study for their continued cooperation and participa-
tion; to Al Wing, M.B.A., Mira Kaufman, Karen Corsano and Marcia
Goetsch for computer assistance; to Jill Arnold, Betsy Frost-Hawes,
Kerry Demers, Mitzi Wolff, Gary Chase and Barbara Egan for their
assistance in the compilation of data; and to Laura Sampson, R.D., for
maintaining the food composition tables.
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TRENDS
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