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Relationship between Dental Caries Prevalence and Sugar Intake or Preference for Sweet of Supertaster Compared to Nontas...

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RELATIONSHIP BETWEEN DENTAL CA RIES PREVALENCE AND SUGAR INTAKE OR PREFERENCE FOR SWEET OF SUPERTASTER COMPARED TO NONTASTER CHILDREN By CLAIRE A. EDGEMON A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2006

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Copyright 2006 by Claire A. Edgemon

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iii ACKNOWLEDGMENTS I would like to thank the members of my supervisory committee, Gail P.A. Kauwell, PhD, Charles A. Sims, PhD, and Fr ank Catalanotto, DMD. I would especially like to thank Dr. Kauwell, my major profe ssor, for all her help and guidance throughout every stage of this project. Her expertise and attention to detail were invaluable. I also would like to thank Karla Shelnutt, PhD, for us ing her many skills to further the project. Additional thanks are extended to Melissa Gr eenhow who helped manage the project on a daily basis and to Qin Li for her assi stance with the statistical analyses. I would also like to thank my fellow cla ssmates, Crystal Jackson, Shawna Mobley, and Stacy Bursuk, for making this experience more enjoyable. I will remember the lunchtime laughter and the encourag ing words that were shared. In addition, I would like to thank the members of my family for their continued support and encouragement. Most importantl y, I would like to thank my husband Daryl. There were many days that his words motivated me to continue this process. I am a better person because of his love for me and his belief in my success.

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iv TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iii LIST OF TABLES.............................................................................................................vi LIST OF FIGURES..........................................................................................................vii LIST OF ABBREVIATIONS..........................................................................................viii ABSTRACT....................................................................................................................... ix CHAPTER 1 INTRODUCTION........................................................................................................1 Hypothesis....................................................................................................................2 Specific Aim.................................................................................................................3 2 BACKGROUND AND LI TERATURE REVIEW......................................................4 Taste Perception............................................................................................................4 Bitter Taste............................................................................................................5 Sweet Taste............................................................................................................6 Determining Taste Status..............................................................................................6 Genetics of Taste..........................................................................................................9 Bitter Taste Receptor.............................................................................................9 Sweet Taste Receptor..........................................................................................11 Fungiform Papillae and Taste..............................................................................12 Taste Preferences........................................................................................................14 Dental Caries..............................................................................................................18 Prevalence............................................................................................................18 Development........................................................................................................19 Dietary Carbohydrates.........................................................................................20 Early Childhood Caries.......................................................................................23 Dental Caries and Taste Sensitivity.....................................................................24 Methods of Dietary Data Collection...........................................................................25 Research Significance.................................................................................................26 3 RESEARCH DESIGN AND METHODS..................................................................28

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v Subject Recruitment....................................................................................................28 Taste Sensitivity..........................................................................................................28 Demographic Data......................................................................................................30 Anthropometric Measures..........................................................................................30 Food Preferences........................................................................................................30 Dental Exam...............................................................................................................31 Bottle Feeding History................................................................................................31 Food, Beverage and Supplement Diary......................................................................32 Youth/Adolescent Questionnaire (YAQ)...................................................................32 Hedonic Response to Sweet........................................................................................33 Sucrose Intensity Rating.............................................................................................34 Statistical Analysis......................................................................................................34 4 RESULTS...................................................................................................................35 Subjects....................................................................................................................... 35 Demographic Data......................................................................................................36 Dental Exam...............................................................................................................36 Food Preferences........................................................................................................36 Food, Beverage and Supplement Diary......................................................................42 Youth/Adolescent Questionnaire (YAQ)...................................................................44 Bottle Feeding History................................................................................................46 Anthropometric Data..................................................................................................46 Hedonic Response to Sweet........................................................................................48 Sucrose Intensity Rating.............................................................................................49 5 DISCUSSION AND CONCLUSIONS......................................................................51 APPENDIX A SENSATION LIST USED WITH THE GENERAL LABELED MAGNITUDE SCALE........................................................................................................................57 B FOOD PREFERENCE QUESTIONNAIRE..............................................................58 C HEDONIC SCALE FOR CHILDREN.......................................................................62 D BOTTLE FEEDING QUESTIONNAIRE..................................................................63 E THREE DAY FOOD, BEVERAGE AND SUPPLEMENT DIARY WITH INSTRUCTIONS.......................................................................................................65 F YOUTH/ADOLESCENT QUESTIONNAIRE (YAQ).............................................70 LIST OF REFERENCES...................................................................................................82 BIOGRAPHICAL SKETCH.............................................................................................90

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vi LIST OF TABLES Table page 4-1. Sample characteristics of the study groups................................................................35 4-2. Number of individuals li ving in each subjects household........................................36 4-3. Family income per household....................................................................................36 4-4. Food preference scores (mean SD ) for food categories by taster status................37 4-5. Relationship between dental caries prevalence and food pref erences for STs and NTs............................................................................................................................ 43 4-6. Carbohydrate and suga r intake of ST and NT children by food category.................44 4-7. Responses and logistic re gression analysis of specific bottle feeding practices of ST compared to NT parents/caregivers.....................................................................47 4-8. Percent sugar in apple juice samples measured by refractometry.............................48 4-9. Responses and logistic regression anal ysis of STs compared to NTs regarding the graded solutions of sucrose in apple juice.................................................................49

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vii LIST OF FIGURES Figure page 2-1. Location of papillae and nerve innervation of tongue.................................................4 3-1. Study protocol and timeline.......................................................................................29 4-1. Dental caries prevalence of ST and NT children as a function of vegetable preference..................................................................................................................38 4-2. Dental caries prevalence of ST and NT children as a function of fruit preference..................................................................................................................39 4-3. Dental caries prevalence of ST and NT children as a function of dairy preference..39 4-4. Dental caries prevalence of ST and NT children as a functi on of sweetened dairy preference..................................................................................................................40 4-5. Dental caries prevalence of ST and NT children as a function of beverage preference..................................................................................................................40 4-6. Dental caries prevalence of ST and NT children as a function of baked goods preference..................................................................................................................41 4-7. Dental caries prevalence of ST and NT children as a function of cereal preference41 4-8. Dental caries prevalence of ST and NT children as a function of sugar preference.42 4-9. Dental caries prevalence of ST and NT children as a function of salted snacks preference..................................................................................................................42 4-10. Dental caries prevalence of ST and NT children as a func tion of sugar intake......44 4-11. Dental caries prevalence of ST and NT children as a functi on of sucrose intake...46 4-12. Dental caries prevalence of ST and NT children as a function of BMI percentile..48 4-13. Dental caries prevalence of ST and NT children as a function of sucrose intensity rating........................................................................................................50

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viii LIST OF ABBREVIATIONS AVI alanine-valine-isoleucine BMI body mass index defs decayed, extracted, filled surfaces in primary teeth DEFS decayed, extracted, filled surfaces in permanent teeth ECC early childhood caries FFQ food frequency questionnaire gLMS general labeled magnitude scale IRB Institutional Review Board MT medium taster N-C=S nitrogen-carbon-sulfur NT nontaster OR odds ratio PAV proline-alanine-valine PROP propylthiouracil PTC phenylthiocarbamide SD standard deviation SES socioeconomic status ST supertaster T12r (T1r2) sweet taste receptor in humans (mice) T2R bitter taste receptor TAS2R38 bitter taste recep tor specific for PTC/PROP T1R3 (T1r3) sweet taste receptor in humans (mice) YAQ Youth/Adolescent Questionnaire 95% CI 95% confidence interval

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ix Abstract of Thesis Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science RELATIONSHIP BETWEEN DENTAL CA RIES PREVALENCE AND SUGAR INTAKE OR PREFERENCE FOR SWEET OF SUPERTASTER COMPARED TO NONTASTER CHILDREN By Claire A. Edgemon May 2006 Chair: Gail P.A. Kauwell Major Department: Food Science and Human Nutrition Taster status has been defined as the de gree to which an individual is able to perceive the bitter compound, 6-n-propylthiour acil (PROP). Based on the intensity rating of this substance, individuals are categorized as supertasters (ST) (high sensitivity to bitter taste), medium tasters (MT) (modera te sensitivity), and nontasters (NT) (low/no sensitivity). Since some research suggests that PROP STs also are more sensitive to sweet and have a decreased preference for sw eet substances compared to PROP NTs, it has been hypothesized that taster status may af fect the development of dental caries. The only study that tested this hypothesis reported an inverse relationship between PROP sensitivity and dental caries in children; however, the invest igator did not consider the impact of dietary intake a nd feeding practices during infa ncy in his study design. Since these factors also may influence the developm ent of dental caries, examination of these variables in conjunction with PROP tast er status warrants investigation.

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x The present study examined whether there wa s a relationship between dental caries prevalence of 17 ST and 15 NT children as a function of preference for and intake of sugar containing foods and beverages. Food preferences were assessed using a questionnaire. Three day food, beverage, a nd supplement diaries from children 6 to 12 years of age were evaluated for quantity of in take of sugar, starc h, and sugar-containing foods and beverages as well as number of ea ting occasions per day. A food frequency questionnaire was used to assess foods eaten over the preceding year, particularly sugarcontaining foods and beverages. The influence of early infant feeding practices on dental caries prevalence in STs compared to NTs also was evaluated using a bottle feeding history questionnaire. Five a pple juice solutions with graded sucrose concentrations were evaluated for likeability and the intensity of a sucrose solution was rated. No linear relationship was detected between dental caries prevalence of STs and NTs as a function of the percen t of total energy intake from total sugars or sucrose. Significant differences were not detected in the number of carious lesions or the consumption of or preference for sweetened foods and beverages between STs and NTs. This study does not support the previous findi ng that NT children are likely to have more dental caries compared to ST children. The r ecent identification of several genes related to taste sensitivity, including a gene that en codes the receptor that recognizes bitter taste and for which several polymorphisms have b een identified, suggests that a subjective measure of taste perception such as PROP may not adequately distinguish taste sensitivity. These findings provi de new opportunities for the clas sification of taster status based on genotype instead of PROP.

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1 CHAPTER 1 INTRODUCTION Taste sensitivity plays a role in food pref erences (1-3) and food preferences affect dietary intake, which can have an impact on he alth and disease, incl uding oral health. Poor oral health due to de ntal caries during childhood may ha ve long-lasting effects that can negatively impact nutritional status and the ability to enjoy food la ter in life. Factors affecting dental caries during childhood incl ude infant/toddler feeding practices and the intake of sugar/sweetened foods and snacks. The accidental discovery of differences in sens itivity to bitter led to the theory that there was a genetic component to tast e. The naturally bitter compound, 6-npropylthiouracil (PROP), has b een used to categorize peopl e as supertasters, medium tasters, and nontasters. Supertasters have a low threshold (high sensitivity) to PROP, nontasters have a high threshold and medium ta sters have a moderate threshold. Several forms of a gene related to the ability to detect bitter tasti ng substances such as PROP (4) have been discovered, which may help explain th e differences in the ability to taste bitter substances. Although PROP is used to categorize bitter sensitivity, there also is an association between PROP status and sweet preference. Individuals who do not taste PROP intensely have been shown to have a greater prefer ence for sweets (2,5). Some researchers speculate that children who are nontasters may consume sugar more frequently and in higher amounts compared to children who are me dium and supertasters (6). In addition,

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2 adults who are more sensitive to PROP have been reported to have a lower preference for sweetened foods, as well as bitter vegetables and high fat foods (7,8). It is well established that dietary intake pl ays a major role in th e etiology of dental caries, particularly with regard to intake of soda/sugared beverage s, sugar and starch consumption (9,10) and number of eating oc casions (11,12), all of which have been positively associated with an increase in dental ca ries. It follows that if nontasters prefer and ingest more sweets and supertasters are le ss inclined to consume sweets, PROP status may be a useful tool in identifying individuals at higher risk for dental caries formation. Although one study (13) reported that supertaster children ha d fewer dental caries than nontaster children, dietary intake and preference data were not collected, which leaves the question of whether differences in sweet pr eference and sugar intake account for the difference in the number of carious surfaces detected between the groups. Many factors influence dental caries forma tion. For example, certain bottle feeding practices such as use of a bottle at bedtime, bottle contents, and age of weaning (14-16) have been associated with early childhood car ies (ECC) in the primary dentition. These practices could influence the de velopment of dental caries in dependent of PROP status. Identifying children who are at higher risk for dental caries formation has important implications for adult dental health. Studies suggest that ECC may be a predictor of the development of future caries (17,18), so pr evention of childhood caries may lead to a reduction in adult caries prevalence. Hypothesis A relationship exists between dental car ies prevalence and supertaster/nontaster status of children as a func tion of sugar intake and/or preference for sugar and sugarcontaining foods.

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3 Specific Aim The main objective of this study is to investigate dental caries prevalence as a function of sugar intake and/or preference for sugar and suga r-containing foods in ST and NT children 6 to 12 years old. This study repres ents the first to eval uate whether such a relationship exists. If this study supports a positive relationship betw een sugar intake or preference and dental caries prevalence in nontasters but not in supertasters it would extend the findings of Lin (2003) and support the use of PROP te sting as a simple screening tool for identifying children at hi gh risk for dental carie s (13). This could provide the impetus for a targeted intervention strategy that could play an important role in reducing dental caries development in adulthood.

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4 CHAPTER 2 BACKGROUND AND LITERATURE REVIEW Taste Perception The taste sensation that occurs when substances are ingested orally is the result of the integration of perceptions arising from true taste and t ouch. One of these perceptions is the actual sensation from one of the five taste qualities: bitter, sweet, sour, salty, and umami. Another perception results from substa nces touching the nerves of the oral cavity that signal temperature and pain (7). The sensation of taste begins on the tongue, which is covered by four kinds of papillae with di stinct shapes and locations. The fungiform (mushroom-like) papillae are located on the anterior tongu e, the foliate (leaf-like) papillae are located on the sides of the late ral posterior t ongue, and the circumvallate (wall-like) papillae form an inverted V on th e posterior tongue (Figure 2-1). The fourth type of papillae, the filiform (thread-like) papi llae, is located on the anterior tongue (19). Figure 2-1. Location of papillae a nd nerve innervation of tongue. Circumvallate papillae Foliate papillae Fungiform papillae Chorda tympani (VII) nerve Glossopharyngeal (IX) nerve Trigeminal (V) nerve

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5 Each type of papilla is tact ile sensitive, but only the circ umvallate, foliate and fungiform papillae are innvervated by nerves that recognize one of the fi ve taste qualities (19-21). Taste buds are located on the papillae. Taste re ceptor cells, which are tightly packed into the taste buds, have taste receptors on their surfaces to recognize th e five taste qualities (20). In humans, both the chorda tympani bran ch of the facial nerve and the trigeminal nerve innervate the taste receptor cells in the anterior two-thirds of the tongue (22,23). The chorda tympani nerve, which helps to rela te taste sensation, inne rvates about 25% of the fungiform papillae. The trigeminal nerve, which perceives pain, touch, and temperature, innervates about 75% of the fungiform papillae (24). Circumvallate and foliate papillae are innervated by the gl ossopharyngeal nerve (Figure 2-1). Bitter Taste It has been suggested that bi tter taste is the most comple x of the five taste qualities due to the large number of genes that code fo r bitter receptors that allow for interaction with a multitude of chemical structures involved in bitter taste (20,25). While these receptors may recognize a wide variety of bitter substances, it has been suggested that the receptors are unable to discriminate among th e various chemical structures associated with bitter taste (26). As demonstrated by Steiner (1977) the ab ility to recognize bi tter substances is innate (27). This characteristic may be beneficial from a survival point of view in that it may help individuals recognize and reject a wide variety of potentially harmful substances they may come in contact w ith in the environment (23,25,28). However, some foods with nutrients and phytochemicals th at are important to health also contain bitter tasting substances such as isothiocyanates, indoles, and flavonoids. For example, raw cruciferous vegetables, such as brocco li, cabbage, and Brussels sprouts, contain

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6 isothiocyanates, which have an N-C=S st ructure that confers a bitter taste. Isothiocyanates can be harmful in geographi cal areas with an incidence of iodine deficiency since they can act as antithyroid ag ents and have been associated with a higher prevalence of endemic goiter, as review ed by Drewnowski and Rock (1995) (29). However, isothiocyanates, as well as other phy tochemicals in fruits and vegetables, also have potential health benefits related to their antioxidant and anticarcinogenic effects (29). Not all bitter tastin g compounds contain the N-C=S structure. Phenolic compounds in tea, cocoa, and wine are other bitter-t asting compounds found in foods and beverages that do not contain this structure (8). Sweet Taste In contrast to bitter taste, which is described as having a bimodal distribution (individuals either recognize or do not recognize bitter taste), the response to sweet taste is unimodal, which means it is recognized by everyone, even though the chemical structures of sweet-tasting substances, natura l and artificial, are almost as varied as substances that taste bitter ( 20). It has been suggested that the sweet taste system, unlike the bitter taste system, is able to discrimina te the various sweet ta stants, (26) which is beneficial in helping an individual re cognize energy rich f ood sources (23,25). Determining Taste Status Differences in bitter taste perception were accidentally discovered in 1931 when a researcher who was synthesizing phenylthio carbamide (PTC) accidentally released crystals of this substance into the air. Th e researcher tasted nothing, while one of his colleagues noted that the crystals tasted bitter (30). This accident led to the idea that some individuals are “taste blind” to bitter wh ile others are tasters. Researchers believed

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7 the ability to taste was inherited since taste blind parents were noted to have taste blind children (31). For years after its discovery, PTC, whic h contains an N-C=S group, was used to determine taste status. However, since PTC ha s a sulfurous odor and is potentially toxic, 6-n-propylthiouracil (PRO P), which also contains an NC=S group, has been used as a substitute for PTC in categorizing taste status (2). Propylthiouracil is an antithyroid agent used to treat hyperthyroidism. It inhibits the synthesis of thyroid hormones by blocking the oxidation of iodine in the thyroid gla nd. An indirect method for assessing taste sensitivity due to genetic differences is to assess the reaction to PR OP by applying a filter paper containing 1.6 milligrams of PROP to th e tongue for 30 seconds. This is a very low dose compared to the amount (50 to 100 mg/day) used to treat hyperthyroidism in children (32). Early in taste status research, category scales (i.e., a 9-point hedonic scale) were used to assess taste sensitivity to PTC/PROP These scales used adjectives, such as strong and weak, to rate taste sensations. A pr oblem with using this type of scale is that the definition of what constitutes “weak” by one individual may be strong to another. This makes it difficult to compare sensations across subjects or groups (22). The results from using these category scales produced di stributions of tasters and nontasters that overlapped, which led researcher s to believe that the abilit y to taste PTC/PROP was an example of classical Mendelia n genetics. Accordingly, it was believed that since supertasters were the most sensitive to PROP (low threshold), they had two dominant alleles for bitter taste. It was suspected the medium tasters had one dominant and one recessive allele since they were moderately sensitive to PROP (moderate threshold).

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8 Since nontasters were the least sensitive to PROP (high threshold), it was believed that they had two recessive alleles (33). While researchers believed th ere was a distinction between supertasters and medium tasters, th ey were unable to clearly define the two groups using category scales, which may have been the result of “ceiling effects”. In other words, the category scale put a limit on how high the PROP sensation could be rated. Both medium and supertasters might ra te the PROP sensation near the top of the scale because the taste is very bitter, but in actuality, the intensity of the bitter taste perceived by supertasters may greatly exceed the limits of the scale being used (i.e., ceiling effects) compared to that which is perceived by medium tasters. Therefore, supertasters do not have the oppor tunity to rate the bitter sensation as high as they perceive it (34). Changes in the methodology of PROP taster assessment have enabled researchers to differentiate among the three taster gr oups. Instead of using a category scale, individuals are asked to rate the sensation of PROP using the general Labeled Magnitude Scale (gLMS), which reduces the ceiling eff ects that may occur when using a 9-point category scale (34-36). While this scale also us es adjectives, it is a ratio scale that allows individuals to rate the PROP sensation as it relates to other sensations, not just taste sensations (36). Since the scale ranges fr om “strongest imaginable” to “no sensation” and refers to any sensation, this creates a nontaste related standard that allows for valid across-group comparisons of taste sensations (24,37). Supertasters are bitter sensitive and rate PROP sensation near th e top of the scale. Nontaste rs are bitter insensitive and rate PROP near the bottom of the scale. Me dium tasters rate the PROP sensation in the middle of the scale (2). While it may be e xpected that the two taster categories (super

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9 and medium) perceive taste se nsations similarly, differing onl y in degree of intensity, newer research suggests that supertasters are distinct, supporting the id ea of three taster categories. For example, a study that ex amined food acceptance among the three taster categories found that supertasters disliked bi tter foods and beverages more than medium and nontasters (38). Prescott et al. (2001) reported that su pertasters perceived higher intensities for the four taste qualities measured (i.e., sweet, bitter, sour, salty) than either medium or nontasters. In this study, medi um and nontasters tended not to rate the intensities differently (35). The idea of three taster groups is now accepted and has been supported by recent studies examining differences in taste-related genes. Genetics of Taste Bitter Taste Receptor Approximately 30 genes for the bitter taste receptors (T2Rs) have been identified as members of a seven transmembrane domai n, G-protein-coupled -receptor superfamily (25,26). The bitter taste receptors (T2Rs) ar e rarely expressed in fungiform taste buds, but are present in 15 to 20% of the cells of all circumvallate and foliate taste buds (26,39). Recently, two PTC/PROP sensitive loci have been lo cated near bitter receptor genes on chromosomes 5 and 7 (40). The PT C/PROP sensitive gene on chromosome 7 was identified as TAS2R38. Five haplot ypes result from three single nucleotide polymorphisms in this gene leading to am ino acid substitutions: Pro49Ala, Ala262Val, and Val296Ile. The two most common haplot ypes are proline-alan ine-valine (PAV) and alanine-valine-isoleucine (AVI). The PAV haplotype is sensitive to PTC/PROP, while the AVI haplotype is not sens itive to PTC/PROP (4). Th e three other haplotypes (AAV, AAI, PVI) are considered as having intermedia te sensitivity to PT C/PROP, but have not been studied as much as the PAV and AVI forms (20). PAV homozygotes (PAV/PAV)

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10 rate the sensation of PTC highest while AVI homozygotes (AVI/AVI) rate it the lowest. PAV heterozygotes rate PTC slightly, but significantly lower than PAV homozygotes suggesting that the effect of th e PAV gene is additive (41). The PAV variant of the gene is the or iginal form since studies in nonhuman primates revealed that all were PAV ho mozygotes (41). Some researchers have questioned why the AVI variant of the gene emerged and why both forms continue to be expressed in the population to varying degrees. Limited research has shown that approximately 49% of Europeans have the PAV variant and 47% have the AVI variant with only 3% having one of the “intermediate” variants. Asians ha ve a slightly higher percentage of the PAV variant than AVI with no intermediate variants. Approximately 50% of Africans have the PAV variant while 25% have the AVI vari ant. The remaining 25% have “intermediate” variants. Native Americans are predominantly PAV (41). The PAV variant of the TAS2R38 gene appear s to be specific for bitter compounds containing an N-C=S group sin ce a response was seen with PTC and PROP, but not with other bitter tasting compounds. The ability of supertasters to de tect bitter compounds containing the N-C=S structure, such as is othiocyanates, would be beneficial in geographical regions with low iodine. This w ould give supertasters an advantage in these areas since avoidance of isothi ocyanates, found in cruciferou s vegetables, would decrease over ingestion of anti-thyroid to xins that would contribute to thyroid disease and goiter. Kim et al. (2005) suggest that the variety in haplotypes may exist as a local adaptation to avoid the toxins found in local plants sin ce very limited research has found a higher percentage of the PAV haplotype in Asia n, African, and Native American populations (42). The AVI variant appears to be se nsitive to other bitter compounds, but is

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11 insensitive to PTC/PROP (43). While supertasters may have an advantage in their ability to recognize and avoid bitter compounds, nontas ters may have an advantage that results from their inability to detect bitterness. In addition to their anti-thyroid properties, isothiocyanates are known for their actions as antioxidants, which have been associated with anti-cancer effects. Therefore, c onsumption of bitter tasting vegetables by nontasters may provide an adva ntage in populations with a higher cancer risk (43). Sweet Taste Receptor Two sweet taste receptors in humans, T1R2 and T1R3, have been identified (26) using genetic mapping from the corresponding re ceptors in mice, T1r2 and T1r3 (44). While T1R3 has been found in all three types of taste sensing papillae, T1R2 is almost exclusively found in circumvallate and foliate papillae (25,26). It has been suggested that T1R3 may function alone or inte ract with T1R2 to create a heterodimer that is sensitive to a variety of sweet compounds, including natu ral sugars, artificial sweeteners, D-amino acids, and sweet-tasting proteins (20,25,26,45). Si milar to the bitter receptors, the sweet receptors also have a seven transmembrane domain, but have large N-terminal domains that allow for interactions with ligands of sweet tasting compounds (25). Max et al. (2001) suggest that th ese N-terminal domains also may allow for dimerization. When these researchers examined the amino acid sequence of the T1r3 receptor in mice sensitive to sweet taste and mice insensitive to sweet taste, they found an amino acid substitution in the mice that were insensitive to sweet taste that they predict introduces a novel N-linked glycosylation si te in the N-terminal domain. This glycosylation may interfere with the dimerization of the sweet receptor that prevents the mice from being able to taste sweet substan ces (44). Other studies in mice have shown that although sweet and bitter taste receptor cells have di fferent receptors, they use a common signaling

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12 pathway to generate a taste re sponse (23). In addition to activating the sweet receptor, Zhao et al. (2003) suggest that artificial sweetene rs may activate the bitter receptors, causing the aftertaste often asso ciated with saccharin (45). Fungiform Papillae and Taste In addition to the genetic variability among PROP tast er categories, research suggests that the difference among the three ta ster groups also may be related to the number of fungiform papillae and taste buds on the dorsal surface of the tongue (4). Miller and Reedy, who were the first to de velop a method for counting taste pores in fungiform papillae, reported that PROP tast ers had more taste pores in the fungiform papillae than nontasters (46). Bartoshuk et al. noted that s upertasters not only had more taste pores, but also smaller, more abundant f ungiform papillae (47). Prutkin et al. (2000) reported that 17% of females had more taste pores in the fungiform papillae than males (24). Similarly, Duffy et al. (2004), found that women who were PAV/PAV were more likely to have a greater number of fungifo rm papillae than women who were AVI/AVI (4). Since the fungiform papillae are inne rvated by both the chorda tympani and the trigeminal nerves, the greater abundance of f ungiform papillae and taste pores associated with PROP tasters and indi viduals with the PAV/PAV genotype (supertasters) may partially explain why these individuals have stronger perceptions of bitter and sweet tastes, as well as the sensation of creamine ss and oral burn (24). A review by Bartoshuk (2000) suggests that substances that provide tactile stimula tion in the mouth, such as the fat in dairy products and salad dressings, ma y result in more intense sensations for supertasters. In addition, oral irritants, such as capsaici n from chili peppers, piperine from black pepper, and ethanol may cause the greatest irritation and pa in in supertasters compared to nontasters (33). Studies such as these suggest that be ing classified as a

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13 supertaster is the result of an individual’s genotype for TAS2R38 (i.e., PAV/PAV) and an unknown genetic determinant that influences fungiform papillae density. On the other hand, nontaster status is sole ly attributed to the AVI/ AVI genotype independent of fungiform papillae density. There is little information about tongue growth, fungiform papillae and taste buds in children. A study that examined the di fferences between children and adult tongue size found that the anterior dorsa l tongue of 8 to 10 year old ch ildren was the same size as the corresponding region of the adult tongue. However, the remainder of the tongue did not reach adult size until 15 to 16 years of age (21). Even though the anterior region of the tongue is mature in size by mid-childhood, other studies have suggested that the function may not be mature. Using tastants (i.e ., sweet, salty, bitter and sour) dissolved in water, James et al. (1997) reported that the taste system of 8 to 9 year old boys was not fully mature compared to girls of the same age and adults. The boys needed higher concentrations of the tastants in order to detect their presence. Significant differences were not detected in the de tection thresholds between the girls and the young adult controls (48). A study by Segovia et al. (2002) found that male children (mean age 8.4 years) had a smaller mean fungiform papilla di ameter than adult male s, but a significantly higher papillae density than adults (49). Wh ile the researchers found that the taste pore diameters in children were smaller than those of adu lts, they found no significant difference in the number of pores per papilla between children and a dults. Stein et al. (1994) reported that in the majority of tongue regions (i.e., anterior posterior, lateral), children had a significantly higher sensitivity to sucrose compared to adults (50). The researchers found that children had more fungi form papillae in selected areas of the

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14 tongue, which may have led to the increased sensitivity to sucrose. Even though they found no difference in the number of total papillae be tween adults and children, they did find a different distribution of papillae in children. While the production of taste buds may be complete by mid-childhood as suggested by the studies that found that certain areas of the tongue appear more sensitive to taste, the innervation of the papillae is incomplete (49) since whole mouth tests show that male children need more of a tastant in order to perceive the taste. Taste Preferences Taste preferences are present early in life and have a gene tic basis as described in the previous section. The preference for sweet taste is universal among infants and children. Steiner (1977) demonstrated that when neonates were given a sweet stimulus, the face relaxed and the facial movements seemed to suggest satisfaction or enjoyment. However, when infants were given a bitter s timulus, the face contorted to reflect disgust or rejection, which was followed by spitting or the initial movement s associated with vomiting (27). For several of the neonates, ex perience was not a factor in their responses to these stimuli since they displayed these f acial expressions before receiving their first feeding. Mennella et al. (2005) suggest that ch ildren’s taste preference s have more of an influence on intake, whereas experience more often determines adul ts’ taste preferences (28). Food preferences appear to be determined in part by taste sensitivity, and some researchers suggest that sensor y factors are the major influe nce on food preferences. For example, bitterness seems to play a major role in food acceptance or rejection (8), a phenomenon supported by a study using PROP to determine taste status that found that supertasters had lower acceptanc e ratings for bitter cruciferous vegetables (i.e., Brussels

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15 sprouts, cauliflower, raw and cooked cabbage) an d bitter citrus fruits (i.e., grapefruit and lemons) compared to medium and nontasters (38). Other studies investigating the relationship between PROP st atus and food preferences f ound that women who tasted PROP as more bitter had a lo wer acceptance of bitter vege tables (3), sweet foods and high fat foods (7). With regard to preferen ce for sweet, Duffy et al (2003) observed that adults who were less sensitive to PROP show ed a greater preference for sweet foods and also had a higher intake of added sugar (2). In addition, Looy and Weingarten (1992) reported that adults and children who dislik ed sweet taste were almost always PROP tasters, while PROP nontasters almost always liked sweet taste. However, compared to nontaster adults, more nontaster children like d sweet taste, which suggests that by the time they are adults the liking for sweet dec lines (5). This may be due to increased experience with food as one ages and to the development of h ealth concepts that lead to categorizing some foods as h ealthier than others. Genot yping for the PTC/PROP gene was not done in the previous studies. Gender differences also may play a role in food acceptance. Duffy and Bartoshuk (2000) reported that women had a decrea sed liking for sweets with an increased perception of PROP bitterness. Men, however had an increase in sweet preference with increased perception of PROP bitterness (7). Using genotyping for the PTC/PROP gene, as well as categorizing taster status based on the response to PROP, Mennella et al. (2005) reported that children who were PAV/AVI (medium tasters) and PAV/PAV (supe rtasters) preferred si gnificantly higher concentrations of sucrose solutions, s ugar-sweetened cereal, and sugar-sweetened beverages compared to children who were AVI/AVI (nontasters) (28). Additionally,

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16 another study using PROP to determine taste status in preschool ch ildren found that the percentage of daily energy from sugars, as re ported by parents, was higher in tasters than in nontasters (51). However, the taster group included both supert asters and medium tasters, and some studies have suggested th at medium tasters may be more similar to nontasters than to supertasters (35,38), so by combining the data from both medium and supertasters within the same category, the distinctness of th e supertaster data may have been lost. The majority of studies based on the results of PROP testing seem to suggest that compared to PROP tasters, nontaster s may prefer and consume more sweets. Experience also plays a role in tast e preference. A study examining food preferences in preschool child ren reported that repeated exposure of an unknown food item increased the familiarity of the item, which led to an increase in the liking of that item (52). A recent study highlighted the eff ect of experience on preference when it was observed that children who preferred higher leve ls of sugar in apple juice and cereals had mothers who routinely added sugar to their ch ildren’s diets (53). However, Mennella et al. (2005) suggest that compar ed to adults, young children’s intakes are less influenced by experience and more influenced by preference (28). Studies have found that nontasters appear to like a wider vari ety of foods than tasters. One study of children aged 5 to 7 years found that the mean number of foods liked by nontaster children was higher compared to taster children (1 ). In a review by Drewnowski and Rock (1995), it was reported that PROP tasters had a higher percentage of foods disliked compared to nontasters (2 9). In contrast, a study from Tunisia found that while supertasters cons umed a significantly lower number of food items compared to medium or nontasters, there was no differe nce between tasters and nontasters in food

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17 preferences and number of f ood dislikes (54). Ullrich et al. (2004) examined the relationship between taster status and food adventurousness, which was defined as the frequency of trying new foods. It appear s that food adventur ousness has a greater influence on food preference than PROP stat us. Researchers found that PROP tasters who were food adventurous reported a greater liking for bitter foods, while PROP tasters who were not food adventurous disliked bitter foods (55). Most taste studies examining taste pref erence have been conducted using single taste stimulants (i.e., sweet, bitter, sour, salty). However, taste sensations are rarely experienced in isolation. A recent study exam ining the perception of four binary taste mixtures (i.e., sweet-bitter, sweet-sour, salt y-bitter, salty-sour) by adults in the three different PROP taster categories found that PR OP supertasters rated the overall intensity of binary taste mixtures higher compared to nontasters (35). The researchers found that higher concentrations of sucrose suppressed th e intensity of bitterness of binary taste mixtures of sweet and bitter. This may e xplain why individuals who are sensitive to bitter compounds add sugar or salt to bitter foods. They also found that high concentrations of a bitter compound (i.e ., quinine hydrochloride) suppressed the perception of the sweet taste when the two we re in a mixture. The researchers suggest that while one tastant may suppress another, th e intensities of the ta stants are added to give an overall perceptio n of intensity of the mixture. However, certain tastes may be more influential in determining overall inte nsity (35). Since most foods contain a combination of the five taste qualities, the ta stant with the most influence may drive an individual’s choice when determining which foods are preferred and consumed.

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18 Since PROP tasters appear to have a heightened sensitivity and decreased preference for higher fat and highly sweetened foods, it follows that they would consume less of these items. Conversely, since PROP nontasters may need more of these items to achieve the same taste sensations, they may consume greater quanti ties of sweet tasting foods, which could increase body weight (56) Goldstein et al (2005) found that nontaster women had a mean BMI of almost 30, a level that is categorized as borderline between overweight and obese, while supert aster women had a mean BMI of 23.5, which is within the healthy range. These research ers suggest that PROP status may put women at an increased risk for weight gain and ad iposity (56). Other st udies conducted with adults also have shown that PROP supert asters are thinner an d have a lower BMI compared to nontasters (24,33). The relations hip between BMI and PROP status also has been observed in children. A study by Ke ller and Tepper (2004) found that nontaster preschool boys had significantly higher body weights (ageand gender-adjusted weightfor-height percentiles) than taster s. In contrast, they found th at taster preschool girls had significantly higher body weights than nontaste rs (51). However, this study did not separate supertasters from medium tasters, which may ha ve caused a dilutional effect since other studies have shown that medium ta sters are more similar to nontasters than supertasters (35). Dental Caries Prevalence Dental caries is one of the most prevalen t oral infectious diseases and one of the most common childhood diseases in the Un ited States (57). Even though water fluoridation, use of fluoride products, diet modification, improved oral hygiene, and regular professional care have led to dramatic reductions in dental caries over the past 30

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19 years (58), some populations in the United States still str uggle with this disease. According to the May 2000 Surgeon General’s re port on oral health, dental caries is the most common chronic disease in children 5 to 17 years old. The re port states that over 50% of 5 to 9 year old children have at le ast one cavity or fill ing and that proportion increases to 78% among 17 year olds (59). Socioeconomic status (SES) and ethnicity seem to influence the prevalence of dental caries. Autio-Gold and Tomar (2005) reported that 5 and 6 year old children participating in the Head St art program in Alachua County, Florida, had a high prevalence of untreated tooth decay. They found that in this group of low income children, African-American chil dren had significantly more lesions compared to Caucasian children and children from other races (60). A study of school children in the Bronx, New York, found that African-American sixth graders had the highest percentage of untreated caries in their permanent dentition, and Hispanic second graders had the highest percentage in thei r primary dentition. Of the children who participated in the study, approximately 99.5% of the children qualified for the reduced or free lunch program. The researchers also reported that Hispanic children had more dental caries experience than African-American children from the same SES living in the same location (61). Development Dental caries is a multifactorial disease. Two factors related to the etiology of dental caries are the presen ce of acid-producing bacteria and fermentable carbohydrates. Bacteria in the mouth, mostly Streptococcus mutans ( S. mutans ), are most often transmitted from mother to child (62). These bacteria mix with saliva to form a plaque that sticks to the surface of the teeth. As the bacteria metabolize fermentable carbohydrates they produce acid, which drops the pH of the plaque below 5.5. This

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20 reduction in pH leads to the growth of acidoge nic bacteria as well as demineralization or dissolution of the enamel. Every time the oral cavity comes into contact with fermentable carbohydrates or an acidogenic f ood, there is a reduction in the pH of the oral cavity. It has been show n that the pH of plaque droppe d from 6.5 to 5.0 within three minutes after rinsing the teet h with a sucrose solution. The pH remained low for 40 minutes. A reduction in pH did not occur, however, when the teeth were brushed immediately after rinsing with the sucrose solution. Remineralization of the enamel occurs when the pH increases to greater than 6.0. This may occur when the teeth are brushed to remove the plaque, when suga rless gum is chewed to stimulate saliva secretion, or when fluoride is administered. When the demineralization and remineralization processes remains in balance, the teeth remain caries free. However, when remineralization is slower than demi neralization, a lesion develops, which could result in a cavity if preventiv e measures are not taken (57). Dietary Carbohydrates Dental caries is one of the two primary or al infectious diseases that is directly influenced by diet and nutr ition (63). As dietary carbohydr ates such as sugars (i.e., glucose, fructose, and sucrose) and some st arches are digested by salivary amylase the bacteria in the oral cavity begin to meta bolize them. This is why some dietary carbohydrates are considered fermentable carbo hydrates. Studies have found that dental caries risk is related to an increase in s ugar intake. In addition to being one of the preferred fuel sources for bacteria in th e oral cavity, sugars may enhance bacterial growth. Wan et al. (2003) reporte d that colonization of the teeth by S. mutans is facilitated by sucrose (62). Sugars may occu r naturally in foods, such as fruit, honey, and dairy products, or they may be added to f oods during processing. Examples of sugars

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21 added during processing include white or brow n sugar, corn syrup and high-fructose corn syrup (63). The Carbohydrate Technical Committ ee of the North American branch of the International Life Sciences Institute c onvened a Sugars and Health Workshop in 2003 where they defined “sugar” as sucrose, “sugars” as all monoand disaccharides, including sucrose, and “added sugars” as “sugars eaten separately or used as ingredients in processed or prepared foods ” (64). Many processed foods contain starches as well as added sugars. Items such as bread, crackers, cookies, cakes, pies and chips all have starches that can be fermented. As th ese starches are digested into smaller oligosaccharides, the bacteria in the oral ca vity are able to use these carbohydrates to produce acid (57). Specific interrelated charact eristics of carbohydrates make them more susceptible to fermentation, such as the form of th e carbohydrates, frequency of consumption, and the time it takes to clear the carbohydrates fr om the oral cavity. For example, while liquids that contain sugars, incl uding soft drinks, fruit juice and fruit juice beverages, are rapidly cleared from the oral cavity with onl y a brief period of cont act with the teeth, constantly sipping a sugar-containing beverage increases the time teet h are exposed to the sugar, which leads to extended periods of tooth demineralization. Similarly, holding sugar-containing items such as hard candies a nd lollipops in the oral cavity increases the amount of time the bacteria on the teeth are in contact with sugar. In contrast to what might be expected, studies have shown that items such as cookies, chips and white bread are retained longer in the oral cavity than sticky candies (i.e., caramels, jellybeans), chocolate, and bananas. This can be explained by the additional time needed for salivary amylase to break down food items that contai n starch (i.e., cookies, chips, and white

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22 bread). This longer retention time creates extended periods of tooth demineralization since amylase has more time to break the st arch into caries-promoting sugars (57). Szpunar et al. (1995) reported that in child ren aged 11 to 15 years, each additional 5 grams of daily sugars intake above the m ean intake of 142.9 grams was associated with a 1% increase in the probability of developing caries (10). These same researchers also found that the relationship between carious le sions and dietary variables were stronger with total sugars intake than w ith frequency of intake (6). In contrast, other studies have found a stronger relationship be tween frequency of snack cons umption and dental caries. Creedon and O’Mullane (2001) found that childre n who snacked three or more times per day between meals had a higher caries experi ence than children who snacked less than once a day (65). A study of 5, 8, and 11-y ear-old children repor ted that those who reported a frequency of sweet snack consumpti on more than 5 times a day appeared to have more caries (66). Vanobberg en et al. (2001) reported that the risk for dental caries in children with a mean age of 7 years incr eased with the frequenc y of consumption of sugared beverages and frequency of between meal snacks (12). Researchers in Saudi Arabia found that children who consumed car bonated drinks at least once a day had significantly more caries than children w ho had carbonated drinks only once or twice a week (14). One study found that both tota l sugar intake and frequency of eating occasions led to an increase in dental carie s, but did not give emphasis to one variable over the other (67). Researchers seem divi ded about whether the relationship between dental caries and sugar intake is more strong ly influenced by total intake or by frequency of intake.

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23 Early Childhood Caries Early childhood caries (ECC), previously known as baby bottle tooth decay or nursing caries, describes the caries found in the primary dentition soon after the eruption of the first teeth in infants and toddlers (17,68). The immatu re host defense system of a child in combination with the presence of fermentable carbohydrates provides an ideal environment for the proliferation of S. mutans factors that may be responsible for the development of ECC (69). Generally, the four maxillary (upper) incisors are affected, but not the four mandibular (lower) incisors. On e explanation for this pattern is that milk or sweetened liquid from the baby bottle pool s around the maxillary incisors while the child is sleeping (16). A variety of factors may lead to ECC, including bottle contents, use of a bottle when going to sleep, and age of weaning. In general, prolonged a nd inappropriate bottle feeding is the cause of ECC (68). Research ers from Saudi Arabia re ported that preschool children with a high caries experience were significantly more likely to have received nocturnal bottle feedings with formula. Fre quency of consumption of soft drinks, use of sweetened milk in the bottle and consumption of sweets also were significantly higher in these children compared to children with a de creased incidence of ECC (15). Al-Malik et al. (2001) found that children w ith the highest prevalence of ca ries were given fruit syrup or fruit juice in a bottle at bedtime as an infant or carbonated dri nks at bedtime as an older child (14). Mohan et al. (1998) reported that childr en under 2 years of age who consumed sweetened beverages from a bottle had a significant increase in colonization of S. mutans compared to children who either only drank milk or who did not use a bottle (68). Researchers in the United States found that children who went to sleep with a bottle, regardless of bottle contents, were mo re likely to have ECC. Additionally, this

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24 same study found a significant difference in ca ries risk depending on the age at which children were weaned from the bottle. Childre n with ECC were more likely to have been weaned after 14 months of age (16). A study conducted in Hong Kong reported similar results in that children with caries were weaned at approximately 20 months, while children without caries had been weaned 7 m onths earlier (70). Douglass (2001) reported a significant relationship between nighttime bottle use and ECC and that older children (25 to 36 months) who were still using the bot tle were more likely to have a history of sleeping with the bottle, which increa ses their risk for ECC (71). The presence of ECC is significant because ECC may be a predictor for future carious lesions (18), specifically caries in adolescence (17). A study by Peretz et al. (2003) that followed children with ECC for se ven to ten years, found that the children with ECC had a greater risk fo r dental caries compared to children who either had caries in their posterior teeth or ha d no caries (17). Interestingl y, Almeida (2000) reported that after two years of routine dental visits a nd increased dietary counseling, 79% of children with ECC were diagnosed with additional caries In contrast, caries developed in 29% of children in the control gr oup who initially had no caries and received no dietary counseling (69). Dental Caries and Taste Sensitivity Lin (2003) identified a relations hip between PROP taster st atus and dental caries. The study reported that children classified as PROP nontasters had a higher prevalence of dental caries than tasters (13) One potential explanation for this finding is that food preferences and intake may be affected by ge netically determined differences in taste such that PROP nontasters prefer and cons ume foods that are mo re likely to promote dental caries; however, Lin did not examine dietary intake in his study.

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25 Methods of Dietary Data Collection There are several methods available fo r collecting dietary information. Two popular methods are multiple day food records and food frequency questionnaires. Since all methods for collecting dietary informati on have strengths and weaknesses, it is desirable to collect the information using mo re than one method (72). Multiple day food records are time consuming si nce subjects must be instruct ed on how to record foods eaten. Other weaknesses include the burden placed on the respondent and the possibility that the days on which food intake is recorded are atypical. Also, subjects may alter their eating behaviors if they know they have to keep a record. However, because food records are open-ended, they have the potenti al to provide fairly accurate information regarding food intake since subjects have the freedom to include whatever they ate instead of having forced or limited choices (73). Food frequency questionnaires (FFQs) are good for assessing usual intake in time peri ods of the preceding we ek, month, or year. This method places less burden on the subject, but also requires higher level thinking and good memory (72). For example, if the FFQ is measuring intake ove r the past year and the subject eats ice cream once a week only in the summer, the total number of times eaten (for example, 12 times) must be divide d by 12 months. Instead of eating ice cream once a week, the FFQ will record the data as once a month. It has been suggested that FFQs may be the most appropriate method of assessing dietary intake when examining relationships between diet and disease since they are designed to measure usual or longterm intake (74). However, investigators of ten use at least two methods for collecting dietary intake, so that they can have a bette r picture of subjects’ usual intake (75). Obtaining dietary intake data from child ren is especially difficult due to their limited cognitive abilities, lack of knowledge of food preparation methods, and limited

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26 ability to remember what they have eaten (75). In a study that compared 3-day food records, a 24-hour recall and a 5-day food fr equency questionnaire in 9 and 10 year old girls, the 3-day food records more accurately reported intake compared to the other two methods (76). Younger children, approximately 7 to 8 years ol d, are not able to complete dietary assessment instruments adequately; therefore, the parents/caregivers of younger children must accept the responsibility fo r providing information regarding dietary intake. In contrast, children 10 to12 years of age have been shown to report their food intake reliably (77). Research Significance It is widely accepted that dietary in take of sugars and other fermentable carbohydrates is associated with an increased risk for de ntal caries. Intake of carbohydrates is affected by an individual’s preference for sweet taste. Many studies examining the influence of taster status on food intake suggest that individuals who are PROP tasters have a decreased preference fo r sweetened foods and beverages, which may lead to decreased consumption of these items. Reduced intake of these foods also has been associated with a more normal BMI. However, several studies have reported an increased preference for and intake of sweeten ed foods and beverages by tasters, as well as higher BMIs compared to nontasters. Differences in outcomes among these studies could be due to differences in methods used to assess taster status (i.e., genotyping versus PROP testing), the scales used to identify ta ster status when PROP is used as a method for “determining” taste perception, lack of sepa ration of supertasters from medium tasters and the age of subjects. Only one study to date has examined the relationship between PROP sensitivity and dental caries in childre n. The findings of this study support a positive relationship

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27 between PROP nontaster status and dental car ies. However, no dietary intake or food preference data were collected, so it is not po ssible to discern if the differences observed in dental caries prevalence in ST and NT was related to intake or fr equency of intake of sugar/sugar-sweetened foods/beverages and starches. Determining whether a relationship exists between dental caries prevalence of ST and NT as a function of preference for and consumption of sugar and sugar-containing foods would be useful in identifying indivi duals most at risk for developing caries, especially children. Early screening to identify these higher ri sk children and the development of targeted interv ention strategies could be used to reduce caries prevalence in adolescence and adulthood. To investigate the relationships among dent al caries prevalence and diet in ST and NT children, information related to food pref erences, dietary intake of carbohydrates and sugars, number of eating occasions, BMI, bottl e feeding practices, a nd preference ratings for sweet were collected and compared betw een supertasters and nontasters. It was hypothesized that dental caries prevalence of ST and NT children would be different based on preferences for sweetened foods a nd beverages, consumption of sweetened foods and beverages and BMI.

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28 CHAPTER 3 RESEARCH DESIGN AND METHODS Subject Recruitment The University of Florida Health Scie nce Center Institut ional Review Board (IRB) approved the study protoc ol. Eligible subjects were recruited from the Pediatric Dentistry Clinic of the University of Florid a College of Dentistry. IRB approved flyers were posted in the Pediatric Dentistry Clinic waiting area to inform potential subjects about the study. Children 6 to 12 years old w ho attended the clinic for routine dental treatment and were free of ch ronic diseases/conditions that require dietary modifications as part of disease management were consid ered for participation in this study. After obtaining informed consent from the parent or caregiver and assent from the child, the subject was screened for taste sensitivity. Subjects were comp ensated for participating in the study. Taste Sensitivity To screen for taste sensitivity, the childr en were given verbal instructions on how to rate the intensity of a va riety of sensations using the general Labeled Magnitude Scale (gLMS). They were shown a lined scale with numbers ranging from 0 to 100 on one side and descriptive adjectives on the other side (0 = no sensation, 100 = strongest imaginable) (36). The children were asked to rate the intensity of a series of common occurrences, such as the loudness of a whis per, brightness of a well-lit room and strongest oral pain experienced, using the gL MS (Appendix A). The last sensation in the series was the PROP test. The children were asked to place a 3 cm circle of filter paper

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29 impregnated with 1.6 milligrams of pharmaceu tical grade PROP on the dorsal surface of the tongue for 30 seconds and to rate the sens ation in relation to the other intensities already rated on the scale. Based on their gL MS ratings, the children were classified as supertasters (rating above 60), medium taster s (rating 12 to 60), and nontasters (rating below 12). Only children classi fied as supertasters or nontas ters were recruited for the remainder of the study. After the first 30 chil dren were screened, the screening procedure was adjusted because the researchers believ ed some of the children rated the PROP intensity high as a result of having the filter paper in their mouths (i.e., the taste of the paper), not as a true intensity rating. Subse quently, all prospective subjects were given a plain piece of filter paper before the filter paper containing PROP to acquaint them with the sensation of the paper. The children w ho qualified for the study prior to adjusting the screening procedure (n = 15) were screen ed a second time using the two filter paper method. Four of these children did not re-quali fy as subjects. After the screening visit, the subjects selected for particip ation in the study returned to the Dentistry Clinic for two additional visits (Figure 3-1). Figure 3-1. Study prot ocol and timeline Second Return Visit Screening First Return Visit PROP screening performed Demographic data collected Food preferences obtained Dental exam performed Bottle feeding questionnaire administered Food diary instructions explained Youth/Adolescent Questionnaire administered Hedonic response to sweet evaluated Sucrose intensity evaluated

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30 Demographic Data Immediately after subjects qualified for the study, the following demographic data were collected from the subjects or parents/ caregivers: gender, age in months (on the day of screening), ethnic origin, number of people living in the su bject’s household, and family income. Anthropometric Measures The anthropometric measures collected at the screening visit included height and weight. Weight without shoes was measured to the nearest tenth of a kilogram using a digital scale (Seca 770, Hamburg, Germany) a nd height was measured to the nearest tenth of a centimeter using a stadiometer (Seca 222, Hamburg, Germany). Weight, height, and age on the day these measurements were taken were entered into the BMI percentile calculator on the Sh ape Up America! Web site ( www.shapeup.org/oap/entry.php ). This calculator plots the BMI percentile on age and gender specific growth charts. The mean pe rcentiles were used to compare subjects according to PROP status. Food Preferences Food preferences were evaluated using a food preference que stionnaire at the screening visit. Unsuccessful attempts were made to attain questionnaires used in published studies (1,2). A 60-item food pref erence questionnaire was created after a literature search yielded ideas for food categories and methods to check validity (Appendix B). Categories of foods/beverages examined included vegetables, fruits, dairy, sweetened dairy, beverages, baked goods, cereals, sugar/sw eetened foods, and salted snacks. Five of the food items were as ked twice to examine internal validity (1). Subjects were asked to rate food preference s for the 60 food items using a hedonic scale

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31 for children (Appendix C). This scale has numbe rs defined with Peryam and Kroll verbal descriptors: 1 = super bad, 2 = really bad, 3 = bad, 4 = maybe good or maybe bad, 5 = good, 6 = really good, 7 = super good. Each number and definition is accompanied by varying degrees of smiling or frowning faces to illustrate the seven le vels of likeability (78-80) An additional choice wa s added as an empty circle w ith the number 0 to account for unfamiliar food items as well as items that the children had not tasted. Dental Exam As part of the dental examination conduc ted for routine dental treatment purposes, each subject received a standard clinical examination by one of the investigators using a dental light, mouth mirror, and e xplorer at the subject’s first re turn visit to the clinic. To check reliability, a test a nd retest were conducted on 11 subjects. Dental caries (including white spot lesions), restorations and extracted teeth in the primary teeth surfaces were recorded on the standard clini cal form used in the UF Pediatric Dentistry Clinic. In addition, the bite wing radiographs taken for treatment purposes were examined (no radiographs were taken for research purposes ). The results of the existing clinical and radiographic examinations were recorded as the total number of decayed extracted and filled surfaces in primary/PERMANENT teeth (defs/DEFS). Bottle Feeding History Bottle feeding history was obtained using a questionnaire to provide data regarding early childhood feeding practices that may ha ve influenced the development of early childhood caries (71) (Appendix D). Informa tion such as number of bottle feedings, types of beverages included in bottle feedings times of bottle feedi ngs, and age at which the child was weaned from the bottle was obt ained from parents/ca regivers during the first return visit.

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32 Food, Beverage and Supplement Diary To investigate the relationship among ta ste sensitivity, food intake, and dental caries prevalence, dietary inta ke and patterns were evaluate d using three, nonconsecutive, 24-hour food diaries that included at leas t one weekend day (9,73,81,82). These records provided the opportunity to asse ss the quantity of sugar cons umption of the subjects as well as the number of eating occasions per day. At the first return visit, subjects and their parents/caregivers were inst ructed to record all foods, beverages, and supplements consumed on each of three nonconsecutive days. The diary form included spaces to record: time at which the item was consume d, a list of foods, beverages and supplements consumed, a description of each food/bevera ge/supplement, and the amount consumed (Appendix E). In addition, a handout was given that contained examples of portion sizes relative to common household items (e.g., a medium piece of fruit is approximately equal to the size of a tennis ball). Reported food intake was analyzed for macro(including total sugar intake) and micro-nutrient conten t using the computerized software program, Food Processor (ESHA version 8.01). Inta ke of sugar from sweeteners and sugarcontaining foods was assessed af ter categorizing intake by fo od type (i.e., beverages, starch only foods and sugar-con taining foods, etc.). The pe rcent of total calories from carbohydrates and the percent of total calories from sugars were calculated so that comparisons could be made between child ren with different energy intakes. Youth/Adolescent Questionnaire (YAQ) In addition to the food diary, a food frequenc y questionnaire (FFQ), specifically the Youth/Adolescent Questionnaire (YAQ), was admi nistered to the subjects with the help of one of the researchers duri ng the second return vi sit to the clinic (Appendix F). This questionnaire, modified from the Willet FFQ contains 152 questions and includes snack

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33 foods as well as other foods commonly cons umed by children (83). The YAQ is a semiquantitative FFQ that assesses the usual diet of children ove r the preceding year and has been validated as a reliable method for determ ining nutrient intakes of children 9 to 18 years old (75,84). The questionnaire also as ks information about meals and snacks eaten away from home as well as the child’s responsibility for preparation of meals and snacks. The YAQ contains spaces to write in the specif ic type of ready-to-e at breakfast cereal consumed, brand and type of margarine us ed, and other foods usually eaten but not contained in the questionnaire. Subjects and parents/caregivers completed the YAQ in approximately 45 minutes. Information gathered from the food preference questionnaire was used to correlate food pr eferences with data from the food diaries and YAQ, since previous research reported a relationship between foods pr eferred and foods consumed (85). Hedonic Response to Sweet The sensory methodology to determine the he donic response to varying levels of sweetness included the creation of five levels of sweetness in commercial apple juice by adding graded amounts of sucrose: 0, 3, 6, 9, and 12 grams to 100 grams of juice, which is similar to that used by Liem and Mennell a (2002)(53). This provided sweetness levels ranging from relatively moderate (i.e., no added sucrose, typi cal natural sugar content of 10 to 12%) to very high for a typical food product (20 to 22% total sugar) (86). At the second return visit, the juice samples were presented to the subject s in random order in plastic cups labeled with random 3-digit num bers. The subjects rated how much they liked the apple juice on the same hedonic scale that was used for the food preference questionnaire without the opti on of never tried (78-80).

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34 Sucrose Intensity Rating A 1M sucrose solution was prepared for use during the second return visit. Subjects were given five milliliters of the solution to taste. They rated the intensity of the sucrose solution using the gLMS (86). Statistical Analysis The main objective of this study was to de termine the differences in mean decayed, extracted and filled surfaces in primary (d efs) and permanent (DEFS) teeth between supertasters and nontasters as determined by PROP. The difference between these groups as defined by Lin (2003), was 17 units (i.e., 1.0 for supertasters versus 18.19 for nontasters) (13). To detect half that differe nce (i.e., 8.5 units) using the pooled standard deviation (SD) of 7 and a two-tailed alpha = 0.05 with 80% power, a sample size of 15 subjects was required in each taster group. Based on this power analysis, it was estimated that 30 subjects, 15 supertasters a nd 15 nontasters, were needed for this study. The statistical analysis was performed with a standard statistical personal computer software package (SAS, version 9.1, SAS Institu te Inc. Cary NC, USA) that included ttests and paired t-tests to examine the signi ficance of the differences between numerical variables, Chi square and Fish er exact tests to examine the significance of distribution of a categorical parameter by anot her categorical variable, and logistic regression analyses to examine the significance of the influen ce of different dependent variables on an independent variable for both tasters and nontasters.

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35 CHAPTER 4 RESULTS Subjects One hundred and four children were screened for taster status. Forty-two children qualified for the study. Two of these subjects withdrew, 4 did not re-qualify after the PROP re-screening, and 4 completed only the in itial visit and the fi rst return visit. Seventeen subjects classified as supertasters and 15 subjects clas sified as nontasters completed all three visits; however, the th ree day food, beverage, and supplement diary for six of these subjects (18.75%) were not analyzed because three supertasters and 2 nontasters did not return their food diaries and one nontaster’s diary was incomplete. There were 14 girls (44%) and 18 boys ( 56%) with a mean age SD of 112.7 22.6 months (i.e., 9 years); (ra nge = 74 to 155 months or 6 to 12 years). No significant difference was detected with regard to gende r and taster status (P = 0.69) (Table 4-1). Table 4-1. Sample characteristics of the study groups Supertasters N = 17 (53%) Nontasters N = 15 (47%) Gender* n (%) n (%) Male 9 (28.1) 9 (28.1) Female 8 (25) 6 (18.8) Ethnic Origin** African-American 4 (23.5) 3 (20) African-American/Caucasian 0 1 (6.6) Hispanic 3 (17.6) 1 (6.6) Hispanic/Caucasian 0 1 (6.6) Caucasian 10 (58.8) 9 (60) *P = 0.69 **P = 0.78

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36 Demographic Data Subjects’ ethnic origin is reported in Ta ble 4-1. No signifi cant difference was detected with regard to ethnic or igin and taster status (P = 0.7 8). The ethnic origin of the study subjects is reflective of the population of Alachua Count y, Florida. The number of people living in subjects’ households is repo rted in Table 4-2 and family income per household is reported in Table 4-3. Table 4-2. Number of individuals living in each subject’s household Size of Household (Number of indi viduals) Number of Subjects (%) 3 1 (3.1) 4 12 (37.5) 5 9 (28.1) 6 4 (12.5) 7 4 (12.5) 8 2 (6.25) Table 4-3. Family income per household Family Income Range Nu mber of Subjects (%) $19000 or less 11 (34.4) $20000 $29000 9 (28.1) $30000 $39000 7 (21.9) $40000 $69000 4 (12.5) $70000 or more 1 (3.1) Dental Exam No significant differences were detected between the two taster groups regarding present experience of defs/DEFS: nontasters (12.1 12.5) versus s upertasters (8.4 8.8) (P = 0.33); caries history: nontas ters (7.6 5.8) versus supert asters (6.3 8.4) (P = 0.62); and present caries experience combined with caries hist ory: nontasters (19.7 15.2) versus supertasters (14.6 17) (P = 0.39). Food Preferences The preference ratings for foods listed in each food category included in the food preference questionnaire were averaged to calculate a category mean. The means were

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37 compared between the two taster groups. No significant differences were detected between nontasters and s upertasters for any of the food pref erence categories (Table 4-4). Table 4-4. Food preference scores (mean SD) for food categories by taster status Food Category Supertaster* (mean SD) Nontaster (mean SD) Vegetables: broccoli, spinach, green beans, potatoes, carrots, corn, greens 32.2 5.7 32.5 7.7 Fruits: strawberries, bananas, pineapple, apples, grapes, raisins, lemons 36.2 7.2 37.4 6.6 Dairy: cheddar cheese, American cheese, cottage cheese, milk 17.0 6.5 17.7 4.9 Sweetened dairy: ice cream, flavored milk (chocolate, strawberry), frozen yogurt, flavored yogurt, milkshake, pudding 34.9 5.7 33.7 2.7 Beverages: soft drinks (regular and diet), tea (sweetened and unsweetened), 100% juice, juice drinks (lemonade), Kool-aid 33.9 5.8 33.0 8.8 Baked goods: cookies, brownies, cake, poptarts, pie, snack cakes, graham crackers 38.5 5.4 39.4 5.1 Cereals: breakfast cereals (sweetened and unsweetened), cereal bars, granola bars 19.7 3.4 19.5 5.5 Sugar/sweetened foods: candy (chocolate and non-chocolate), popsicles, fruit rollups, jam/jelly, syrup, doughnuts, Jello, sweet roll 50.4 7.1 51.6 7.1 Salted snacks: popcorn, pretzels, chips, peanuts 21.0 3.0 21.3 3.1 *P>0.05, two-tailed test, for each food cat egory comparison between ST and NT For individual foods, strawberries, ic e cream and doughnuts were rated highest by both taster groups. In addition, milk and choc olate candy were rated within the top five items for STs and popcorn and cookies rounded ou t the top five foods for NTs. Cottage

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38 cheese and spinach were rated the lowest by bot h taster groups. Supe rtasters also rated lemons, greens (i.e., collard, mustard) and uns weetened tea lowest, while nontasters gave broccoli, diet soft drinks and cer eal bars the lowest ratings. The linear relationship between dental caries prevalence of STs and NTs as a function of food preference was examined for each of the nine food categories included in the food preference questi onnaire. There was no evid ence to indicate a linear relationship between dental caries prevalen ce of ST compared to NT children as a function of food preference for any food cat egory (Figures 4.1 to 4.9). There was no Figure 4-1. Dental caries preval ence of ST and NT children as a function of vegetable preference evidence to suggest a correlation between dent al caries status and food preferences based on food preference categories for either STs or NTs, with one exception (Table 4-5). A positive correlation (P = 0.04) was noted between dental caries status of ST children and preference for cereal (i.e., sweetened and unsw eetened ready-to-eat cereal, granola bars and cereal bars). 15 20 25 30 35 40 45 -5 0 5 10 15 20 25 30 35 40Nontaster Supertaster Nontaster Supertaster Vegetable preference scoreDental caries (defs/DEFS) R 2 = 0.08 P = 0.36

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39 Figure 4-2. Dental caries prevalen ce of ST and NT children as a function of fruit preference Figure 4-3. Dental caries prevalence of ST and NT children as a function of dairy preference 0 10 20 30 40 50 60 -5 0 5 10 15 20 25 30 35 40Nontaster Supertaster Nontaster Supertaster Fruit preference scoreDental caries (defs/DEFS) R 2 = 0.1 P = 0.24 0 5 10 15 20 25 30 -5 0 5 10 15 20 25 30 35 40Nontasters Supertasters Nontasters Supertasters Dairy preference scoreDental caries (defs/DEFS) R 2 = 0.04 P = 0.96

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40 Figure 4-4. Dental caries prev alence of ST and NT childre n as a function of sweetened dairy preference Figure 4-5. Dental caries prev alence of ST and NT childre n as a function of beverage preference 20 25 30 35 40 45 -5 0 5 10 15 20 25 30 35 40Nontasters Supertasters Nontasters Supertasters Sweetened dairy preference scoreDental caries (defs/DEFS) R 2 = 0.03 P = 0.98 20 30 40 50 60 -5 0 5 10 15 20 25 30 35 40Nontasters Supertasters Nontasters Supertasters Beverage preference scoreDental caries (defs/DEFS) R 2 = 0.04 P = 0.44

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41 Figure 4-6. Dental caries prev alence of ST and NT childre n as a function of baked goods preference Figure 4-7. Dental caries prevalence of ST and NT children as a function of cereal preference 0 5 10 15 20 25 30 -5 0 5 10 15 20 25 30 35 40Nontasters Supertasters Nontasters Supertasters Cereal preference scoreDental caries (defs/DEFS) R 2 = 0.13 P = 0.06 25 30 35 40 45 50 55 -5 0 5 10 15 20 25 30 35 40Nontasters Supertasters Nontasters Supertasters Baked goods preference scoreDental caries (defs/DMFS) R 2 = 0.09 P = 0.4

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42 Figure 4-8. Dental caries prevalence of ST and NT children as a function of sugar preference Figure 4-9. Dental caries prevalence of ST and NT children as a function of salted snacks preference Food, Beverage and Supplement Diary Items from the three day food, beverage, and supplement diary were entered into Food Processor (ESHA version 8.01) to determin e the 3 day average intake for nutrients and food components such as sugars. The percent of total calories from carbohydrates and the percent of total calori es from sugars (i.e., sucros e, fructose, lactose) were calculated so that comparisons could be made between children with different calorie 0 10 20 30 40 -5 0 5 10 15 20 25 30 35 40Nontasters Supertasters Nontasters Supertasters Salted snacks preference scoreDental caries (defs/DEFS) R 2 = 0.05 P = 0.65 30 40 50 60 70 80 -5 0 5 10 15 20 25 30 35 40Nontasters Supertasters Nontasters Supertasters Sugar preference scoreDental caries (defs/DEFS) R 2 = 0.03 P = 0.87

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43 Table 4-5. Relationship between dental caries prevalence and food preferences for STs and NTs Supertasters Nontasters r-value P-value r-value P-value Vegetable -0.32 0.21 0.13 0.66 Fruit -0.28 0.28 0.25 0.39 Dairy 0.06 0.83 0.10 0.73 Sweetened dairy -0.09 0.74 0.001 1.0 Beverages 0.16 0.53 -0.07 0.80 Salted snacks -0.06 0.81 0.15 0.60 Baked goods 0.02 0.95 0.31 0.26 Cereal 0.49 0.04 -0.15 0.59 Sugar and sugar sweetened foods 0.03 0.92 0.004 0.99 intakes. No significant difference was detect ed between STs and NTs, respectively, with regard to total calories consumed (1966 486; 2054 530; P = 0.67), carbohydrate intake (mean percent of total calories SD): (54.6 5; 52.9 5.5; P = 0.43), sugar intake (mean percent of total calo ries SD): (26.8 3.8; 26.3 5.4; P = 0.76), or number of eating occasions per day (5.4 1.2; 5.5 1.5; P = 0.81). Carbohydrate and sugar intakes as a percent of total calories were calculated after categorizing specific items recorded in the f ood diaries. The catego ries included: sugar (i.e., candy, syrup, jam/jelly), sugar and starch (i.e., cakes, cookies, pies), starch (i.e., bread, rice, pasta), milk (i.e., regular and chocolate), and sw eetened beverages (i.e., soda, tea, juice/juice drinks ). No significant di fferences were detected between nontasters and supertasters for any of the categories that included sugar containing foods (Table 4-6). There was no evidence to indicate a difference in the slope of the line for ST compared to NT children when examining the linear re lationship between dental caries prevalence as a function of the percent of total calories from sugar intake (Figure 4-10). There was no evidence to suggest a correlation between dent al caries prevalence and sugar intake as

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44 a percent of total calories for either STs or NTs (r = -0.06; P = 0.84; r = 0.21; P = 0.50, respectively). Table 4-6. Carbohydrate and sugar intake of ST and NT children by food category Category Supertaster Nontaster P-value % of total calori es (mean SD) Sugar CHO 11.3 9.1 7.5 3.5 0.17 sugar 18.9 15.3 13.6 9.2 0.31 Sugar/starch CHO 22.2 10.3 16.6 9.2 0.16 sugar 19.7 8.2 15.7 8.8 0.25 Starch CHO 22.7 8.9 23.3 13.4 0.91 sugar 4.0 3.2 3.9 3.8 0.95 Milk CHO 8.7 4.6 12.1 10.2 0.31 sugar 17.9 9.9 22.4 17.2 0.41 Sweetened beverages CHO 14.5 10.5 16.1 10.2 0.70 sugar 30.7 21.3 30.3 18.2 0.96 Figure 4-10. Dental caries prevalence of ST and NT children as a function of sugar intake Youth/Adolescent Questionnaire (YAQ) Completed YAQs were hand-coded for t ype and brand of margarine used and brand of ready-to-eat breakfa st cereals consumed, and were sent to Channing Laboratory 17.5 20.0 22.5 25.0 27.5 30.0 32.5 35.0 37.5 -5 0 5 10 15 20 25 30 35 40nontaster supertaster nontaster supertaster Su g ar intake ( %of total calories ) Dental caries (defs/DEFS) R2 = 0.06 P = 0.63

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45 at Harvard Medical School for analysis. No significant differences were detected between ST and NT children for total cal ories (mean SD): (2431 889 vs. 2410 781; P = 0.94), total carbohydrate intake (57.1 9.9 vs. 53.5 5.3; P = 0.21) or sucrose consumption (10.3 2.7 vs. 10.6 2.6; P = 0.8), respectively. A significant difference (P = 0.048) in the total energy intake reported from the food diaries compared to the YAQ was detected. The mean total calories from the food diaries (2007 kcals 499) was lower than the mean of total calories from the YAQ (2421 kcals 827). The difference in estimated energy intake may be due to inherent differences in the methods used to obtain di etary intake data. The calories from the food diaries represent actual intake over a thr ee day period while the calories from the YAQ do not represent actual intake but usual intake from the pr eceding year. The range for total calories from the food diaries was 1163 to 3119 calories while the range from the YAQ was 820 to 4717. No significant differenc e was detected in carbohydrate intake expressed as a percent of tota l calories when comparing the re sults of analysis of the food diaries (53.8 5.5) to the YAQ (55.4 8.2) (P = 0.90). There was no evidence to indicate a diffe rence in the slope of the line for ST compared to NT children when examining th e linear relationship between dental caries prevalence as a function of the percent of to tal calories from sucrose (Figure 4-11). There was no evidence to suggest a correla tion between dental caries prevalence and sugar intake as a percent of total calories for either STs or NTs (r = 0.18; P = 0.50; r = 0.13; P = 0.65, respectively).

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46 Figure 4-11. Dental caries prevalence of ST and NT children as a function of sucrose intake Bottle Feeding History Responses of parents/caregivers of ST compar ed to NT children regarding early infant feeding practices are shown in Table 4-7. L ogistic regression analysis was performed to obtain the odds ratio (OR) and 95% confid ence interval (95% CI) for each feeding practice (Table 4-7). No difference between ST and NT parents/caregivers regarding the addition of sweeteners, cereal or strained fru it, or sweetened beverages (i.e., juice, Koolaid, sweetened tea, soda) to the bottle was detected. In addition, no difference between ST and NT parents/caregivers was detected regarding the use of a bottle or sippy cup while in bed, being allowed to breastfeed throughout the night as desired or age of weaning. Anthropometric Data A t-test was used to determine whether diffe rences existed between taster groups with regard to BMI. No significant difference wa s detected between the mean BMI percentile of supertasters (74.2% 17.7) compared to nontasters (64.4% 25) (P = 0.20). There was no evidence to indicate a difference in the slope of the line for ST compared to NT 5 6 7 8 9 10 11 12 13 14 15 16 17 -5 0 5 10 15 20 25 30 35 40Supertaster Nontaster Supertaster Nontaster Sucrose intake (%of total calories)Dental caries (defs/DEFS) R 2 = 0.05 P = 0.33

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47 children when examining the linear relationshi p between dental caries prevalence as a function of BMI percentile (F igure 4-12). There was no evid ence to suggest a correlation between dental caries prevalence and BMI per centile for either STs or NTs (r = -0.11; P = 0.68; r = -0.21; P = 0.46, respectively). Table 4-7. Responses and logist ic regression analysis of spec ific bottle feeding practices of ST compared to NT parents/caregivers Feeding Practices Frequency Supertas tersNontastersOdds Ratio (95% CI)* Never, rarely, occasionally 16 12 Addition of sweeteners Weekly, daily 0 3 0.22 (0 – 2.16) Never, rarely, occasionally 10 9 Addition of cereal or strained fruit Weekly, daily 6 6 0.90 (0.21 – 3.82) Never, rarely, occasionally 12 9 Addition of sweetened beverages Weekly, daily 4 6 0.51 (0.08 – 2.93) Never, rarely, occasionally 7 9 Use of bottle or sippy cup in bed Weekly, daily 9 6 1.93 (0.46 – 8.05) Never, rarely, occasionally 6 7 Fed at breast throughout night as desired Weekly, daily 8 5 1.87 (0.39 – 8.89) Before 9 months 1 0 9-12 months 3 4 13-15 months 5 5 After 15 months 5 3 Age at weaning Not sure 0 1 1.00 (0.25 – 3.95) *P>0.05

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48 Figure 4-12. Dental caries prevalence of ST and NT children as a function of BMI percentile Hedonic Response to Sweet The sugar content of the apple juice sa mples was verified using a refractometer (Abbe Mark II, Model 10480 S/ N, Reichert, Buffalo, New York) (Table 4-8). The Table 4-8. Percent sugar in apple juice samples measured by refractometry Sample (g sucrose/100 g juice) % sugar (beginning of study) % sugar (midpoint of study) 0 11.55 11.65 3 14.1 14.25 6 16.8 16.55 9 18.9 18.0 12 21.15 18.65 graded solutions of sucrose in apple juice we re prepared at the be ginning of the study and again at the midpoint of the study. Due to the small subject number, answers from the hedonic scale were combined for comparison: “tastes bad” included super bad, really bad and bad, while “tastes good” included supe r good, really good, and good. The subjects’ responses to the five graded solutions of sucr ose in apple juice are reported in Table 4-9. Logistic regression analysis was performed to obtain the OR and 95% CI (Table 4-9). Supertasters were 20.8% more likely to rate all the apple juice samples as good compared 20 30 40 50 60 70 80 90 100 110 -5 0 5 10 15 20 25 30 35 40nontaster supertaster nontaster supertaster BMI percentileDental caries (defs/DEFS) R 2 = 0.08 P = 0.65

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49 to nontasters; however, a signifi cant difference was not detected (P = 0.60). Significant differences were not detected between STs a nd NTs for any of the apple juice samples. Table 4-9. Responses and logist ic regression analysis of STs compared to NTs regarding the graded solutions of sucrose in apple juice Amount of sucrose added to 100 g juice Response STs NTs OR (95% CI)* Bad 2 0 Neutral 3 5 0 gram Good 12 10 1.00 (0.23 – 4.40) Bad 2 3 Neutral 4 0 3 grams Good 11 12 0.58 (0.12 – 2.81) Bad 1 3 Neutral 1 1 6 grams Good 15 11 2.85 (0.44 – 18.37) Bad 1 3 Neutral 4 0 9 grams Good 12 12 0.78 (0.16 – 3.86) Bad 1 3 Neutral 2 2 12 grams Good 14 10 2.50 (0.49 – 12.79) *P>0.05 Sucrose Intensity Rating No significant difference was de tected between the taster groups’ ratings of the intensity of a 1M sucrose solution: supertasters (34.4 28.9) versus nontaste rs (21.4 20.1) (P = 0.16) (Figure 4-13). There was no evidence to indicate a difference in the slope of the line for ST compared to NT children when examining the linear relationship between dental caries prevalence and sucrose intens ity ratings (Figure 4-13). There was no evidence to suggest a correlation between dent al caries prevalence a nd sucrose intensity rating for either STs or NTs (r = -0.32; P = 0.21; r = -0.17; P = 0.56, respectively).

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50 Figure 4-13. Dental caries prevalence of ST and NT children as a function of sucrose intensity rating 0 25 50 75 100 -5 0 5 10 15 20 25 30 35 40nontaster supertaster nontaster supertaster Sucrose intensity ratingDental caries (defs/DEFS) R 2 = 0.08 P = 0.66

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51 CHAPTER 5 DISCUSSION AND CONCLUSIONS Much of the previous research related to taste sensitivity as measured by the response to PROP has suggested that supertasters are more sensitive to bitter and sweet substances. This has led some researchers to speculate that supe rtasters may have a decreased preference for and cons umption of sweetened foods and beverages. It follows, then, that supertasters may have fewer dental caries as well as lower BMIs, as some studies have shown. The present study was the first to examine if there was a relationship between dental caries prevalen ce in supertaster and nontaster children as a function of sugar intake or pr eference for sweet. Identifyi ng a connection between dental caries prevalence based on taster status as identified by a simple method such as PROP testing could provide the impetus for more ta rgeted intervention st rategies that could strengthen the collaboration between nutrition and dental pr ofessionals as promoted by the American Dietetic Association position st atement on oral health and nutrition (63). Only one study to date has examined th e relationship betw een dental caries prevalence and taster status in children. Lin (2003) found that supertasters had fewer dental caries compared to nont asters (13). In contrast to that study, no significant difference was detected in dental caries prev alence between ST and NT children in the present study despite having ad equate power to detect a di fference in dental caries between STs and NTs. Based on the findings by Lin (2003) (13), differences in the carious surfaces between the s upertasters and the nontasters should have been detected with this sample size. While no differences were detected, NTs did appear to have more

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52 dental caries (12.1) compared to STs (8.4). A larger sample size may have detected a difference in dental caries betw een the two taster groups. The development of dental caries is aff ected by a variety of factors aside from sugar intake, including bottle feeding practi ces, age at weaning a nd frequency of eating occasions. Studies also have reported a positive relationship between dental caries prevalence and certain racial/ethnic groups. In examining the linear relationship between dental caries prevalence of ST compared to NT children as a function of sugar intake, it is important to consider the pot ential influence of these va riables as they could confound the results. However, no si gnificant differences between ST s and NTs were detected for any of these variables. Furthermore, there was no evidence to sugge st a difference in the linear relationship between dental caries prev alence and sucrose/sugar intake for either STs or NTs. In addition, there was no evid ence to suggest a difference in mean sucrose or sugar intake as a pe rcent of total calories between STs and NTs. Based on previous studies, it was expected that STs and NTs would have differing food preferences. It was expected that NT s would give higher pr eference ratings to sweetened, high fat foods and beverages compar ed to STs and that STs would give lower ratings to bitter vegetables. There was no evidence to suggest a difference in the linear relationship between dental cari es prevalence and food preferences for either STs or NTs. The food preference ratings of STs and NTs were very similar, suggesting that children in this study prefer similar types of foods, re gardless of taster status. In addition, no significant differences were detected re garding the preferences for the graded concentrations of sucrose in apple juice or the ratings of the 1M sucrose solution. A 7point hedonic scale was used for the apple ju ice samples, which may have led to ceiling

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53 effects. Additionally, it may have been diffi cult for the children to differentiate between really good and super good. A better option woul d have been to use the gLMS scale to help reduce the possibility of a ceiling eff ect. Also no differences may have been detected in the batch of sucrose solutions containing the 9 grams or the 12 grams of sucrose per 100 grams of apple juice that were prepared later in the study, since refractometry revealed no differe nce between the two samples. In contrast to several studies, but in support of other studie s, the mean percent BMI of NTs in the present study was lower than that of STs; however, significant differences were not detected. Previous studies have suggest ed that NTs may need to eat more in order to have the same taste sens ations as STs. However, no significant difference was detected between STs and NT s regarding total cal orie intake. One potential limitation of the pres ent study is that the power analysis was based on the number of subjects needed to detect a differe nce in dental caries prevalence between STs and NTs. Based on the data produced in this pilot study, a larger sample size would have been needed to detect a difference in the dietary variables. In addition, information regarding exercise habits wa s not collected. Nontaster children may have been more active than supertaster children leading to lower BMIs. Strengths of the present study included the exclusion of medium tasters, the use of the gLMS to categorize children into taste st atus groups and the use of more than one method to collect dietary data. Current resear ch seems to suggest that medium tasters are more like nontasters. Since this study di d not combine medium taster data with supertaster data, there should be no dilutional effects in the supertaster data. Also, the gLMS was used to categorize the subjects, which is currently the gold standard for

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54 assessing PROP taster status. Another strengt h is that two methods were used to collect dietary data. The food frequency questionnair e (YAQ) included a wide variety of foods and examined intake over a longer period of time compared to the food diary. The three day food diary provided more specific data on types of foods eate n, including portion sizes. Limitations of the study include a sma ll number of subjects drawn from a limited pool, the age of the subjects, th e responsibility of parents/car egivers to complete the food diaries and the use of an unvalidated food pr eference questionnaire. The subjects who participated in this study we re recruited from a limited pool since all subjects were current patients at the Pediatric Dentistry Clinic of the University of Florida College of Dentistry. Patients that attend the clinic often come from low socioeconomic backgrounds. The age of the subjects also co uld have affected the results since younger male children may not have had fully devel oped taste systems, as suggested by some studies. If this is the case, the data ma y not accurately reflect taster status in young males. In addition, the responsibility of completing the food, beverage, and supplement diaries rested solely with the parents/careg ivers of the younger children. Since we asked for two weekdays, children had to report to their parents/caregivers what they ate for lunch and snacks while at school. As some studies have shown, children often are not able to accurately report foods recently cons umed. Another limitation was the use of an unvalidated food preference questionnaire. Th e categories and specific foods chosen may not have been distinct enough to allow for the detection of significant differences. Taste perception is very complex. Recent discoveries of PTC/PROP genes on chromosomes 5 and 7 suggest that the abil ity to taste PTC/PROP is genetically

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55 determined. In addition to the ability to taste PROP, the number of fungiform papillae may contribute to the supertaste r phenotype. Only a small percentage of the bitter taste receptors (T2Rs) have been found on the fungiform papillae. However, a high percentage of the sweet taste receptors (T1R and T3R) are found on these papillae. The use of PROP as a method for assessing an individual’s taste sensitivity may not accurately reflect the true taste status. Th e identification of three single nucleotide polymorphisms of the taste sensitivity gene TAS2R38 suggests that a subjective measure of taste perception such as PROP may not adequately distinguish taste sensitivity. Future studies should determine whether a rela tionship exists among the various genotype combinations for taste and the phenotype of an individual based on PROP. Studies should be undertaken to determine if f ood preferences and intake vary among the different genotypes since there are inconsis tencies among published reports with some studies suggesting that supertas ters eat more sweets, while ot hers suggest that nontasters have a higher sugar intake. Since obesity is becoming such an epidemic in developed countries, it would be interest ing to have more conclusive data about the relationship between BMI and sugar intake of taster status as determined by genotype. The results from this study do not suppor t the findings of Lin (2003) (13) that nontaster children had more dental caries co mpared to supertaster children and do not support a linear relationship betw een dental caries prevalence of ST and NT children as a function of sugar intake or pr eference for sugar. Since ta ste sensitivity research in children is limited, additional st udies that address the limita tions of the present study and use genetic information to determine taster status are warranted. Future studies should determine whether a relations hip exists among the various genotype combinations for

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56 taste and the phenotype of the individual ba sed on PROP and whether dental caries prevalence is correlated with ta ste perception based on the tast e-related genotype status of an individual.

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57 APPENDIX A SENSATION LIST USED WITH THE GENERAL LABELED MAGNITUDE SCALE Used with permission of Linda M. Bartoshuk, Visiting Professor, University of Florida, lbartoshuk@phhp.ufl.edu Phone: 352-273-5119

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58 APPENDIX B FOOD PREFERENCE QUESTIONNAIRE Subject number _____________________ Food Preference Questionnaire General Information: The researcher will explain the directions to the subject and his/her parent/caregiver. The researcher will read the name of each food on the questionnaire, one at a time, and will use this form to record the number that corresponds to the “face” selected by the subject. Directions for Subjects: A list of foods will be read to you one at a time. For each food item, look at the faces on the paper in front of you. Decide which of the faces best describes how much you like or dislike the food and point to the face you picked. If you have never tried the food, then pick the circle with no face. 1. apples 0 1 2 3 4 5 6 7 2. milkshake/ 0 1 2 3 4 5 6 7 smoothie 3. popcorn 0 1 2 3 4 5 6 7 4. cereal bars 0 1 2 3 4 5 6 7 5. cookies 0 1 2 3 4 5 6 7 6. jello 0 1 2 3 4 5 6 7 7. broccoli 0 1 2 3 4 5 6 7 8. cottage cheese 0 1 2 3 4 5 6 7 9. regular soft drinks 0 1 2 3 4 5 6 7 10. chips 0 1 2 3 4 5 6 7 11. crackers 0 1 2 3 4 5 6 7

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59 12. lemons 0 1 2 3 4 5 6 7 13. pudding 0 1 2 3 4 5 6 7 14. poptarts 0 1 2 3 4 5 6 7 15. 100% juice 0 1 2 3 4 5 6 7 (orange, apple) 16. jam/jelly 0 1 2 3 4 5 6 7 17. bananas 0 1 2 3 4 5 6 7 18. spinach 0 1 2 3 4 5 6 7 19. brownies 0 1 2 3 4 5 6 7 20. diet soft drinks 0 1 2 3 4 5 6 7 21. chocolate candy 0 1 2 3 4 5 6 7 22. American cheese 0 1 2 3 4 5 6 7 23. grapes 0 1 2 3 4 5 6 7 24. frozen yogurt 0 1 2 3 4 5 6 7 25. sweetened tea 0 1 2 3 4 5 6 7 26. green beans 0 1 2 3 4 5 6 7 27. flavored milk 0 1 2 3 4 5 6 7 (chocolate, strawberry) 28. Popsicles 0 1 2 3 4 5 6 7 29. pre-sweetened 0 1 2 3 4 5 6 7 cereal (Reese’s, Apple Jacks, Cocoa Puffs) 30. pineapple 0 1 2 3 4 5 6 7 31. cinnamon roll/ 0 1 2 3 4 5 6 7 pastry 32. juice drinks 0 1 2 3 4 5 6 7

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60 (Hawaiian Punch) 33. pretzels 0 1 2 3 4 5 6 7 34. carrots 0 1 2 3 4 5 6 7 35. cake/cupcakes 0 1 2 3 4 5 6 7 36. granola bars 0 1 2 3 4 5 6 7 37. syrup (pancakes) 0 1 2 3 4 5 6 7 38. greens 0 1 2 3 4 5 6 7 (collard, mustard) 39. cheddar cheese 0 1 2 3 4 5 6 7 40. pie 0 1 2 3 4 5 6 7 41. unsweetened tea 0 1 2 3 4 5 6 7 42. non-chocolate 0 1 2 3 4 5 6 7 candy (jelly beans, lollipops) 43. corn 0 1 2 3 4 5 6 7 44. banana 0 1 2 3 4 5 6 7 45. flavored yogurt 0 1 2 3 4 5 6 7 46. fruit roll-ups/ 0 1 2 3 4 5 6 7 fun fruit 47. peanuts 0 1 2 3 4 5 6 7 48. snack cakes 0 1 2 3 4 5 6 7 (Twinkies) 49. Kool-aid 0 1 2 3 4 5 6 7 50. non-sweetened 0 1 2 3 4 5 6 7 cereal (Life, Corn Flakes) 51. cookies 0 1 2 3 4 5 6 7 52. mashed potatoes 0 1 2 3 4 5 6 7

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61 53. ice cream 0 1 2 3 4 5 6 7 54. regular soft drinks 0 1 2 3 4 5 6 7 55. doughnuts 0 1 2 3 4 5 6 7 56. raisins 0 1 2 3 4 5 6 7 57. popcorn 0 1 2 3 4 5 6 7 58. milk 0 1 2 3 4 5 6 7 59. chocolate candy 0 1 2 3 4 5 6 7 60. strawberries 0 1 2 3 4 5 6 7

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62 APPENDIX C HEDONIC SCALE FOR CHILDREN Adapted from Resurreccion AVA. (1998) Affec tive Testing with Children. In: Consumer Sensory Testing for Product Development, p. 171. Aspen Publishers, Inc. Gaithersburg, Maryland.

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63 APPENDIX D BOTTLE FEEDING QUESTIONNAIRE Subject number: _______________________ Bottle Feeding History Questionnaire 1. How often were sweeteners (sugar, honey, molasses, Karo syrup, chocolate syrup, etc.) added to milk/formula in your child’s bottle or sippy cup? _____ Never _____ Rarely (no more than once every 2-3 months) _____ Occasionally (about 1-2 times a month) _____ Weekly (about once a week) _____ Daily (almost every day) 2. How often was cereal or strained fruit added to milk/formula in your child’s bottle or sippy cup? _____ Never _____ Rarely (no more than once every 2-3 months) _____ Occasionally (about 1-2 times a month) _____ Weekly (about once a week) _____ Daily (almost every day) 3. How often was sweetened condensed milk used to make your child’s formula? _____ Never _____ Rarely (no more than once every 2-3 months) _____ Occasionally (about 1-2 times a month) _____ Weekly (about once a week) _____ Daily (almost every day)

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64 4. How often were juice, Kool-aid, sweetened tea, chocolate milk and/or soda given to your child in a bottle? _____ Never _____ Rarely (no more than once every 2-3 months) _____ Occasionally (about 1-2 times a month) _____ Weekly (about once a week) _____ Daily (almost every day) 5. How often was your child allowed to drink from a bottle or sippy cup while they were in bed? _____ Never _____ Rarely (no more than once every 2-3 months) _____ Occasionally (about 1-2 times a month) _____ Weekly (about once a week) _____ Daily (almost every day) 6. If your child was breastfed, how often was your child allowed to feed at the breast throughout the night as desired (i.e., sleep in the bed and feed whenever they wanted to)? _____ Never _____ Rarely (no more than once every 2-3 months) _____ Occasionally (about 1-2 times a month) _____ Weekly (about once a week) _____ Daily (almost every day) 7. At what age was your child weaned from the bottle? _____ before 9 months _____ 9-12 months _____ 13-15 months _____ after 15 months _____ not sure

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APPENDIX E THREE DAY FOOD, BEVERAGE AND SUPPLEMENT DIARY WITH INSTRUCTIONS

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66Name:________________________ Questions? Pl ease call Claire Edgemon at 352-317-3907 3-day Food and Supplement Diary Day 1 Time Consumed List the time at which the item was consumed. Foods, Beverages and Supplements Consumed List each food, beverage, snack, chewing gum or supplement you consume. List only one item per line. Description List the brand name and product description or include the product label or recipe for everything you eat. Tell how the food was cooked (fried, baked, etc). If you ate away from home, list the name of the restaurant or food shop. Be sure to include information about things that you add to your food before you eat it, like margarine, salt, sugar, milk, etc. Amount Consumed List the amount of each food, beverage, snack, chewing gum or supplement you consume. Tell how many cups, ounces (oz), teaspoons (tsp), tablespoons (tbsp) you eat or the weight or number of portions or pieces you eat.

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67 Directions for 24-hour Food, Beverage, and Supplement Diary *Please record everything your child consum es in a 24 hour period, including all foods, beverages, snacks, chewing gum and supplements. If you have any questions, please call Claire Edgemon at 352-317-3907. 1. Please record your child’s intake fo r a full 24 hour period on 3 nonconsecutive days (at least one day betw een each of the days you record your child’s intake). Include at least one weeke nd day (Saturday or Sunday). 2. Please record the time of day when items are consumed; the foods, beverages, snacks, chewing gum and supplements your child consumes; and the amounts of each that your child consumes as soon after eating as possible. This will help prevent you from forgetting foods, or overor underestimating what your child has consumed. 3. In the column labeled “ Time Consumed ” record the time of day at which the items are consumed. 4. In the column labeled “Foods and Beverages Consumed” record what your child ate. Please be as specific as possible. For example if your child consumed milk: indicate skim, 1%, 2%, or whole. If your child consumed cereal, indicate what kind of cereal. If your child cons umed bread, indicate what kind of bread (white, wheat, rye, oat bran, etc.). Don’ t forget to include condiments, such as catsup, mustard, jelly, salad dressing, sauces, etc. For example: Time Consumed Foods, Beverages, Supplements Consumed Description Amount Consumed 7:00 am Milk 1% low fat 1 cup 7:00 am Cornflakes Kellogg’s 1 cups 7:00 am Bread Publix honey wheat 1 slice 7:00 am Jelly (on bread) Smucker’s strawberry jam 1 teaspoon 7:00 am Sugar (on cereal) White granulated 2 teaspoons 8:30 am Gum Extra Winterfresh 1 piece 10:00 am Lollipop Orange flavored – no brand 1 small In the column labeled “Description” please list the brand na me and give a product description or include the produc t label or recipe whenever possible. Tell how the food was cooked (fried, baked, etc). If your child ate away from home, list the name of the restaurant or food shop. If your child cons umes candy or gum, indicate what kind was consumed (Hershey’s Kiss, Extra Winterfresh, etc.). Be sure to include information about things that were added to the food before it was eaten, like margarine, salt, sugar, milk, etc. Please refer to the example above.

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68 6. In the column labeled “Amount Consumed” please list the amount of each food and beverage your child consumed. Te ll how many cups, ounces (oz), teaspoons (tsp), tablespoons (tbsp) your child ate or the weight or number of portions or pieces your child ate. 7. A sample food diary is included to help you. Sample: Time Consumed Foods, Beverages or Supplements Consumed List each food or beverage your child consumed. List only one item per line. Description List the brand name and product description or include the product label or recipe for everything your child ate. Tell how the food was cooked (fried, baked, etc). If your child ate away from home, list the name of the restaurant or food shop. Be sure to include information about things that were added to the food before they were eaten, like margarine, salt, sugar, milk, etc. Amount Consumed List the amount of each food or beverage your child consumed. Tell how many cups, ounces (oz), teaspoons (tsp), tablespoons (tbsp) your child ate or the weight or number of portions or pieces your child ate. 7:30 am Corn Flakes Kellogg’s brand 1 cup 7:30 am Milk 2% 1/2 cup 7:30 am Banana, Small 5 inches 11:45 am Turkey Baked 2 oz 11:45 am Bread Whole wheat, toasted 2 slices 11:45 am Mayonnaise Hellmann’s Light 1 tsp 11:45 am Tomato 2 slices 12 noon Apple With skin 1 medium 12 noon Pepsi Pepsi, regular 12 oz can 3:15 pm Ice cream Albertson’s, chocolate 1 cup 6:30 pm Chicken Breast Grilled, no skin 3 oz. 6:30 pm Green beans Canned, prepared with 1 tbsp. butter and 1 tsp. salt cup 6:30 pm Rice White, Boiled 1 cup 7:10 pm Candy Hershey’s Kisses 5 pieces 8:00 pm Apple pie Store bought, bakery 1/5 pie 9:00 pm Children’s multivitamin Flintstone’s Brand 1 1 cup = 8 fluid ounces (8 fl. oz.) = 237 ml 3 teaspoons = 1 tablespoon 4 tablespoons = cup 1 oz = 28 g (grams)

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69 Estimating Portion Sizes 3 ounces of meat, poultry, or fish is about the size and thickness of a deck of playing cards = A medium-size piece of fruit (e.g., apple or peach) is about the size of a tennis ball = 1 ounce of cheese is about the size of 4 dice = cup of ice cream, frozen yogurt, yogurt, or cottage cheese is about the size of a tennis ball = 1 cup of mashed potatoes or broccoli is about the size of your fist Or = 1 teaspoon of butter, margarine, or peanut butter is about the size of the tip of your thumb = 1 ounce of nuts or small candies is about one handful = Adapted from: Southern Illinois Universi ty Carbondale Wellness Center Nutrition Program 3-Day Recall. 2002. http://www.siu.edu/~shp/ Acrobat2002/Recall.PDF

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70 APPENDIX F YOUTH/ADOLESCENT QU ESTIONNAIRE (YAQ) Reprinted with permission of Helaine Rockett, Channing Laboratory, Boston, MA, nhhrh@channing.harvard.edu phone: 617-525-4207

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82 LIST OF REFERENCES 1. Anliker JA, Bartoshuk L, Ferris AM Hooks LD. (1991) Children's food preferences and genetic sensitivity to the bitter taste of 6-n-propylthiouracil (PROP). Am J Clin Nutr. 54: 316-320. 2. Duffy VB, Peterson JM, Dinehart ME Bartoshuk LM. (2003) Genetic and environmental variation in taste: Associ ations with sweet in tensity, preference, and intake. Top in Clin Nutr 18: 209-220. 3. Kaminski LC, Henderson SA, Drewnowski A. (2000) Young women's food preferences and taste res ponsiveness to 6-n-propylthiouracil (PROP). Physiol Behav 68: 691-697. 4. Duffy VB, Davidson AC, Kidd JR, Kidd KK, Speed WC, Pakstis AJ, Reed DR, Snyder DJ, Bartoshuk LM. (2004) Bitter receptor gene (TAS2R38), 6-npropylthiouracil (PROP) bitter ness and alcohol intake. Alcohol Clin Exp Res 28: 1629-1637. 5. Looy H, Weingarten HP. (1992) Facial e xpressions and genetic sensitivity to 6-npropylthiouracil predict hedonic response to sweet. Physiol Behav 52: 75-82. 6. Burt BA, Eklund SA, Morgan KJ, Lark in FE, Guire KE, Brown LO, Weintraub JA. (1988) The effects of sugars intake and frequency of ingestion on dental caries increment in a three-year long itudinal study. J Dent Res 67: 1422-1429. 7. Duffy VB, Bartoshuk LM. (2000) Food accepta nce and genetic variation in taste. J Am Diet Assoc 100: 647-655. 8. Drewnowski A, Henderson SA, Hann CS, Berg WA, Ruffin MT. (2000) Genetic taste markers and preferences for vegeta bles and fruit of female breast care patients. J Am Diet Assoc 100: 191-197. 9. Rugg-Gunn AJ, Hackett AF, Appleton DR, Jenkins GN, Eastoe JE. (1984) Relationship between dietary habits and caries increment assessed over two years in 405 English adolescent school ch ildren. Arch Oral Biol 29: 983-992. 10. Szpunar SM, Eklund SA, Burt BA. (1995) Sugar consumption and caries risk in schoolchildren with low caries experience. Community Dent Oral Epidemiol 23: 142-146.

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83 11. Holt RD. (1991) Foods and drinks at four daily time intervals in a group of young children. Br Dent J 170: 137-143. 12. Vanobbergen J, Martens L, Lesaffre E, B ogaerts K, Declerck D. (2001) Assessing risk indicators for dental caries in th e primary dentition. Community Dent Oral Epidemiol 29: 424-434. 13. Lin BP. (2003) Caries experience in ch ildren with various genetic sensitivity levels to the bitter taste of 6-n-pr opylthiouracil (PROP): a pilot study. Pediatr Dent 25: 37-42. 14. Al-Malik MI, Holt RD, Bedi R. (2001) The relationship between erosion, caries and rampant caries and dietary habits in pr eschool children in Saudi Arabia. Int J Paediatr Dent 11: 430-439. 15. al Ghanim NA, Adenubi JO, Wyne AA, Khan NB. (1998) Caries prediction model in pre-school children in Riyadh, Sa udi Arabia. Int J Paediatr Dent 8: 115122. 16. Febres C, Echeverri EA, Keene HJ. (1997) Parental awareness, habits, and social factors and their relationship to baby bo ttle tooth decay. Pediatr Dent 19: 22-27. 17. Peretz B, Ram D, Azo E, Efrat Y. ( 2003) Preschool caries as an indicator of future caries: a longitudinal study. Pediatr Dent 25: 114-118. 18. al-Shalan TA, Erickson PR, Hardie NA. (1997) Primary incisor decay before age 4 as a risk factor for future de ntal caries. Pediatr Dent 19: 37-41. 19. Jung HS, Akita K, Kim JY. (2004) Spaci ng patterns on tongue surface-gustatory papilla. Int J Dev Biol 48: 157-161. 20. Kim UK, Breslin PA, Reed D, Drayna D. (2004) Genetics of human taste perception. J Dent Res 83: 448-453. 21. Temple EC, Hutchinson I, Laing DG, Jinks AL. (2002) Taste development: differential growth rates of tongue regi ons in humans. Brain Res Dev Brain Res 135: 65-70. 22. Duffy VB, Peterson JM, Bartoshuk LM. (2004) Associations between taste genetics, oral sensation and alc ohol intake. Physiol Behav 82: 435-445. 23. Zhang Y, Hoon MA, Chandrashekar J, Mueller KL, Cook B, Wu D, Zuker CS, Ryba NJ. (2003) Coding of sweet, bitter, and umami tastes: different receptor cells sharing similar signaling pathways. Cell 112: 293-301.

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84 24. Prutkin J, Fisher EM, Etter L, Fast K, Gardner E, Lucchina LA, Snyder DJ, Tie K, Weiffenbach J, Bartoshuk LM. (2000) Ge netic variation and inferences about perceived taste intensity in mi ce and men. Physiol Behav 69: 161-173. 25. Montmayeur JP, Matsunami H. (2002) Receptors for bitter and sweet taste. Curr Opin Neurobiol 12: 366-371. 26. Nelson G, Hoon MA, Chandrashekar J, Zhang Y, Ryba NJ, Zuker CS. (2001) Mammalian sweet taste receptors. Cell 106: 381-390. 27. Steiner JE. (1977) Facial expressions of the neonate infant indicating the hedonics of food-related chemical stimuli. In: Ta ste and development: The genesis of sweet preference (Weiffenbach JM, ed.). US De partment of Health, Education, and Welfare, National Institutes of Health, Bethesda, MD. 28. Mennella JA., Pepino MY, Reed DR. (2005) Genetic and environmental determinants of bitter perception and sw eet preferences. Pediatrics 115: e216-222. 29. Drewnowski A, Rock CL. (1995) The influence of genetic taste markers on food acceptance. Am J Clin Nutr 62: 506-511. 30. Fox AL. (1932) The relationship between chemical constitution and taste. Proc Natl Acad Sci 18: 115-120. 31. Blakeslee AF. (1932) Genetics of sensory thresholds: Taste for phenylthiocarbamide. Proc Natl Acad Sci 18: 120-130. 32. Hebel SK, ed. (2005). Antithyroid agents. In: Drug Facts and Comparisions, Pocket Version, Tenth Edition, 2006. Wolters Kluwer Health, Inc., St. Louis, MO. 33. Bartoshuk LM. (2000) Comparing sensory e xperiences across i ndividuals: recent psychophysical advances illuminate geneti c variation in taste perception. Chem Senses 25: 447-460. 34. Batroshuk LM. (2000) Psychophysical advances aid the study of genetic variation in taste. Appetite 34: 105. 35. Prescott J, Ripandelli N, Wakeling I. ( 2001) Binary taste mixture interactions in prop non-tasters, medium-tasters and s uper-tasters. Chem Senses 26: 993-1003. 36. Bartoshuk LM, Fast K, Snyder DJ. (2005) Differences in our sensory worlds. Current Directions in Psyc hological Science 14: 122-125. 37. Bartoshuk LM, Duffy VB, Green BG, Hoffm an HJ, Ko CW, Lucchina LA, Marks LE, Snyder DJ, Weiffenbach JM. (2004) Valid across-group comparisons with labeled scales: the gLMS versus magnitude matching. Physiol Behav 82: 109-114.

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85 38. Drewnowski A, Henderson SA, Shore AB Barratt-Fornell A. (1998) Sensory responses to 6-n-propylt hiouracil (PROP) or sucr ose solutions and food preferences in young women. A nn N Y Acad Sci 855: 797-801. 39. Adler E, Hoon MA, Mueller KL, Chandrashekar J, Ryba NJ, Zuker CS. (2000) A novel family of mammalian taste receptors. Cell 100: 693-702. 40. Reed DR, Nanthakumar E, North M, Bell C, Bartoshuk LM, Price RA. (1999) Localization of a gene for bitter-taste perception to human chromosome 5p15. Am J Hum Genet 64: 1478-1480. 41. Kim UK, Jorgenson E, Coon H, Leppert M, Risch N, Drayna D. (2003) Positional cloning of the human quantit ative trait locus underlying taste sensitivity to phenylthiocarbamide. Science 299: 1221-1225. 42. Kim U, Wooding S, Ricci D, Jorde LB, Drayna D. (2005) Worldwide haplotype diversity and coding sequence variation at human bitter taste receptor loci. Hum Mutat 26: 199-204. 43. Bufe B, Breslin PA, Kuhn C, Reed DR, Tharp CD, Slack JP, Kim UK, Drayna D, Meyerhof W. (2005) The molecular ba sis of individual differences in phenylthiocarbamide and pr opylthiouracil bitterness pe rception. Curr Biol 15: 322-327. 44. Max M, Shanker YG, Huang L, Rong M, Liu Z, Campagne F, Weinstein H, Damak S, Margolskee RF. (2001) Tas1 r3, encoding a new candidate taste receptor, is allelic to the sweet respon siveness locus Sac. Nat Genet 28: 58-63. 45. Zhao GQ, Zhang Y, Hoon MA, Chandrashe kar J, Erlenbach I, Ryba NJ, Zuker CS. (2003) The receptors for mammalian sw eet and umami taste. Cell 115: 255266. 46. Miller IJ, Jr, Reedy FE, Jr (1990) Variations in human taste bud density and taste intensity perception. Physiol Behav 47: 1213-1219. 47. Bartoshuk LM, Duffy VB, Miller IJ. (1994) PTC/PROP tasting: anatomy, psychophysics, and sex effects. Physiol Behav 56: 1165-1171. 48. James CE, Laing DG, Oram N. (1997) A co mparison of the ability of 8-9-year-old children and adults to detect ta ste stimuli. Physiol Behav 62: 193-197. 49. Segovia C, Hutchinson I, Laing DG, Ji nks AL. (2002) A quantitative study of fungiform papillae and taste pore density in adults and children. Brain Res Dev Brain Res 138: 135-146.

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86 50. Stein N, Laing DG, Hutchinson I. (1994) Topographical differences in sweetness sensitivity in the peripheral gustatory system of adults and children. Brain Res Dev Brain Res 82: 286-292. 51. Keller KL, Tepper BJ. (2004) Inherited tast e sensitivity to 6-n-propylthiouracil in diet and body weight in ch ildren. Obes Res 12: 904-912. 52. Birch LL. (1979) Dimensions of preschool children's food preferences. Journal of Nutrition Education 11: 77-80. 53. Liem DG, Mennella JA. (2002) Sweet and sour preferences during childhood: role of early experiences Dev Psychobiol 41: 388-395. 54. Pasquet P, Oberti B, El Ati J, Hl adik CM. (2002) Relationships between threshold-based PROP sensitivity and food preferences of Tunisians. Appetite 39: 167-173. 55. Ullrich NV, Touger-Decker R, O'Sulliv an-Maillet J, Tepper BJ. (2004) PROP taster status and self-perceived food a dventurousness influence food preferences. J Am Diet Assoc 104: 543-549. 56. Goldstein GL, Daun H, Tepper BJ. (2005) Adiposity in middle-aged women is associated with genetic taste blindness to 6-n-propylthiouracil. Obes Res 13: 1017-1023. 57. Touger-Decker R, van Loveren C. (2003) Sugars and dental caries. Am J Clin Nutr 78: 881S-892S. 58. Woodward M, Walker AR. (1994) Sugar c onsumption and dental caries: evidence from 90 countries. Br Dent J 176: 297-302. 59. U.S. Department of Health and Human Se rvices. (2000) Oral health in America: A report of the Surgeon General. U.S. De partment of Health and Human Services, National Institute of Dental and Craniof acial Research, National Institutes of Health, Rockville, MD. 60. Autio-Gold JT, Tomar SL. (2005) Preval ence of noncavitated and cavitated carious lesions in 5-year-old head start schoolchildren in Alachua County, Florida. Pediatr Dent 27: 54-60. 61. Okunseri C, Badner V, Kumar J, Cruz GD. (2002) Dental cari es prevalence and treatment need among racial/ethnic minority schoolchildren. N Y State Dent J 68: 20-23.

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89 86. Bates RP, Morris JR, Crandall PG. (2001) Pr inciples and practices of smalland medium-scale fruit juice processing. Food and Agricultural Or ganization of the United Nations, Rome.

PAGE 100

90 BIOGRAPHICAL SKETCH Claire Allinda Lewis Edgemon was born in Houston, Texas, on June 12, 1970. In 1992, she graduated with a Bachelor of Arts degree in biology from Austin College in Sherman, Texas. She spent 2 years teaching English at a community center in Senegal, West Africa. In 1999, she graduated from Gold en Gate Baptist Theological Seminary in Mill Valley, California, with a Master of Divi nity degree. After living in Djibouti, East Africa, for 2 years where she worked for a relief and development agency, she pursued her interest in nutrition and di etetics and graduated from the University of Florida with a Bachelor of Science degree in food science a nd human nutrition, specializing in dietetics. She received the American Dietetics Associ ation’s Outstanding Dietetics Student Award for a Didactic Program in Dietetics in 2003. Th at same year she entered the University of Florida’s combined Master of Science-Dietetic Internship program. Upon completion of her Master of Science degree, she will ta ke the national examination for registered dietitians to complete the last step in earning the Registered Dietitian credential.


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RELATIONSHIP BETWEEN DENTAL CARIES PREVALENCE AND SUGAR
INTAKE OR PREFERENCE FOR SWEET OF SUPERTASTER COMPARED TO
NONTASTER CHILDREN















By

CLAIRE A. EDGEMON


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA


2006

































Copyright 2006

by

Claire A. Edgemon















ACKNOWLEDGMENTS

I would like to thank the members of my supervisory committee, Gail P.A.

Kauwell, PhD, Charles A. Sims, PhD, and Frank Catalanotto, DMD. I would especially

like to thank Dr. Kauwell, my major professor, for all her help and guidance throughout

every stage of this project. Her expertise and attention to detail were invaluable. I also

would like to thank Karla Shelnutt, PhD, for using her many skills to further the project.

Additional thanks are extended to Melissa Greenhow who helped manage the project on a

daily basis and to Qin Li for her assistance with the statistical analyses.

I would also like to thank my fellow classmates, Crystal Jackson, Shawna Mobley,

and Stacy Bursuk, for making this experience more enjoyable. I will remember the

lunchtime laughter and the encouraging words that were shared.

In addition, I would like to thank the members of my family for their continued

support and encouragement. Most importantly, I would like to thank my husband Daryl.

There were many days that his words motivated me to continue this process. I am a

better person because of his love for me and his belief in my success.
















TABLE OF CONTENTS
page

A C K N O W L E D G M E N T S ................................................................................................. iii

LIST OF TABLES .................. ............. ...... ..................... ....... vi

L IST O F F IG U R E S .... ...... ................................................ .. .. ..... .............. vii

LIST OF ABBREVIATION S ............. ................... ....... ................. .............. viii

ABSTRACT .............. ................. .......... .............. ix

CHAPTER

1 IN TR OD U CTION ............................................... .. ......................... ..

H hypothesis ......................................................................... . 2
Specific A im ................................................................. 3

2 BACKGROUND AND LITERATURE REVIEW ..................... ........................... 4

T aste P perception ............................................. 4
Bitter Taste ................................ ...................... .......... ..
Sw eet T aste .................................................. 6
D eterm ining T aste Statu s.................................................................... ..................6
G genetics of T aste ....................................................... 9
Bitter Taste Receptor ........................................... .. .. ... .................. .9
Sw eet Taste R eceptor .................................................... .. ............ ........ 11
Fungiform P apillae and T aste......................................... ............................... 12
Taste Preferences .................................................................. ... ......... 14
D mental C aries ................................................................... 18
P re v a le n c e ...................................................................................................... 1 8
D evelopm ent ............................................. 19
Dietary Carbohydrates........................................ ........20
Early Childhood Caries ............................... ...............23
Dental Caries and Taste Sensitivity ........................................................... 24
M methods of Dietary Data Collection ................................ ................... ........ 25
R research Significance..... ................................................................................ 26

3 RESEARCH DESIGN AND METHODS..................... .......................................28









Subject R ecruitm ent................................ .. ...... ... .......... .............. .. 28
Taste Sensitivity ...................................... ........... ........... ................. 28
D em graphic D ata ................ ...................... ........ .. ............ .............. .. 30
A nthropom etric M measures ................................................ .............................. 30
Food Preferences ............................................ .. .. ........... .... ....... 30
D e n ta l E x a m ............................................................................................................... 3 1
Bottle Feeding History ................ ..................... ....... .. 31
Food, Beverage and Supplement Diary ............. ................................ ...............32
Youth/Adolescent Questionnaire (YAQ) ....................................... ............... 32
H edonic R response to Sw eet................................................ ............................ 33
Sucrose Intensity R eating ...................................................... ............................. 34
Statistical A nalysis................................................... 34

4 R E S U L T S ............................................................................. 3 5

S u b j e c ts ................................................................................................................. 3 5
Demographic Data .................. ............................. ......................... 36
D e n ta l E x a m ...............................................................................................................3 6
F ood P referen ces .............. .. ........................................ .................. .. .... .... .... .. 36
Food, Beverage and Supplement Diary .......................................... ...............42
Youth/Adolescent Questionnaire (YAQ) ....................................... ............... 44
Bottle Feeding History .................. .......................... .. ..... ................. 46
A nthropom etric D ata ......................................................................... ...................46
H edonic R response to Sw eet................................................ ............................ 48
Sucrose Intensity R eating ...................................................... ............................. 49

5 DISCUSSION AND CONCLUSIONS ............................................................... 51

APPENDIX

A SENSATION LIST USED WITH THE GENERAL LABELED MAGNITUDE
S C A L E ..............................................................................................57

B FOOD PREFERENCE QUESTIONNAIRE............................................................58

C HEDONIC SCALE FOR CHILDREN.................................... ....................... 62

D BOTTLE FEEDING QUESTIONNAIRE............................................. 63

E THREE DAY FOOD, BEVERAGE AND SUPPLEMENT DIARY WITH
IN STRU CTION S ......................... ........... .. ........... ... ...... 65

F YOUTH/ADOLESCENT QUESTIONNAIRE (YAQ) ..........................................70

L IST O F R E F E R E N C E S ........................................................................ .....................82

B IO G R A PH IC A L SK E TCH ..................................................................... ..................90
















LIST OF TABLES


Table page

4-1. Sample characteristics of the study groups............................................ 35

4-2. Number of individuals living in each subject's household.....................................36

4-3. Family income per household................ ................... ..... ..........................36

4-4. Food preference scores (mean + SD) for food categories by taster status ................37

4-5. Relationship between dental caries prevalence and food preferences for STs and
N T s .......... .. ............ ...... ................ ......... ........... ................. 4 3

4-6. Carbohydrate and sugar intake of ST and NT children by food category ...............44

4-7. Responses and logistic regression analysis of specific bottle feeding practices of
ST compared to NT parents/caregivers ...........................................................47

4-8. Percent sugar in apple juice samples measured by refractometry .............................48

4-9. Responses and logistic regression analysis of STs compared to NTs regarding the
graded solutions of sucrose in apple juice...................................... ............... 49
















LIST OF FIGURES


Figure p

2-1. Location of papillae and nerve innervation of tongue...................... ..... .............

3-1. Study protocol and tim eline............................................................ .....................29

4-1. Dental caries prevalence of ST and NT children as a function of vegetable
preference ............................................................... ................. .. 38

4-2. Dental caries prevalence of ST and NT children as a function of fruit
preference ................... ....... ................ .... ............ 39

4-3. Dental caries prevalence of ST and NT children as a function of dairy preference..39

4-4. Dental caries prevalence of ST and NT children as a function of sweetened dairy
preference ............................................................... ..... .... ......... 40

4-5. Dental caries prevalence of ST and NT children as a function of beverage
preference ............................................................... ..... .... ......... 40

4-6. Dental caries prevalence of ST and NT children as a function of baked goods
preference ............................................................... ..... ..... ........ 41

4-7. Dental caries prevalence of ST and NT children as a function of cereal preference 41

4-8. Dental caries prevalence of ST and NT children as a function of sugar preference .42

4-9. Dental caries prevalence of ST and NT children as a function of salted snacks
preference ............................................................... .... ..... ........ 42

4-10. Dental caries prevalence of ST and NT children as a function of sugar intake ......44

4-11. Dental caries prevalence of ST and NT children as a function of sucrose intake ...46

4-12. Dental caries prevalence of ST and NT children as a function of BMI percentile..48

4-13. Dental caries prevalence of ST and NT children as a function of sucrose
inten sity rating .......................................................................50















LIST OF ABBREVIATIONS


AVI alanine-valine-isoleucine
BMI body mass index
defs decayed, extracted, filled surfaces in primary teeth
DEFS decayed, extracted, filled surfaces in permanent teeth
ECC early childhood caries
FFQ food frequency questionnaire
gLMS general labeled magnitude scale
IRB Institutional Review Board
MT medium taster
N-C=S nitrogen-carbon-sulfur
NT nontaster
OR odds ratio
PAV proline-alanine-valine
PROP propylthiouracil
PTC phenylthiocarbamide
SD standard deviation
SES socioeconomic status
ST supertaster
T12r (Tlr2) sweet taste receptor in humans (mice)
T2R bitter taste receptor
TAS2R38 bitter taste receptor specific for PTC/PROP
T1R3 (Tlr3) sweet taste receptor in humans (mice)
YAQ Youth/Adolescent Questionnaire
95% CI 95% confidence interval















Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

RELATIONSHIP BETWEEN DENTAL CARIES PREVALENCE AND SUGAR
INTAKE OR PREFERENCE FOR SWEET OF SUPERTASTER COMPARED TO
NONTASTER CHILDREN

By

Claire A. Edgemon

May 2006

Chair: Gail P.A. Kauwell
Major Department: Food Science and Human Nutrition

Taster status has been defined as the degree to which an individual is able to

perceive the bitter compound, 6-n-propylthiouracil (PROP). Based on the intensity rating

of this substance, individuals are categorized as supertasters (ST) (high sensitivity to

bitter taste), medium tasters (MT) (moderate sensitivity), and nontasters (NT) (low/no

sensitivity). Since some research suggests that PROP STs also are more sensitive to

sweet and have a decreased preference for sweet substances compared to PROP NTs, it

has been hypothesized that taster status may affect the development of dental caries. The

only study that tested this hypothesis reported an inverse relationship between PROP

sensitivity and dental caries in children; however, the investigator did not consider the

impact of dietary intake and feeding practices during infancy in his study design. Since

these factors also may influence the development of dental caries, examination of these

variables in conjunction with PROP taster status warrants investigation.









The present study examined whether there was a relationship between dental caries

prevalence of 17 ST and 15 NT children as a function of preference for and intake of

sugar containing foods and beverages. Food preferences were assessed using a

questionnaire. Three day food, beverage, and supplement diaries from children 6 to 12

years of age were evaluated for quantity of intake of sugar, starch, and sugar-containing

foods and beverages as well as number of eating occasions per day. A food frequency

questionnaire was used to assess foods eaten over the preceding year, particularly sugar-

containing foods and beverages. The influence of early infant feeding practices on dental

caries prevalence in STs compared to NTs also was evaluated using a bottle feeding

history questionnaire. Five apple juice solutions with graded sucrose concentrations were

evaluated for likeability and the intensity of a sucrose solution was rated.

No linear relationship was detected between dental caries prevalence of STs and

NTs as a function of the percent of total energy intake from total sugars or sucrose.

Significant differences were not detected in the number of carious lesions or the

consumption of or preference for sweetened foods and beverages between STs and NTs.

This study does not support the previous finding that NT children are likely to have more

dental caries compared to ST children. The recent identification of several genes related

to taste sensitivity, including a gene that encodes the receptor that recognizes bitter taste

and for which several polymorphisms have been identified, suggests that a subjective

measure of taste perception such as PROP may not adequately distinguish taste

sensitivity. These findings provide new opportunities for the classification of taster status

based on genotype instead of PROP.














CHAPTER 1
INTRODUCTION

Taste sensitivity plays a role in food preferences (1-3) and food preferences affect

dietary intake, which can have an impact on health and disease, including oral health.

Poor oral health due to dental caries during childhood may have long-lasting effects that

can negatively impact nutritional status and the ability to enjoy food later in life. Factors

affecting dental caries during childhood include infant/toddler feeding practices and the

intake of sugar/sweetened foods and snacks.

The accidental discovery of differences in sensitivity to bitter led to the theory that

there was a genetic component to taste. The naturally bitter compound, 6-n-

propylthiouracil (PROP), has been used to categorize people as supertasters, medium

tasters, and nontasters. Supertasters have a low threshold (high sensitivity) to PROP,

nontasters have a high threshold and medium tasters have a moderate threshold. Several

forms of a gene related to the ability to detect bitter tasting substances such as PROP (4)

have been discovered, which may help explain the differences in the ability to taste bitter

substances.

Although PROP is used to categorize bitter sensitivity, there also is an association

between PROP status and sweet preference. Individuals who do not taste PROP intensely

have been shown to have a greater preference for sweets (2,5). Some researchers

speculate that children who are nontasters may consume sugar more frequently and in

higher amounts compared to children who are medium and supertasters (6). In addition,









adults who are more sensitive to PROP have been reported to have a lower preference for

sweetened foods, as well as bitter vegetables and high fat foods (7,8).

It is well established that dietary intake plays a major role in the etiology of dental

caries, particularly with regard to intake of soda/sugared beverages, sugar and starch

consumption (9,10) and number of eating occasions (11,12), all of which have been

positively associated with an increase in dental caries. It follows that if nontasters prefer

and ingest more sweets and supertasters are less inclined to consume sweets, PROP status

may be a useful tool in identifying individuals at higher risk for dental caries formation.

Although one study (13) reported that supertaster children had fewer dental caries than

nontaster children, dietary intake and preference data were not collected, which leaves the

question of whether differences in sweet preference and sugar intake account for the

difference in the number of carious surfaces detected between the groups.

Many factors influence dental caries formation. For example, certain bottle feeding

practices such as use of a bottle at bedtime, bottle contents, and age of weaning (14-16)

have been associated with early childhood caries (ECC) in the primary dentition. These

practices could influence the development of dental caries independent of PROP status.

Identifying children who are at higher risk for dental caries formation has important

implications for adult dental health. Studies suggest that ECC may be a predictor of the

development of future caries (17,18), so prevention of childhood caries may lead to a

reduction in adult caries prevalence.

Hypothesis

A relationship exists between dental caries prevalence and supertaster/nontaster

status of children as a function of sugar intake and/or preference for sugar and sugar-

containing foods.









Specific Aim

The main objective of this study is to investigate dental caries prevalence as a

function of sugar intake and/or preference for sugar and sugar-containing foods in ST and

NT children 6 to 12 years old. This study represents the first to evaluate whether such a

relationship exists. If this study supports a positive relationship between sugar intake or

preference and dental caries prevalence in nontasters but not in supertasters it would

extend the findings of Lin (2003) and support the use of PROP testing as a simple

screening tool for identifying children at high risk for dental caries (13). This could

provide the impetus for a targeted intervention strategy that could play an important role

in reducing dental caries development in adulthood.













CHAPTER 2
BACKGROUND AND LITERATURE REVIEW

Taste Perception

The taste sensation that occurs when substances are ingested orally is the result of

the integration of perceptions arising from true taste and touch. One of these perceptions

is the actual sensation from one of the five taste qualities: bitter, sweet, sour, salty, and

umami. Another perception results from substances touching the nerves of the oral cavity

that signal temperature and pain (7). The sensation of taste begins on the tongue, which

is covered by four kinds of papillae with distinct shapes and locations. The fungiform

(mushroom-like) papillae are located on the anterior tongue, the foliate (leaf-like)

papillae are located on the sides of the lateral posterior tongue, and the circumvallate

(wall-like) papillae form an inverted V on the posterior tongue (Figure 2-1). The fourth

type of papillae, the filiform (thread-like) papillae, is located on the anterior tongue (19).


Circumvallate o Glossopharyng<
papillae o o-ooo (IX) nerve


Foliate Trigeminal
papillae (V) nerve


Fungiform * *
Fungiform vChorda tympani
papillae rp
1papillae (VII) nerve

Figure 2-1. Location of papillae and nerve innervation of tongue.


eal









Each type of papilla is tactile sensitive, but only the circumvallate, foliate and fungiform

papillae are innvervated by nerves that recognize one of the five taste qualities (19-21).

Taste buds are located on the papillae. Taste receptor cells, which are tightly packed into

the taste buds, have taste receptors on their surfaces to recognize the five taste qualities

(20). In humans, both the chorda tympani branch of the facial nerve and the trigeminal

nerve innervate the taste receptor cells in the anterior two-thirds of the tongue (22,23).

The chorda tympani nerve, which helps to relate taste sensation, innervates about 25% of

the fungiform papillae. The trigeminal nerve, which perceives pain, touch, and

temperature, innervates about 75% of the fungiform papillae (24). Circumvallate and

foliate papillae are innervated by the glossopharyngeal nerve (Figure 2-1).

Bitter Taste

It has been suggested that bitter taste is the most complex of the five taste qualities

due to the large number of genes that code for bitter receptors that allow for interaction

with a multitude of chemical structures involved in bitter taste (20,25). While these

receptors may recognize a wide variety of bitter substances, it has been suggested that the

receptors are unable to discriminate among the various chemical structures associated

with bitter taste (26).

As demonstrated by Steiner (1977) the ability to recognize bitter substances is

innate (27). This characteristic may be beneficial from a survival point of view in that it

may help individuals recognize and reject a wide variety of potentially harmful

substances they may come in contact with in the environment (23,25,28). However,

some foods with nutrients and phytochemicals that are important to health also contain

bitter tasting substances such as isothiocyanates, indoles, and flavonoids. For example,

raw cruciferous vegetables, such as broccoli, cabbage, and Brussels sprouts, contain









isothiocyanates, which have an N-C=S structure that confers a bitter taste.

Isothiocyanates can be harmful in geographical areas with an incidence of iodine

deficiency since they can act as antithyroid agents and have been associated with a higher

prevalence of endemic goiter, as reviewed by Drewnowski and Rock (1995) (29).

However, isothiocyanates, as well as other phytochemicals in fruits and vegetables, also

have potential health benefits related to their antioxidant and anticarcinogenic effects

(29). Not all bitter tasting compounds contain the N-C=S structure. Phenolic compounds

in tea, cocoa, and wine are other bitter-tasting compounds found in foods and beverages

that do not contain this structure (8).

Sweet Taste

In contrast to bitter taste, which is described as having a bimodal distribution

(individuals either recognize or do not recognize bitter taste), the response to sweet taste

is unimodal, which means it is recognized by everyone, even though the chemical

structures of sweet-tasting substances, natural and artificial, are almost as varied as

substances that taste bitter (20). It has been suggested that the sweet taste system, unlike

the bitter taste system, is able to discriminate the various sweet tastants, (26) which is

beneficial in helping an individual recognize energy rich food sources (23,25).

Determining Taste Status

Differences in bitter taste perception were accidentally discovered in 1931 when a

researcher who was synthesizing phenylthiocarbamide (PTC) accidentally released

crystals of this substance into the air. The researcher tasted nothing, while one of his

colleagues noted that the crystals tasted bitter (30). This accident led to the idea that

some individuals are "taste blind" to bitter while others are tasters. Researchers believed









the ability to taste was inherited since taste blind parents were noted to have taste blind

children (31).

For years after its discovery, PTC, which contains an N-C=S group, was used to

determine taste status. However, since PTC has a sulfurous odor and is potentially toxic,

6-n-propylthiouracil (PROP), which also contains an N-C=S group, has been used as a

substitute for PTC in categorizing taste status (2). Propylthiouracil is an antithyroid agent

used to treat hyperthyroidism. It inhibits the synthesis of thyroid hormones by blocking

the oxidation of iodine in the thyroid gland. An indirect method for assessing taste

sensitivity due to genetic differences is to assess the reaction to PROP by applying a filter

paper containing 1.6 milligrams of PROP to the tongue for 30 seconds. This is a very

low dose compared to the amount (50 to 100 mg/day) used to treat hyperthyroidism in

children (32).

Early in taste status research, category scales (i.e., a 9-point hedonic scale) were

used to assess taste sensitivity to PTC/PROP. These scales used adjectives, such as

strong and weak, to rate taste sensations. A problem with using this type of scale is that

the definition of what constitutes "weak" by one individual may be strong to another.

This makes it difficult to compare sensations across subjects or groups (22). The results

from using these category scales produced distributions of tasters and nontasters that

overlapped, which led researchers to believe that the ability to taste PTC/PROP was an

example of classical Mendelian genetics. Accordingly, it was believed that since

supertasters were the most sensitive to PROP (low threshold), they had two dominant

alleles for bitter taste. It was suspected the medium tasters had one dominant and one

recessive allele since they were moderately sensitive to PROP (moderate threshold).









Since nontasters were the least sensitive to PROP (high threshold), it was believed that

they had two recessive alleles (33). While researchers believed there was a distinction

between supertasters and medium tasters, they were unable to clearly define the two

groups using category scales, which may have been the result of "ceiling effects". In

other words, the category scale put a limit on how high the PROP sensation could be

rated. Both medium and supertasters might rate the PROP sensation near the top of the

scale because the taste is very bitter, but in actuality, the intensity of the bitter taste

perceived by supertasters may greatly exceed the limits of the scale being used (i.e.,

ceiling effects) compared to that which is perceived by medium tasters. Therefore,

supertasters do not have the opportunity to rate the bitter sensation as high as they

perceive it (34).

Changes in the methodology of PROP taster assessment have enabled researchers

to differentiate among the three taster groups. Instead of using a category scale,

individuals are asked to rate the sensation of PROP using the general Labeled Magnitude

Scale (gLMS), which reduces the ceiling effects that may occur when using a 9-point

category scale (34-36). While this scale also uses adjectives, it is a ratio scale that allows

individuals to rate the PROP sensation as it relates to other sensations, not just taste

sensations (36). Since the scale ranges from "strongest imaginable" to "no sensation"

and refers to any sensation, this creates a non-taste related standard that allows for valid

across-group comparisons of taste sensations (24,37). Supertasters are bitter sensitive

and rate PROP sensation near the top of the scale. Nontasters are bitter insensitive and

rate PROP near the bottom of the scale. Medium tasters rate the PROP sensation in the

middle of the scale (2). While it may be expected that the two taster categories (super









and medium) perceive taste sensations similarly, differing only in degree of intensity,

newer research suggests that supertasters are distinct, supporting the idea of three taster

categories. For example, a study that examined food acceptance among the three taster

categories found that supertasters disliked bitter foods and beverages more than medium

and nontasters (38). Prescott et al. (2001) reported that supertasters perceived higher

intensities for the four taste qualities measured (i.e., sweet, bitter, sour, salty) than either

medium or nontasters. In this study, medium and nontasters tended not to rate the

intensities differently (35). The idea of three taster groups is now accepted and has been

supported by recent studies examining differences in taste-related genes.

Genetics of Taste

Bitter Taste Receptor

Approximately 30 genes for the bitter taste receptors (T2Rs) have been identified as

members of a seven transmembrane domain, G-protein-coupled-receptor superfamily

(25,26). The bitter taste receptors (T2Rs) are rarely expressed in fungiform taste buds,

but are present in 15 to 20% of the cells of all circumvallate and foliate taste buds

(26,39). Recently, two PTC/PROP sensitive loci have been located near bitter receptor

genes on chromosomes 5 and 7 (40). The PTC/PROP sensitive gene on chromosome 7

was identified as TAS2R38. Five haplotypes result from three single nucleotide

polymorphisms in this gene leading to amino acid substitutions: Pro49Ala, Ala262Val,

and Val296Ile. The two most common haplotypes are proline-alanine-valine (PAV) and

alanine-valine-isoleucine (AVI). The PAV haplotype is sensitive to PTC/PROP, while

the AVI haplotype is not sensitive to PTC/PROP (4). The three other haplotypes (AAV,

AAI, PVI) are considered as having intermediate sensitivity to PTC/PROP, but have not

been studied as much as the PAV and AVI forms (20). PAV homozygotes (PAV/PAV)









rate the sensation of PTC highest while AVI homozygotes (AVI/AVI) rate it the lowest.

PAV heterozygotes rate PTC slightly, but significantly lower than PAV homozygotes

suggesting that the effect of the PAV gene is additive (41).

The PAV variant of the gene is the original form since studies in nonhuman

primates revealed that all were PAV homozygotes (41). Some researchers have

questioned why the AVI variant of the gene emerged and why both forms continue to be

expressed in the population to varying degrees. Limited research has shown that

approximately 49% of Europeans have the PAV variant and 47% have the AVI variant

with only 3% having one of the "intermediate" variants. Asians have a slightly higher

percentage of the PAV variant than AVI with no intermediate variants. Approximately

50% of Africans have the PAV variant while 25% have the AVI variant. The remaining

25% have "intermediate" variants. Native Americans are predominantly PAV (41). The

PAV variant of the TAS2R38 gene appears to be specific for bitter compounds

containing an N-C=S group since a response was seen with PTC and PROP, but not with

other bitter tasting compounds. The ability of supertasters to detect bitter compounds

containing the N-C=S structure, such as isothiocyanates, would be beneficial in

geographical regions with low iodine. This would give supertasters an advantage in these

areas since avoidance of isothiocyanates, found in cruciferous vegetables, would decrease

over ingestion of anti-thyroid toxins that would contribute to thyroid disease and goiter.

Kim et al. (2005) suggest that the variety in haplotypes may exist as a local adaptation to

avoid the toxins found in local plants since very limited research has found a higher

percentage of the PAV haplotype in Asian, African, and Native American populations

(42). The AVI variant appears to be sensitive to other bitter compounds, but is









insensitive to PTC/PROP (43). While supertasters may have an advantage in their ability

to recognize and avoid bitter compounds, nontasters may have an advantage that results

from their inability to detect bitterness. In addition to their anti-thyroid properties,

isothiocyanates are known for their actions as antioxidants, which have been associated

with anti-cancer effects. Therefore, consumption of bitter tasting vegetables by

nontasters may provide an advantage in populations with a higher cancer risk (43).

Sweet Taste Receptor

Two sweet taste receptors in humans, T1R2 and T1R3, have been identified (26)

using genetic mapping from the corresponding receptors in mice, Tlr2 and Tlr3 (44).

While T1R3 has been found in all three types of taste sensing papillae, T1R2 is almost

exclusively found in circumvallate and foliate papillae (25,26). It has been suggested that

T1R3 may function alone or interact with T1R2 to create a heterodimer that is sensitive

to a variety of sweet compounds, including natural sugars, artificial sweeteners, D-amino

acids, and sweet-tasting proteins (20,25,26,45). Similar to the bitter receptors, the sweet

receptors also have a seven transmembrane domain, but have large N-terminal domains

that allow for interactions with ligands of sweet tasting compounds (25). Max et al.

(2001) suggest that these N-terminal domains also may allow for dimerization. When

these researchers examined the amino acid sequence of the Tlr3 receptor in mice

sensitive to sweet taste and mice insensitive to sweet taste, they found an amino acid

substitution in the mice that were insensitive to sweet taste that they predict introduces a

novel N-linked glycosylation site in the N-terminal domain. This glycosylation may

interfere with the dimerization of the sweet receptor that prevents the mice from being

able to taste sweet substances (44). Other studies in mice have shown that although

sweet and bitter taste receptor cells have different receptors, they use a common signaling









pathway to generate a taste response (23). In addition to activating the sweet receptor,

Zhao et al. (2003) suggest that artificial sweeteners may activate the bitter receptors,

causing the aftertaste often associated with saccharin (45).

Fungiform Papillae and Taste

In addition to the genetic variability among PROP taster categories, research

suggests that the difference among the three taster groups also may be related to the

number of fungiform papillae and taste buds on the dorsal surface of the tongue (4).

Miller and Reedy, who were the first to develop a method for counting taste pores in

fungiform papillae, reported that PROP tasters had more taste pores in the fungiform

papillae than nontasters (46). Bartoshuk et al. noted that supertasters not only had more

taste pores, but also smaller, more abundant fungiform papillae (47). Prutkin et al. (2000)

reported that 17% of females had more taste pores in the fungiform papillae than males

(24). Similarly, Duffy et al. (2004), found that women who were PAV/PAV were more

likely to have a greater number of fungiform papillae than women who were AVI/AVI

(4). Since the fungiform papillae are innervated by both the chorda tympani and the

trigeminal nerves, the greater abundance of fungiform papillae and taste pores associated

with PROP tasters and individuals with the PAV/PAV genotype (supertasters) may

partially explain why these individuals have stronger perceptions of bitter and sweet

tastes, as well as the sensation of creaminess and oral burn (24). A review by Bartoshuk

(2000) suggests that substances that provide tactile stimulation in the mouth, such as the

fat in dairy products and salad dressings, may result in more intense sensations for

supertasters. In addition, oral irritants, such as capsaicin from chili peppers, piperine

from black pepper, and ethanol may cause the greatest irritation and pain in supertasters

compared to nontasters (33). Studies such as these suggest that being classified as a









supertaster is the result of an individual's genotype for TAS2R38 (i.e., PAV/PAV) and an

unknown genetic determinant that influences fungiform papillae density. On the other

hand, nontaster status is solely attributed to the AVI/AVI genotype independent of

fungiform papillae density.

There is little information about tongue growth, fungiform papillae and taste buds

in children. A study that examined the differences between children and adult tongue

size found that the anterior dorsal tongue of 8 to 10 year old children was the same size as

the corresponding region of the adult tongue. However, the remainder of the tongue did

not reach adult size until 15 to 16 years of age (21). Even though the anterior region of

the tongue is mature in size by mid-childhood, other studies have suggested that the

function may not be mature. Using tastants (i.e., sweet, salty, bitter and sour) dissolved in

water, James et al. (1997) reported that the taste system of 8 to 9 year old boys was not

fully mature compared to girls of the same age and adults. The boys needed higher

concentrations of the tastants in order to detect their presence. Significant differences

were not detected in the detection thresholds between the girls and the young adult

controls (48). A study by Segovia et al. (2002) found that male children (mean age 8.4

years) had a smaller mean fungiform papilla diameter than adult males, but a significantly

higher papillae density than adults (49). While the researchers found that the taste pore

diameters in children were smaller than those of adults, they found no significant

difference in the number of pores per papilla between children and adults. Stein et al.

(1994) reported that in the majority of tongue regions (i.e., anterior, posterior, lateral),

children had a significantly higher sensitivity to sucrose compared to adults (50). The

researchers found that children had more fungiform papillae in selected areas of the









tongue, which may have led to the increased sensitivity to sucrose. Even though they

found no difference in the number of total papillae between adults and children, they did

find a different distribution of papillae in children. While the production of taste buds

may be complete by mid-childhood as suggested by the studies that found that certain

areas of the tongue appear more sensitive to taste, the innervation of the papillae is

incomplete (49) since whole mouth tests show that male children need more of a tastant

in order to perceive the taste.

Taste Preferences

Taste preferences are present early in life and have a genetic basis as described in

the previous section. The preference for sweet taste is universal among infants and

children. Steiner (1977) demonstrated that when neonates were given a sweet stimulus,

the face relaxed and the facial movements seemed to suggest satisfaction or enjoyment.

However, when infants were given a bitter stimulus, the face contorted to reflect disgust

or rejection, which was followed by spitting or the initial movements associated with

vomiting (27). For several of the neonates, experience was not a factor in their responses

to these stimuli since they displayed these facial expressions before receiving their first

feeding. Mennella et al. (2005) suggest that children's taste preferences have more of an

influence on intake, whereas experience more often determines adults' taste preferences

(28).

Food preferences appear to be determined in part by taste sensitivity, and some

researchers suggest that sensory factors are the major influence on food preferences. For

example, bitterness seems to play a major role in food acceptance or rejection (8), a

phenomenon supported by a study using PROP to determine taste status that found that

supertasters had lower acceptance ratings for bitter cruciferous vegetables (i.e., Brussels









sprouts, cauliflower, raw and cooked cabbage) and bitter citrus fruits (i.e., grapefruit and

lemons) compared to medium and nontasters (38). Other studies investigating the

relationship between PROP status and food preferences found that women who tasted

PROP as more bitter had a lower acceptance of bitter vegetables (3), sweet foods and

high fat foods (7). With regard to preference for sweet, Duffy et al. (2003) observed that

adults who were less sensitive to PROP showed a greater preference for sweet foods and

also had a higher intake of added sugar (2). In addition, Looy and Weingarten (1992)

reported that adults and children who disliked sweet taste were almost always PROP

tasters, while PROP nontasters almost always liked sweet taste. However, compared to

nontaster adults, more nontaster children liked sweet taste, which suggests that by the

time they are adults the liking for sweet declines (5). This may be due to increased

experience with food as one ages and to the development of health concepts that lead to

categorizing some foods as healthier than others. Genotyping for the PTC/PROP gene

was not done in the previous studies.

Gender differences also may play a role in food acceptance. Duffy and Bartoshuk

(2000) reported that women had a decreased liking for sweets with an increased

perception of PROP bitterness. Men, however, had an increase in sweet preference with

increased perception of PROP bitterness (7).

Using genotyping for the PTC/PROP gene, as well as categorizing taster status

based on the response to PROP, Mennella et al. (2005) reported that children who were

PAV/AVI (medium tasters) and PAV/PAV (supertasters) preferred significantly higher

concentrations of sucrose solutions, sugar-sweetened cereal, and sugar-sweetened

beverages compared to children who were AVI/AVI (nontasters) (28). Additionally,









another study using PROP to determine taste status in preschool children found that the

percentage of daily energy from sugars, as reported by parents, was higher in tasters than

in nontasters (51). However, the taster group included both supertasters and medium

tasters, and some studies have suggested that medium tasters may be more similar to

nontasters than to supertasters (35,38), so by combining the data from both medium and

supertasters within the same category, the distinctness of the supertaster data may have

been lost. The majority of studies based on the results of PROP testing seem to suggest

that compared to PROP tasters, nontasters may prefer and consume more sweets.

Experience also plays a role in taste preference. A study examining food

preferences in preschool children reported that repeated exposure of an unknown food

item increased the familiarity of the item, which led to an increase in the liking of that

item (52). A recent study highlighted the effect of experience on preference when it was

observed that children who preferred higher levels of sugar in apple juice and cereals had

mothers who routinely added sugar to their children's diets (53). However, Mennella et

al. (2005) suggest that compared to adults, young children's intakes are less influenced

by experience and more influenced by preference (28).

Studies have found that nontasters appear to like a wider variety of foods than

tasters. One study of children aged 5 to 7 years found that the mean number of foods

liked by nontaster children was higher compared to taster children (1). In a review by

Drewnowski and Rock (1995), it was reported that PROP tasters had a higher percentage

of foods disliked compared to nontasters (29). In contrast, a study from Tunisia found

that while supertasters consumed a significantly lower number of food items compared to

medium or nontasters, there was no difference between tasters and nontasters in food









preferences and number of food dislikes (54). Ullrich et al. (2004) examined the

relationship between taster status and food adventurousness, which was defined as the

frequency of trying new foods. It appears that food adventurousness has a greater

influence on food preference than PROP status. Researchers found that PROP tasters

who were food adventurous reported a greater liking for bitter foods, while PROP tasters

who were not food adventurous disliked bitter foods (55).

Most taste studies examining taste preference have been conducted using single

taste stimulants (i.e., sweet, bitter, sour, salty). However, taste sensations are rarely

experienced in isolation. A recent study examining the perception of four binary taste

mixtures (i.e., sweet-bitter, sweet-sour, salty-bitter, salty-sour) by adults in the three

different PROP taster categories found that PROP supertasters rated the overall intensity

of binary taste mixtures higher compared to nontasters (35). The researchers found that

higher concentrations of sucrose suppressed the intensity of bitterness of binary taste

mixtures of sweet and bitter. This may explain why individuals who are sensitive to

bitter compounds add sugar or salt to bitter foods. They also found that high

concentrations of a bitter compound (i.e., quinine hydrochloride) suppressed the

perception of the sweet taste when the two were in a mixture. The researchers suggest

that while one tastant may suppress another, the intensities of the tastants are added to

give an overall perception of intensity of the mixture. However, certain tastes may be

more influential in determining overall intensity (35). Since most foods contain a

combination of the five taste qualities, the tastant with the most influence may drive an

individual's choice when determining which foods are preferred and consumed.









Since PROP tasters appear to have a heightened sensitivity and decreased

preference for higher fat and highly sweetened foods, it follows that they would consume

less of these items. Conversely, since PROP nontasters may need more of these items to

achieve the same taste sensations, they may consume greater quantities of sweet tasting

foods, which could increase body weight (56). Goldstein et al. (2005) found that

nontaster women had a mean BMI of almost 30, a level that is categorized as borderline

between overweight and obese, while supertaster women had a mean BMI of 23.5, which

is within the healthy range. These researchers suggest that PROP status may put women

at an increased risk for weight gain and adiposity (56). Other studies conducted with

adults also have shown that PROP supertasters are thinner and have a lower BMI

compared to nontasters (24,33). The relationship between BMI and PROP status also has

been observed in children. A study by Keller and Tepper (2004) found that nontaster

preschool boys had significantly higher body weights (age- and gender-adjusted weight-

for-height percentiles) than tasters. In contrast, they found that taster preschool girls had

significantly higher body weights than nontasters (51). However, this study did not

separate supertasters from medium tasters, which may have caused a dilutional effect

since other studies have shown that medium tasters are more similar to nontasters than

supertasters (35).

Dental Caries

Prevalence

Dental caries is one of the most prevalent oral infectious diseases and one of the

most common childhood diseases in the United States (57). Even though water

fluoridation, use of fluoride products, diet modification, improved oral hygiene, and

regular professional care have led to dramatic reductions in dental caries over the past 30









years (58), some populations in the United States still struggle with this disease.

According to the May 2000 Surgeon General's report on oral health, dental caries is the

most common chronic disease in children 5 to 17 years old. The report states that over

50% of 5 to 9 year old children have at least one cavity or filling and that proportion

increases to 78% among 17 year olds (59). Socioeconomic status (SES) and ethnicity

seem to influence the prevalence of dental caries. Autio-Gold and Tomar (2005) reported

that 5 and 6 year old children participating in the Head Start program in Alachua County,

Florida, had a high prevalence of untreated tooth decay. They found that in this group of

low income children, African-American children had significantly more lesions

compared to Caucasian children and children from other races (60). A study of school

children in the Bronx, New York, found that African-American sixth graders had the

highest percentage of untreated caries in their permanent dentition, and Hispanic second

graders had the highest percentage in their primary dentition. Of the children who

participated in the study, approximately 99.5% of the children qualified for the reduced

or free lunch program. The researchers also reported that Hispanic children had more

dental caries experience than African-American children from the same SES living in the

same location (61).

Development

Dental caries is a multifactorial disease. Two factors related to the etiology of

dental caries are the presence of acid-producing bacteria and fermentable carbohydrates.

Bacteria in the mouth, mostly Streptococcus mutans (S. mutans), are most often

transmitted from mother to child (62). These bacteria mix with saliva to form a plaque

that sticks to the surface of the teeth. As the bacteria metabolize fermentable

carbohydrates they produce acid, which drops the pH of the plaque below 5.5. This









reduction in pH leads to the growth of acidogenic bacteria as well as demineralization or

dissolution of the enamel. Every time the oral cavity comes into contact with

fermentable carbohydrates or an acidogenic food, there is a reduction in the pH of the

oral cavity. It has been shown that the pH of plaque dropped from 6.5 to 5.0 within three

minutes after rinsing the teeth with a sucrose solution. The pH remained low for 40

minutes. A reduction in pH did not occur, however, when the teeth were brushed

immediately after rinsing with the sucrose solution. Remineralization of the enamel

occurs when the pH increases to greater than 6.0. This may occur when the teeth are

brushed to remove the plaque, when sugarless gum is chewed to stimulate saliva

secretion, or when fluoride is administered. When the demineralization and

remineralization processes remains in balance, the teeth remain caries free. However,

when remineralization is slower than demineralization, a lesion develops, which could

result in a cavity if preventive measures are not taken (57).

Dietary Carbohydrates

Dental caries is one of the two primary oral infectious diseases that is directly

influenced by diet and nutrition (63). As dietary carbohydrates such as sugars (i.e.,

glucose, fructose, and sucrose) and some starches are digested by salivary amylase the

bacteria in the oral cavity begin to metabolize them. This is why some dietary

carbohydrates are considered fermentable carbohydrates. Studies have found that dental

caries risk is related to an increase in sugar intake. In addition to being one of the

preferred fuel sources for bacteria in the oral cavity, sugars may enhance bacterial

growth. Wan et al. (2003) reported that colonization of the teeth by S. mutans is

facilitated by sucrose (62). Sugars may occur naturally in foods, such as fruit, honey, and

dairy products, or they may be added to foods during processing. Examples of sugars









added during processing include white or brown sugar, corn syrup and high-fructose corn

syrup (63). The Carbohydrate Technical Committee of the North American branch of the

International Life Sciences Institute convened a Sugars and Health Workshop in 2003

where they defined "sugar" as sucrose, "sugars" as all mono- and disaccharides,

including sucrose, and "added sugars" as "sugars eaten separately or used as ingredients

in processed or prepared foods" (64). Many processed foods contain starches as well as

added sugars. Items such as bread, crackers, cookies, cakes, pies and chips all have

starches that can be fermented. As these starches are digested into smaller

oligosaccharides, the bacteria in the oral cavity are able to use these carbohydrates to

produce acid (57).

Specific interrelated characteristics of carbohydrates make them more susceptible

to fermentation, such as the form of the carbohydrates, frequency of consumption, and

the time it takes to clear the carbohydrates from the oral cavity. For example, while

liquids that contain sugars, including soft drinks, fruit juice and fruit juice beverages, are

rapidly cleared from the oral cavity with only a brief period of contact with the teeth,

constantly sipping a sugar-containing beverage increases the time teeth are exposed to the

sugar, which leads to extended periods of tooth demineralization. Similarly, holding

sugar-containing items such as hard candies and lollipops in the oral cavity increases the

amount of time the bacteria on the teeth are in contact with sugar. In contrast to what

might be expected, studies have shown that items such as cookies, chips and white bread

are retained longer in the oral cavity than sticky candies (i.e., caramels, jellybeans),

chocolate, and bananas. This can be explained by the additional time needed for salivary

amylase to break down food items that contain starch (i.e., cookies, chips, and white









bread). This longer retention time creates extended periods of tooth demineralization

since amylase has more time to break the starch into caries-promoting sugars (57).

Szpunar et al. (1995) reported that in children aged 11 to 15 years, each additional

5 grams of daily sugars intake above the mean intake of 142.9 grams was associated with

a 1% increase in the probability of developing caries (10). These same researchers also

found that the relationship between carious lesions and dietary variables were stronger

with total sugars intake than with frequency of intake (6). In contrast, other studies have

found a stronger relationship between frequency of snack consumption and dental caries.

Creedon and O'Mullane (2001) found that children who snacked three or more times per

day between meals had a higher caries experience than children who snacked less than

once a day (65). A study of 5, 8, and 11-year-old children reported that those who

reported a frequency of sweet snack consumption more than 5 times a day appeared to

have more caries (66). Vanobbergen et al. (2001) reported that the risk for dental caries

in children with a mean age of 7 years increased with the frequency of consumption of

sugared beverages and frequency of between meal snacks (12). Researchers in Saudi

Arabia found that children who consumed carbonated drinks at least once a day had

significantly more caries than children who had carbonated drinks only once or twice a

week (14). One study found that both total sugar intake and frequency of eating

occasions led to an increase in dental caries, but did not give emphasis to one variable

over the other (67). Researchers seem divided about whether the relationship between

dental caries and sugar intake is more strongly influenced by total intake or by frequency

of intake.









Early Childhood Caries

Early childhood caries (ECC), previously known as baby bottle tooth decay or

nursing caries, describes the caries found in the primary dentition soon after the eruption

of the first teeth in infants and toddlers (17,68). The immature host defense system of a

child in combination with the presence of fermentable carbohydrates provides an ideal

environment for the proliferation of S. mutans, factors that may be responsible for the

development of ECC (69). Generally, the four maxillary (upper) incisors are affected,

but not the four mandibular (lower) incisors. One explanation for this pattern is that milk

or sweetened liquid from the baby bottle pools around the maxillary incisors while the

child is sleeping (16).

A variety of factors may lead to ECC, including bottle contents, use of a bottle

when going to sleep, and age of weaning. In general, prolonged and inappropriate bottle

feeding is the cause of ECC (68). Researchers from Saudi Arabia reported that preschool

children with a high caries experience were significantly more likely to have received

nocturnal bottle feedings with formula. Frequency of consumption of soft drinks, use of

sweetened milk in the bottle and consumption of sweets also were significantly higher in

these children compared to children with a decreased incidence of ECC (15). Al-Malik et

al. (2001) found that children with the highest prevalence of caries were given fruit syrup

or fruit juice in a bottle at bedtime as an infant or carbonated drinks at bedtime as an

older child (14). Mohan et al. (1998) reported that children under 2 years of age who

consumed sweetened beverages from a bottle had a significant increase in colonization of

S. mutans compared to children who either only drank milk or who did not use a bottle

(68). Researchers in the United States found that children who went to sleep with a

bottle, regardless of bottle contents, were more likely to have ECC. Additionally, this









same study found a significant difference in caries risk depending on the age at which

children were weaned from the bottle. Children with ECC were more likely to have been

weaned after 14 months of age (16). A study conducted in Hong Kong reported similar

results in that children with caries were weaned at approximately 20 months, while

children without caries had been weaned 7 months earlier (70). Douglass (2001) reported

a significant relationship between nighttime bottle use and ECC and that older children

(25 to 36 months) who were still using the bottle were more likely to have a history of

sleeping with the bottle, which increases their risk for ECC (71).

The presence of ECC is significant because ECC may be a predictor for future

carious lesions (18), specifically caries in adolescence (17). A study by Peretz et al.

(2003) that followed children with ECC for seven to ten years, found that the children

with ECC had a greater risk for dental caries compared to children who either had caries

in their posterior teeth or had no caries (17). Interestingly, Almeida (2000) reported that

after two years of routine dental visits and increased dietary counseling, 79% of children

with ECC were diagnosed with additional caries. In contrast, caries developed in 29% of

children in the control group who initially had no caries and received no dietary

counseling (69).

Dental Caries and Taste Sensitivity

Lin (2003) identified a relationship between PROP taster status and dental caries.

The study reported that children classified as PROP nontasters had a higher prevalence of

dental caries than tasters (13). One potential explanation for this finding is that food

preferences and intake may be affected by genetically determined differences in taste

such that PROP nontasters prefer and consume foods that are more likely to promote

dental caries; however, Lin did not examine dietary intake in his study.









Methods of Dietary Data Collection

There are several methods available for collecting dietary information. Two

popular methods are multiple day food records and food frequency questionnaires. Since

all methods for collecting dietary information have strengths and weaknesses, it is

desirable to collect the information using more than one method (72). Multiple day food

records are time consuming since subjects must be instructed on how to record foods

eaten. Other weaknesses include the burden placed on the respondent and the possibility

that the days on which food intake is recorded are atypical. Also, subjects may alter their

eating behaviors if they know they have to keep a record. However, because food

records are open-ended, they have the potential to provide fairly accurate information

regarding food intake since subjects have the freedom to include whatever they ate

instead of having forced or limited choices (73). Food frequency questionnaires (FFQs)

are good for assessing usual intake in time periods of the preceding week, month, or year.

This method places less burden on the subject, but also requires higher level thinking and

good memory (72). For example, if the FFQ is measuring intake over the past year and

the subject eats ice cream once a week only in the summer, the total number of times

eaten (for example, 12 times) must be divided by 12 months. Instead of eating ice cream

once a week, the FFQ will record the data as once a month. It has been suggested that

FFQs may be the most appropriate method of assessing dietary intake when examining

relationships between diet and disease since they are designed to measure usual or long-

term intake (74). However, investigators often use at least two methods for collecting

dietary intake, so that they can have a better picture of subjects' usual intake (75).

Obtaining dietary intake data from children is especially difficult due to their

limited cognitive abilities, lack of knowledge of food preparation methods, and limited









ability to remember what they have eaten (75). In a study that compared 3-day food

records, a 24-hour recall and a 5-day food frequency questionnaire in 9 and 10 year old

girls, the 3-day food records more accurately reported intake compared to the other two

methods (76). Younger children, approximately 7 to 8 years old, are not able to complete

dietary assessment instruments adequately; therefore, the parents/caregivers of younger

children must accept the responsibility for providing information regarding dietary

intake. In contrast, children 10 to12 years of age have been shown to report their food

intake reliably (77).

Research Significance

It is widely accepted that dietary intake of sugars and other fermentable

carbohydrates is associated with an increased risk for dental caries. Intake of

carbohydrates is affected by an individual's preference for sweet taste. Many studies

examining the influence of taster status on food intake suggest that individuals who are

PROP tasters have a decreased preference for sweetened foods and beverages, which may

lead to decreased consumption of these items. Reduced intake of these foods also has

been associated with a more normal BMI. However, several studies have reported an

increased preference for and intake of sweetened foods and beverages by tasters, as well

as higher BMIs compared to nontasters. Differences in outcomes among these studies

could be due to differences in methods used to assess taster status (i.e., genotyping versus

PROP testing), the scales used to identify taster status when PROP is used as a method

for "determining" taste perception, lack of separation of supertasters from medium tasters

and the age of subjects.

Only one study to date has examined the relationship between PROP sensitivity

and dental caries in children. The findings of this study support a positive relationship









between PROP nontaster status and dental caries. However, no dietary intake or food

preference data were collected, so it is not possible to discern if the differences observed

in dental caries prevalence in ST and NT was related to intake or frequency of intake of

sugar/sugar-sweetened foods/beverages and starches.

Determining whether a relationship exists between dental caries prevalence of ST

and NT as a function of preference for and consumption of sugar and sugar-containing

foods would be useful in identifying individuals most at risk for developing caries,

especially children. Early screening to identify these higher risk children and the

development of targeted intervention strategies could be used to reduce caries prevalence

in adolescence and adulthood.

To investigate the relationships among dental caries prevalence and diet in ST and

NT children, information related to food preferences, dietary intake of carbohydrates and

sugars, number of eating occasions, BMI, bottle feeding practices, and preference ratings

for sweet were collected and compared between supertasters and nontasters. It was

hypothesized that dental caries prevalence of ST and NT children would be different

based on preferences for sweetened foods and beverages, consumption of sweetened

foods and beverages and BMI.














CHAPTER 3
RESEARCH DESIGN AND METHODS

Subject Recruitment

The University of Florida Health Science Center Institutional Review Board

(IRB) approved the study protocol. Eligible subjects were recruited from the Pediatric

Dentistry Clinic of the University of Florida College of Dentistry. IRB approved flyers

were posted in the Pediatric Dentistry Clinic waiting area to inform potential subjects

about the study. Children 6 to 12 years old who attended the clinic for routine dental

treatment and were free of chronic diseases/conditions that require dietary modifications

as part of disease management were considered for participation in this study. After

obtaining informed consent from the parent or caregiver and assent from the child, the

subject was screened for taste sensitivity. Subjects were compensated for participating in

the study.

Taste Sensitivity

To screen for taste sensitivity, the children were given verbal instructions on how

to rate the intensity of a variety of sensations using the general Labeled Magnitude Scale

(gLMS). They were shown a lined scale with numbers ranging from 0 to 100 on one side

and descriptive adjectives on the other side (0 = no sensation, 100 = strongest

imaginable) (36). The children were asked to rate the intensity of a series of common

occurrences, such as the loudness of a whisper, brightness of a well-lit room and

strongest oral pain experienced, using the gLMS (Appendix A). The last sensation in the

series was the PROP test. The children were asked to place a 3 cm circle of filter paper









impregnated with 1.6 milligrams of pharmaceutical grade PROP on the dorsal surface of

the tongue for 30 seconds and to rate the sensation in relation to the other intensities

already rated on the scale. Based on their gLMS ratings, the children were classified as

supertasters (rating above 60), medium tasters (rating 12 to 60), and nontasters (rating

below 12). Only children classified as supertasters or nontasters were recruited for the

remainder of the study. After the first 30 children were screened, the screening procedure

was adjusted because the researchers believed some of the children rated the PROP

intensity high as a result of having the filter paper in their mouths (i.e., the taste of the

paper), not as a true intensity rating. Subsequently, all prospective subjects were given a

plain piece of filter paper before the filter paper containing PROP to acquaint them with

the sensation of the paper. The children who qualified for the study prior to adjusting the

screening procedure (n = 15) were screened a second time using the two filter paper

method. Four of these children did not re-qualify as subjects. After the screening visit,

the subjects selected for participation in the study returned to the Dentistry Clinic for two

additional visits (Figure 3-1).


Screening First Return Visit

I I

PROP Dental exam
screening performed
performed
Bottle feeding
Demographic questionnaire
data collected administered

Food Food diary
preferences instructions
obtained explained

Figure 3-1. Study protocol and timeline


Second Return Visit

I

Youth/Adolescent
Questionnaire
administered

Hedonic response to
sweet evaluated

Sucrose intensity
evaluated


I









Demographic Data

Immediately after subjects qualified for the study, the following demographic data

were collected from the subjects or parents/caregivers: gender, age in months (on the day

of screening), ethnic origin, number of people living in the subject's household, and

family income.

Anthropometric Measures

The anthropometric measures collected at the screening visit included height and

weight. Weight without shoes was measured to the nearest tenth of a kilogram using a

digital scale (Seca 770, Hamburg, Germany) and height was measured to the nearest

tenth of a centimeter using a stadiometer (Seca 222, Hamburg, Germany). Weight,

height, and age on the day these measurements were taken were entered into the BMI

percentile calculator on the Shape Up America! Web site

(www.shapeup.org/oap/entry.php). This calculator plots the BMI percentile on age and

gender specific growth charts. The mean percentiles were used to compare subjects

according to PROP status.

Food Preferences

Food preferences were evaluated using a food preference questionnaire at the

screening visit. Unsuccessful attempts were made to attain questionnaires used in

published studies (1,2). A 60-item food preference questionnaire was created after a

literature search yielded ideas for food categories and methods to check validity

(Appendix B). Categories of foods/beverages examined included vegetables, fruits,

dairy, sweetened dairy, beverages, baked goods, cereals, sugar/sweetened foods, and

salted snacks. Five of the food items were asked twice to examine internal validity (1).

Subjects were asked to rate food preferences for the 60 food items using a hedonic scale









for children (Appendix C). This scale has numbers defined with Peryam and Kroll verbal

descriptors: 1 = super bad, 2 = really bad, 3 = bad, 4 = maybe good or maybe bad, 5 =

good, 6 = really good, 7 = super good. Each number and definition is accompanied by

varying degrees of smiling or frowning faces to illustrate the seven levels of likeability

(78-80) An additional choice was added as an empty circle with the number 0 to account

for unfamiliar food items as well as items that the children had not tasted.

Dental Exam

As part of the dental examination conducted for routine dental treatment purposes,

each subject received a standard clinical examination by one of the investigators using a

dental light, mouth mirror, and explorer at the subject's first return visit to the clinic. To

check reliability, a test and retest were conducted on 11 subjects. Dental caries

(including white spot lesions), restorations and extracted teeth in the primary teeth

surfaces were recorded on the standard clinical form used in the UF Pediatric Dentistry

Clinic. In addition, the bite wing radiographs taken for treatment purposes were examined

(no radiographs were taken for research purposes). The results of the existing clinical and

radiographic examinations were recorded as the total number of decayed, extracted and

filled surfaces in primary/PERMANENT teeth (defs/DEFS).

Bottle Feeding History

Bottle feeding history was obtained using a questionnaire to provide data regarding

early childhood feeding practices that may have influenced the development of early

childhood caries (71) (Appendix D). Information such as number of bottle feedings,

types of beverages included in bottle feedings, times of bottle feedings, and age at which

the child was weaned from the bottle was obtained from parents/caregivers during the

first return visit.









Food, Beverage and Supplement Diary

To investigate the relationship among taste sensitivity, food intake, and dental

caries prevalence, dietary intake and patterns were evaluated using three, nonconsecutive,

24-hour food diaries that included at least one weekend day (9,73,81,82). These records

provided the opportunity to assess the quantity of sugar consumption of the subjects as

well as the number of eating occasions per day. At the first return visit, subjects and their

parents/caregivers were instructed to record all foods, beverages, and supplements

consumed on each of three nonconsecutive days. The diary form included spaces to

record: time at which the item was consumed, a list of foods, beverages and supplements

consumed, a description of each food/beverage/supplement, and the amount consumed

(Appendix E). In addition, a handout was given that contained examples of portion sizes

relative to common household items (e.g., a medium piece of fruit is approximately equal

to the size of a tennis ball). Reported food intake was analyzed for macro- (including

total sugar intake) and micro-nutrient content using the computerized software program,

Food Processor (ESHA version 8.01). Intake of sugar from sweeteners and sugar-

containing foods was assessed after categorizing intake by food type (i.e., beverages,

starch only foods and sugar-containing foods, etc.). The percent of total calories from

carbohydrates and the percent of total calories from sugars were calculated so that

comparisons could be made between children with different energy intakes.

Youth/Adolescent Questionnaire (YAQ)

In addition to the food diary, a food frequency questionnaire (FFQ), specifically the

Youth/Adolescent Questionnaire (YAQ), was administered to the subjects with the help

of one of the researchers during the second return visit to the clinic (Appendix F). This

questionnaire, modified from the Willet FFQ, contains 152 questions and includes snack









foods as well as other foods commonly consumed by children (83). The YAQ is a semi-

quantitative FFQ that assesses the usual diet of children over the preceding year and has

been validated as a reliable method for determining nutrient intakes of children 9 to 18

years old (75,84). The questionnaire also asks information about meals and snacks eaten

away from home as well as the child's responsibility for preparation of meals and snacks.

The YAQ contains spaces to write in the specific type of ready-to-eat breakfast cereal

consumed, brand and type of margarine used, and other foods usually eaten but not

contained in the questionnaire. Subjects and parents/caregivers completed the YAQ in

approximately 45 minutes. Information gathered from the food preference questionnaire

was used to correlate food preferences with data from the food diaries and YAQ, since

previous research reported a relationship between foods preferred and foods consumed

(85).

Hedonic Response to Sweet

The sensory methodology to determine the hedonic response to varying levels of

sweetness included the creation of five levels of sweetness in commercial apple juice by

adding graded amounts of sucrose: 0, 3, 6, 9, and 12 grams to 100 grams of juice, which

is similar to that used by Liem and Mennella (2002)(53). This provided sweetness levels

ranging from relatively moderate (i.e., no added sucrose, typical natural sugar content of

10 to 12%) to very high for a typical food product (20 to 22% total sugar) (86). At the

second return visit, the juice samples were presented to the subjects in random order in

plastic cups labeled with random 3-digit numbers. The subjects rated how much they

liked the apple juice on the same hedonic scale that was used for the food preference

questionnaire without the option of never tried (78-80).









Sucrose Intensity Rating

A 1M sucrose solution was prepared for use during the second return visit.

Subjects were given five milliliters of the solution to taste. They rated the intensity of the

sucrose solution using the gLMS (86).

Statistical Analysis

The main objective of this study was to determine the differences in mean decayed,

extracted and filled surfaces in primary (defs) and permanent (DEFS) teeth between

supertasters and nontasters as determined by PROP. The difference between these

groups as defined by Lin (2003), was 17 units (i.e., 1.0 for supertasters versus 18.19 for

nontasters) (13). To detect half that difference (i.e., 8.5 units) using the pooled standard

deviation (SD) of 7 and a two-tailed alpha = 0.05 with 80% power, a sample size of 15

subjects was required in each taster group. Based on this power analysis, it was

estimated that 30 subjects, 15 supertasters and 15 nontasters, were needed for this study.

The statistical analysis was performed with a standard statistical personal computer

software package (SAS, version 9.1, SAS Institute Inc. Cary NC, USA) that included t-

tests and paired t-tests to examine the significance of the differences between numerical

variables, Chi square and Fisher exact tests to examine the significance of distribution of

a categorical parameter by another categorical variable, and logistic regression analyses

to examine the significance of the influence of different dependent variables on an

independent variable for both tasters and nontasters.














CHAPTER 4
RESULTS

Subjects

One hundred and four children were screened for taster status. Forty-two children

qualified for the study. Two of these subjects withdrew, 4 did not re-qualify after the

PROP re-screening, and 4 completed only the initial visit and the first return visit.

Seventeen subjects classified as supertasters, and 15 subjects classified as nontasters

completed all three visits; however, the three day food, beverage, and supplement diary

for six of these subjects (18.75%) were not analyzed because three supertasters and 2

nontasters did not return their food diaries and one nontaster's diary was incomplete.

There were 14 girls (44%) and 18 boys (56%) with a mean age SD of 112.7 22.6

months (i.e., 9 years); (range = 74 to 155 months or 6 to 12 years). No significant

difference was detected with regard to gender and taster status (P = 0.69) (Table 4-1).

Table 4-1. Sample characteristics of the study groups
Supertasters Nontasters
N= 17(53%) N = 15(47%)
Gender* n (%) n (%)
Male 9(28.1) 9(28.1)
Female 8(25) 6(18.8)
Ethnic Origin**
African-American 4 (23.5) 3 (20)
African-American/Caucasian 0 1 (6.6)
Hispanic 3 (17.6) 1 (6.6)
Hispanic/Caucasian 0 1 (6.6)
Caucasian 10(58.8) 9 (60)
*P = 0.69
**P = 0.78









Demographic Data

Subjects' ethnic origin is reported in Table 4-1. No significant difference was

detected with regard to ethnic origin and taster status (P = 0.78). The ethnic origin of the

study subjects is reflective of the population of Alachua County, Florida. The number of

people living in subjects' households is reported in Table 4-2 and family income per

household is reported in Table 4-3.

Table 4-2. Number of individuals living in each subject's household
Size of Household (Number of individuals) Number of Subjects (%)
3 1 (3.1)
4 12(37.5)
5 9(28.1)
6 4(12.5)
7 4(12.5)
8 2 (6.25)

Table 4-3. Family income per household
Family Income Range Number of Subjects (%)
$19000 or less 11 (34.4)
$20000 $29000 9 (28.1)
$30000 $39000 7 (21.9)
$40000 $69000 4 (12.5)
$70000 or more 1 (3.1)

Dental Exam

No significant differences were detected between the two taster groups regarding

present experience of defs/DEFS: nontasters (12.1 + 12.5) versus supertasters (8.4 8.8)

(P = 0.33); caries history: nontasters (7.6 5.8) versus supertasters (6.3 8.4) (P = 0.62);

and present caries experience combined with caries history: nontasters (19.7 15.2)

versus supertasters (14.6 17) (P = 0.39).

Food Preferences

The preference ratings for foods listed in each food category included in the food

preference questionnaire were averaged to calculate a category mean. The means were









compared between the two taster groups. No significant differences were detected

between nontasters and supertasters for any of the food preference categories (Table 4-4).

Table 4-4. Food preference scores (mean SD) for food categories by taster status
Food Category Supertaster* Nontaster
(mean SD) (mean + SD)
Vegetables: broccoli, spinach, green beans,
potatoes, carrots, corn, greens 32.2 + 5.7 32.5 + 7.7

Fruits: strawberries, bananas, pineapple,
apples, grapes, raisins, lemons 36.2 7.2 37.4 + 6.6

Dairy: cheddar cheese, American cheese,
cottage cheese, milk 17.0 + 6.5 17.7 + 4.9

Sweetened dairy: ice cream, flavored milk
(chocolate, strawberry), frozen yogurt, 34.9 5.7 33.7 2.7
flavored yogurt, milkshake, pudding

Beverages: soft drinks (regular and diet),
tea (sweetened and unsweetened), 100% 33.9 + 5.8 33.0 + 8.8
juice, juice drinks (lemonade), Kool-aid

Baked goods: cookies, brownies, cake,
poptarts, pie, snack cakes, graham 38.5 5.4 39.4 + 5.1
crackers

Cereals: breakfast cereals (sweetened and
unsweetened), cereal bars, granola bars 19.7 + 3.4 19.5 + 5.5

Sugar/sweetened foods: candy (chocolate
and non-chocolate), popsicles, fruit 50.4 + 7.1 51.6 + 7.1
rollups, jam/jelly, syrup, doughnuts,
Jello, sweet roll

Salted snacks: popcorn, pretzels, chips, 21.0 3.0 21.3 + 3.1
peanuts
*P>0.05, two-tailed test, for each food category comparison between ST and NT

For individual foods, strawberries, ice cream and doughnuts were rated highest by

both taster groups. In addition, milk and chocolate candy were rated within the top five

items for STs and popcorn and cookies rounded out the top five foods for NTs. Cottage










cheese and spinach were rated the lowest by both taster groups. Supertasters also rated

lemons, greens (i.e., collard, mustard) and unsweetened tea lowest, while nontasters gave

broccoli, diet soft drinks and cereal bars the lowest ratings.

The linear relationship between dental caries prevalence of STs and NTs as a

function of food preference was examined for each of the nine food categories included

in the food preference questionnaire. There was no evidence to indicate a linear

relationship between dental caries prevalence of ST compared to NT children as a

function of food preference for any food category (Figures 4.1 to 4.9). There was no


40-
S* Nontaster
0 A A Supertaster
2 25 Nontaster
R 20- A ---Supertaster
W 15- A R
M 10 A
R' = 0.08
5- ,.... -P = 0.36
O- Am -
A A a

15 20 25 30 35 40 45
Vegetable preference score


Figure 4-1. Dental caries prevalence of ST and NT children as a function of vegetable
preference

evidence to suggest a correlation between dental caries status and food preferences based

on food preference categories for either STs or NTs, with one exception (Table 4-5). A

positive correlation (P = 0.04) was noted between dental caries status of ST children and

preference for cereal (i.e., sweetened and unsweetened ready-to-eat cereal, granola bars

and cereal bars).











40-
n Nontaster
LL 35-
u A A Supertaster
23 2 Nontaster
S20- ---Supertaster
15- 2 = 0.1


C 0- Mm
0aA

0 10 20 30 40 50 60
Fruit preference score


Figure 4-2. Dental caries prevalence of ST and NT children as a function of fruit
preference




40-
S35n Nontasters
LL 35-
u30 A A Supertasters
25 3 Nontasters
,20- A --- Supertasters
1a 5- A
10 A LJ R2 = 0.04
S ...1-------- P = 0.96

1 A A A A 30

0 5 10 15 20 25 30
Dairy preference score


Figure 4-3. Dental caries prevalence of ST and NT children as a function of dairy
preference












* 0


) A 0
5 _A A

O- -mm m -m-
A on A

20 25 30 35 40 47
Sweetened dairy preference score


* Nontasters
A Supertasters
- Nontasters
-- Supertasters

R2 = 0.03
P = 0.98


Dental caries prevalence of ST and NT children as a function of sweetened
dairy preference


)- A A _




A A A AA
----------- I-- -



20 30 40 50 61
Beverage preference score


* Nontasters
A Supertasters
- Nontasters
---Supertasters


R2 = 0.04
P = 0.44


Figure 4-5. Dental caries prevalence of ST and NT children as a function of beverage
preference


Figure 4-4.

















A U


AA
A A A
--------------------

AU A* AAAE


mm Nontasters
A Supertasters
Nontasters
* --- Supertasters


R2= 0.09
P = 0.4


25 30 35 40 45 50 5"
Baked goods preference score


Dental caries prevalence of ST and NT children as a function of baked goods
preference


* 0


40 AN
0 A# AA


Nontasters
A Supertasters
Nontasters
---Supertasters


R2 = 0.13
P = 0.06
*


0 5 10 15 20 25 31
Cereal preference score


Figure 4-7. Dental caries prevalence of ST and NT children as a function of cereal
preference


Figure 4-6.












* U
A


40-
35-
30-
25-
20-
15-
10-
5-
0-

30


Nontasters
A Supertasters
- Nontasters
---Supertasters


R2 = 0.03
P = 0.87


Dental caries prevalence of ST and NT children as a function of sugar
preference


A


A A


A A a A




0 10 20 30 41
Salted snacks preference score


* Nontasters
A Supertasters
- Nontasters
---Supertasters


R2 = 0.05
P = 0.65


Figure 4-9. Dental caries prevalence of ST and NT children as a function of salted
snacks preference

Food, Beverage and Supplement Diary

Items from the three day food, beverage, and supplement diary were entered into

Food Processor (ESHA version 8.01) to determine the 3 day average intake for nutrients

and food components such as sugars. The percent of total calories from carbohydrates

and the percent of total calories from sugars (i.e., sucrose, fructose, lactose) were

calculated so that comparisons could be made between children with different calorie


*A 0
A
A A
-1111

Am


40 50 60 70 8C
Sugar preference score


Figure 4-8.









Table 4-5. Relationship between dental caries prevalence and food preferences for STs
and NTs
Supertasters Nontasters
r-value P-value r-value P-value
Vegetable -0.32 0.21 0.13 0.66
Fruit -0.28 0.28 0.25 0.39
Dairy 0.06 0.83 0.10 0.73
Sweetened dairy -0.09 0.74 0.001 1.0
Beverages 0.16 0.53 -0.07 0.80
Salted snacks -0.06 0.81 0.15 0.60
Baked goods 0.02 0.95 0.31 0.26
Cereal 0.49 0.04 -0.15 0.59
Sugar and sugar 0.03 0.92 0.004 0.99
sweetened foods

intakes. No significant difference was detected between STs and NTs, respectively, with

regard to total calories consumed (1966 486; 2054 530; P = 0.67), carbohydrate

intake (mean percent of total calories SD): (54.6 5; 52.9 5.5; P = 0.43), sugar intake

(mean percent of total calories SD): (26.8 3.8; 26.3 5.4; P = 0.76), or number of

eating occasions per day (5.4 1.2; 5.5 1.5; P = 0.81).

Carbohydrate and sugar intakes as a percent of total calories were calculated after

categorizing specific items recorded in the food diaries. The categories included: sugar

(i.e., candy, syrup, jam/jelly), sugar and starch (i.e., cakes, cookies, pies), starch (i.e.,

bread, rice, pasta), milk (i.e., regular and chocolate), and sweetened beverages (i.e., soda,

tea, juice/juice drinks). No significant differences were detected between nontasters and

supertasters for any of the categories that included sugar containing foods (Table 4-6).

There was no evidence to indicate a difference in the slope of the line for ST compared

to NT children when examining the linear relationship between dental caries prevalence

as a function of the percent of total calories from sugar intake (Figure 4-10). There was

no evidence to suggest a correlation between dental caries prevalence and sugar intake as







44


a percent of total calories for either STs or NTs (r = -0.06; P = 0.84; r = 0.21; P = 0.50,

respectively).

Table 4-6. Carbohydrate and sugar intake of ST and NT children by food category
Category Supertaster Nontaster P-value
% of total calories (mean SD)
Sugar
CHO 11.3 9.1 7.5 3.5 0.17
sugar 18.9+ 15.3 13.6 9.2 0.31
Sugar/starch
CHO 22.2+ 10.3 16.6 9.2 0.16
sugar 19.7 8.2 15.7 8.8 0.25
Starch
CHO 22.7 8.9 23.3 13.4 0.91
sugar 4.0 3.2 3.9 3.8 0.95
Milk
CHO 8.7 + 4.6 12.1 + 10.2 0.31
sugar 17.9 + 9.9 22.4 + 17.2 0.41
Sweetened beverages
CHO 14.5 + 10.5 16.1 + 10.2 0.70
sugar 30.7 + 21.3 30.3 18.2 0.96


A.

----------------------


* nontaster
A supertaster
- nontaster
-- supertaster

R2 = 0.06
P = 0.63


17.5 20.0 22.5 25.0 27.5 30.0 32.5 35.0 37.5
Sugar intake (%of total calories)


Figure 4-10. Dental caries prevalence of ST and NT children as a function of sugar
intake

Youth/Adolescent Questionnaire (YAQ)

Completed YAQs were hand-coded for type and brand of margarine used and

brand of ready-to-eat breakfast cereals consumed, and were sent to Channing Laboratory









at Harvard Medical School for analysis. No significant differences were detected

between ST and NT children for total calories (mean SD): (2431 889 vs. 2410 781;

P = 0.94), total carbohydrate intake (57.1 + 9.9 vs. 53.5 5.3; P = 0.21) or sucrose

consumption (10.3 2.7 vs. 10.6 + 2.6; P = 0.8), respectively.

A significant difference (P = 0.048) in the total energy intake reported from the

food diaries compared to the YAQ was detected. The mean total calories from the food

diaries (2007 kcals 499) was lower than the mean of total calories from the YAQ (2421

kcals 827). The difference in estimated energy intake may be due to inherent

differences in the methods used to obtain dietary intake data. The calories from the food

diaries represent actual intake over a three day period while the calories from the YAQ

do not represent actual intake, but usual intake from the preceding year. The range for

total calories from the food diaries was 1163 to 3119 calories while the range from the

YAQ was 820 to 4717. No significant difference was detected in carbohydrate intake

expressed as a percent of total calories when comparing the results of analysis of the food

diaries (53.8 5.5) to the YAQ (55.4 8.2) (P = 0.90).

There was no evidence to indicate a difference in the slope of the line for ST

compared to NT children when examining the linear relationship between dental caries

prevalence as a function of the percent of total calories from sucrose (Figure 4-11).

There was no evidence to suggest a correlation between dental caries prevalence and

sugar intake as a percent of total calories for either STs or NTs (r = 0.18; P = 0.50; r = -

0.13; P = 0.65, respectively).










-. 40-
S35n Nontaster
LL 35-
S A A Supertaster
2- Nontaster
25-
-- 20- --- Supertaster


-- ....* P= 0.33
S A


5 6 7 8 9 10 11 12 13 14 15 16 17
Sucrose intake (%of total calories)


Figure 4-11. Dental caries prevalence of ST and NT children as a function of sucrose
intake

Bottle Feeding History

Responses of parents/caregivers of ST compared to NT children regarding early infant

feeding practices are shown in Table 4-7. Logistic regression analysis was performed to

obtain the odds ratio (OR) and 95% confidence interval (95% CI) for each feeding

practice (Table 4-7). No difference between ST and NT parents/caregivers regarding the

addition of sweeteners, cereal or strained fruit, or sweetened beverages (i.e., juice, Kool-

aid, sweetened tea, soda) to the bottle was detected. In addition, no difference between

ST and NT parents/caregivers was detected regarding the use of a bottle or sippy cup

while in bed, being allowed to breastfeed throughout the night as desired or age of

weaning.

Anthropometric Data

A t-test was used to determine whether differences existed between taster groups with

regard to BMI. No significant difference was detected between the mean BMI percentile

of supertasters (74.2% + 17.7) compared to nontasters (64.4% + 25) (P = 0.20). There

was no evidence to indicate a difference in the slope of the line for ST compared to NT









children when examining the linear relationship between dental caries prevalence as a

function of BMI percentile (Figure 4-12). There was no evidence to suggest a correlation

between dental caries prevalence and BMI percentile for either STs or NTs (r = -0.11; P =

0.68; r = -0.21; P = 0.46, respectively).

Table 4-7. Responses and logistic regression analysis of specific bottle feeding practices
of ST compared to NT parents/caregivers
Feeding Practices Frequency Supertasters Nontasters Odds Ratio (95% CI)*
Addition of Never, rarely, 16 12
sweeteners occasionally
0.22 (0 2.16)
Weekly, daily 0 3

Addition of Never, rarely, 10 9
cereal or occasionally
strained fruit 0.90 (0.21 3.82)
Weekly, daily 6 6

Addition of Never, rarely, 12 9
sweetened occasionally
beverages 0.51 (0.08 2.93)
Weekly, daily 4 6

Use of bottle or Never, rarely, 7 9
sippy cup in occasionally
bed 1.93 (0.46 8.05)
Weekly, daily 9 6

Fed at breast Never, rarely, 6 7
throughout occasionally
night as desired 1.87 (0.39 8.89)
Weekly, daily 8 5

Age at weaning Before 9 months 1 0
9-12 months 3 4
13-15 months 5 5 1.00 (0.25 3.95)
After 15 months 5 3
Not sure 0 1
*P>0.05










40-
S5 nontaster
30- A A supertaster
25- c nontaster
S20- I A ---supertaster
S15. A
U 10- R2 = 0.08
0 --P =0.65
S0 m A AA A

20 30 40 50 60 70 80 90 100 110
BMI percentile


Figure 4-12. Dental caries prevalence of ST and NT children as a function of BMI
percentile

Hedonic Response to Sweet

The sugar content of the apple juice samples was verified using a refractometer

(Abbe Mark II, Model 10480 S/N, Reichert, Buffalo, New York) (Table 4-8). The

Table 4-8. Percent sugar in apple juice samples measured by refractometry
Sample (g sucrose/100 gjuice) % sugar (beginning of % sugar (midpoint of
study) study)
0 11.55 11.65
3 14.1 14.25
6 16.8 16.55
9 18.9 18.0
12 21.15 18.65

graded solutions of sucrose in apple juice were prepared at the beginning of the study and

again at the midpoint of the study. Due to the small subject number, answers from the

hedonic scale were combined for comparison: "tastes bad" included super bad, really bad

and bad, while "tastes good" included super good, really good, and good. The subjects'

responses to the five graded solutions of sucrose in apple juice are reported in Table 4-9.

Logistic regression analysis was performed to obtain the OR and 95% CI (Table 4-9).

Supertasters were 20.8% more likely to rate all the apple juice samples as good compared









to nontasters; however, a significant difference was not detected (P = 0.60). Significant

differences were not detected between STs and NTs for any of the apple juice samples.

Table 4-9. Responses and logistic regression analysis of STs compared to NTs regarding
the graded solutions of sucrose in apple juice
Amount of sucrose
d to 10 juice Response STs NTs OR (95% CI)*
added to 100 g juice
Bad 2 0
Neutral 3 5
0 gram 3 5 1.00 (0.23 4.40)
Good 12 10

Bad 2 3
Neutral 4 0
3 gramsN 0.58 (0.12 2.81)
Good 11 12

Bad 1 3
Neutral 1 1
6 grams Ne 1 2.85 (0.44- 18.37)
Good 15 11

Bad 1 3
Neutral 4 0
9 grams Good 12 12 0.78 (0.16 3.86)
Good 12 12

Bad 1 3
12 grams Neutral 2 2 2.50 (0.49 12.79)
Good 14 10
*P>0.05

Sucrose Intensity Rating

No significant difference was detected between the taster groups' ratings of the intensity

of a 1M sucrose solution: supertasters (34.4 28.9) versus nontasters (21.4 20.1) (P =

0.16) (Figure 4-13). There was no evidence to indicate a difference in the slope of the

line for ST compared to NT children when examining the linear relationship between

dental caries prevalence and sucrose intensity ratings (Figure 4-13). There was no

evidence to suggest a correlation between dental caries prevalence and sucrose intensity

rating for either STs or NTs (r = -0.32; P = 0.21; r = -0.17; P = 0.56, respectively).







50



40-
2 35 nontaster
35-
3 A A supertaster
2- nontaster
S20 A --- supertaster
U)
.a 15- A A
*A 1 -- R2 0.08
P = 0.66
I 0 -A" 4 A ,

0 25 50 75 100
Sucrose intensity rating


Figure 4-13. Dental caries prevalence of ST and NT children as a function of sucrose
intensity rating














CHAPTER 5
DISCUSSION AND CONCLUSIONS

Much of the previous research related to taste sensitivity as measured by the

response to PROP has suggested that supertasters are more sensitive to bitter and sweet

substances. This has led some researchers to speculate that supertasters may have a

decreased preference for and consumption of sweetened foods and beverages. It follows,

then, that supertasters may have fewer dental caries as well as lower BMIs, as some

studies have shown. The present study was the first to examine if there was a

relationship between dental caries prevalence in supertaster and nontaster children as a

function of sugar intake or preference for sweet. Identifying a connection between dental

caries prevalence based on taster status as identified by a simple method such as PROP

testing could provide the impetus for more targeted intervention strategies that could

strengthen the collaboration between nutrition and dental professionals as promoted by

the American Dietetic Association position statement on oral health and nutrition (63).

Only one study to date has examined the relationship between dental caries

prevalence and taster status in children. Lin (2003) found that supertasters had fewer

dental caries compared to nontasters (13). In contrast to that study, no significant

difference was detected in dental caries prevalence between ST and NT children in the

present study despite having adequate power to detect a difference in dental caries

between STs and NTs. Based on the findings by Lin (2003) (13), differences in the

carious surfaces between the supertasters and the nontasters should have been detected

with this sample size. While no differences were detected, NTs did appear to have more









dental caries (12.1) compared to STs (8.4). A larger sample size may have detected a

difference in dental caries between the two taster groups.

The development of dental caries is affected by a variety of factors aside from

sugar intake, including bottle feeding practices, age at weaning and frequency of eating

occasions. Studies also have reported a positive relationship between dental caries

prevalence and certain racial/ethnic groups. In examining the linear relationship between

dental caries prevalence of ST compared to NT children as a function of sugar intake, it is

important to consider the potential influence of these variables as they could confound

the results. However, no significant differences between STs and NTs were detected for

any of these variables. Furthermore, there was no evidence to suggest a difference in the

linear relationship between dental caries prevalence and sucrose/sugar intake for either

STs or NTs. In addition, there was no evidence to suggest a difference in mean sucrose

or sugar intake as a percent of total calories between STs and NTs.

Based on previous studies, it was expected that STs and NTs would have differing

food preferences. It was expected that NTs would give higher preference ratings to

sweetened, high fat foods and beverages compared to STs and that STs would give lower

ratings to bitter vegetables. There was no evidence to suggest a difference in the linear

relationship between dental caries prevalence and food preferences for either STs or NTs.

The food preference ratings of STs and NTs were very similar, suggesting that children in

this study prefer similar types of foods, regardless of taster status. In addition, no

significant differences were detected regarding the preferences for the graded

concentrations of sucrose in apple juice or the ratings of the 1M sucrose solution. A 7-

point hedonic scale was used for the apple juice samples, which may have led to ceiling









effects. Additionally, it may have been difficult for the children to differentiate between

really good and super good. A better option would have been to use the gLMS scale to

help reduce the possibility of a ceiling effect. Also no differences may have been

detected in the batch of sucrose solutions containing the 9 grams or the 12 grams of

sucrose per 100 grams of apple juice that were prepared later in the study, since

refractometry revealed no difference between the two samples.

In contrast to several studies, but in support of other studies, the mean percent

BMI of NTs in the present study was lower than that of STs; however, significant

differences were not detected. Previous studies have suggested that NTs may need to eat

more in order to have the same taste sensations as STs. However, no significant

difference was detected between STs and NTs regarding total calorie intake. One

potential limitation of the present study is that the power analysis was based on the

number of subjects needed to detect a difference in dental caries prevalence between STs

and NTs. Based on the data produced in this pilot study, a larger sample size would have

been needed to detect a difference in the dietary variables. In addition, information

regarding exercise habits was not collected. Nontaster children may have been more

active than supertaster children leading to lower BMIs.

Strengths of the present study included the exclusion of medium tasters, the use of

the gLMS to categorize children into taste status groups and the use of more than one

method to collect dietary data. Current research seems to suggest that medium tasters are

more like nontasters. Since this study did not combine medium taster data with

supertaster data, there should be no dilutional effects in the supertaster data. Also, the

gLMS was used to categorize the subjects, which is currently the gold standard for









assessing PROP taster status. Another strength is that two methods were used to collect

dietary data. The food frequency questionnaire (YAQ) included a wide variety of foods

and examined intake over a longer period of time compared to the food diary. The three

day food diary provided more specific data on types of foods eaten, including portion

sizes.

Limitations of the study include a small number of subjects drawn from a limited

pool, the age of the subjects, the responsibility of parents/caregivers to complete the food

diaries and the use of an unvalidated food preference questionnaire. The subjects who

participated in this study were recruited from a limited pool since all subjects were

current patients at the Pediatric Dentistry Clinic of the University of Florida College of

Dentistry. Patients that attend the clinic often come from low socioeconomic

backgrounds. The age of the subjects also could have affected the results since younger

male children may not have had fully developed taste systems, as suggested by some

studies. If this is the case, the data may not accurately reflect taster status in young

males. In addition, the responsibility of completing the food, beverage, and supplement

diaries rested solely with the parents/caregivers of the younger children. Since we asked

for two weekdays, children had to report to their parents/caregivers what they ate for

lunch and snacks while at school. As some studies have shown, children often are not

able to accurately report foods recently consumed. Another limitation was the use of an

unvalidated food preference questionnaire. The categories and specific foods chosen may

not have been distinct enough to allow for the detection of significant differences.

Taste perception is very complex. Recent discoveries of PTC/PROP genes on

chromosomes 5 and 7 suggest that the ability to taste PTC/PROP is genetically









determined. In addition to the ability to taste PROP, the number of fungiform papillae

may contribute to the supertaster phenotype. Only a small percentage of the bitter taste

receptors (T2Rs) have been found on the fungiform papillae. However, a high

percentage of the sweet taste receptors (T1R and T3R) are found on these papillae. The

use of PROP as a method for assessing an individual's taste sensitivity may not

accurately reflect the true taste status. The identification of three single nucleotide

polymorphisms of the taste sensitivity gene TAS2R38 suggests that a subjective measure

of taste perception such as PROP may not adequately distinguish taste sensitivity. Future

studies should determine whether a relationship exists among the various genotype

combinations for taste and the phenotype of an individual based on PROP. Studies

should be undertaken to determine if food preferences and intake vary among the

different genotypes since there are inconsistencies among published reports with some

studies suggesting that supertasters eat more sweets, while others suggest that nontasters

have a higher sugar intake. Since obesity is becoming such an epidemic in developed

countries, it would be interesting to have more conclusive data about the relationship

between BMI and sugar intake of taster status as determined by genotype.

The results from this study do not support the findings of Lin (2003) (13) that

nontaster children had more dental caries compared to supertaster children and do not

support a linear relationship between dental caries prevalence of ST and NT children as a

function of sugar intake or preference for sugar. Since taste sensitivity research in

children is limited, additional studies that address the limitations of the present study and

use genetic information to determine taster status are warranted. Future studies should

determine whether a relationship exists among the various genotype combinations for






56


taste and the phenotype of the individual based on PROP and whether dental caries

prevalence is correlated with taste perception based on the taste-related genotype status of

an individual.

















APPENDIX A
SENSATION LIST USED WITH THE GENERAL LABELED MAGNITUDE SCALE



Green scale training items


brightness of a well-lit room 1 1-
brightness of a dimly lit restaurant
brightest light you have seen

loudness of a whisper
loudness of a conversation
loudest sound you have heard
Warm bread in your mouth
sweetness of a coke

bitterness of celery
strongest saltiness experienced
strongest sweetness experienced
strongest sourness experienced

strongest bitterness experienced
strongest oral bur experienced
(e.g., chili peppers)
strongest oral pain experienced
(e.g., toothache
Candy (sweetness)
PROP paper (bitterness)


Used with permission of Linda M. Bartoshuk, Visiting Professor, University of Florida,
lbartoshuk@phhp.ufl.edu, Phone: 352-273-5119


xe
; ^"
^_______














APPENDIX B
FOOD PREFERENCE QUESTIONNAIRE

Subject number

Food Preference Questionnaire

General Information: The researcher will explain the directions to the
subject and his/her parent/caregiver. The researcher will read the name
of each food on the questionnaire, one at a time, and will use this form
to record the number that corresponds to the "face" selected by the
subject.

Directions for Subjects: A list of foods will be read to you one at a time.
For each food item, look at the faces on the paper in front of you. Decide
which of the faces best describes how much you like or dislike the food


and point to the face you picked.
pick the circle with no face.


1. apples


2. milkshake/
smoothie

3. popcorn

4. cereal bars

5. cookies

6. jello


7. broccoli

8. cottage cheese

9. regular soft drinks

10. chips


11. crackers


If you have never tried the food, then


0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7


0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7










12. lemons 0 1

13. pudding 0 1

14. poptarts 0 1

15. 100% juice 0 1
(orange, apple)

16. jam/jelly 0 1

17.bananas 0 1

18. spinach 0 1

19. brownies 0 1

20. diet soft drinks 0 1

21. chocolate candy 0 1

22. American cheese 0 1

23. grapes 0 1

24. frozen yogurt 0 1

25. sweetened tea 0 1

26. green beans 0 1

27. flavored milk 0 1
(chocolate, strawberry)

28. Popsicles 0 1

29. pre-sweetened 0 1
cereal (Reese's, Apple Jacks,

30. pineapple 0 1

31. cinnamon roll/ 0 1
pastry

32. juice drinks 0 1


2

2

2

2


2

2

2

2

2

2

2

2

2

2

2

2


2

2
Cocoa

2

2


3

3

3

3


3

3

3

3

3

3

3

3

3

3

3

3


3

3
Puffs)

3

3


2 3 4 5 6 7









(Hawaiian Punch)

33. pretzels

34. carrots

35. cake/cupcakes

36. granola bars

37. syrup (pancakes)

38. greens
(collard, mustard)

39. cheddar cheese

40. pie

41. unsweetened tea

42. non-chocolate
candy (jelly beans,

43. corn

44.banana

45. flavored yogurt

46. fruit roll-ups/
fun fruit

47. peanuts

48. snack cakes
(Twinkies)

49. Kool-aid

50. non-sweetened
cereal (Life, Corn F

51. cookies

52. mashed potatoes


0 1

0 1

0 1

0 1
lollipops)

0 1

0 1

0 1

0 1


0

0


0

0
lakes)


0 1

0 1






61



53. ice cream 0 1 2 3 4 5 6 7

54. regular soft drinks 0 1 2 3 4 5 6 7

55. doughnuts 0 1 2 3 4 5 6 7

56. raisins 0 1 2 3 4 5 6 7

57. popcorn 0 1 2 3 4 5 6 7

58. milk 0 1 2 3 4 5 6 7

59. chocolate candy 0 1 2 3 4 5 6 7

60. strawberries 0 1 2 3 4 5 6 7















APPENDIX C
HEDONIC SCALE FOR CHILDREN


Never
Tried



0


Super
Bad




1


Really
Bad




2


Bad


Maybe
Good or
Maybe
Bad


3 4


Good





5


Really
Good



6


Super
Good



7


Adapted from Resurreccion AVA. (1998) Affective Testing with Children. In: Consumer
Sensory Testing for Product Development, p. 171. Aspen Publishers, Inc. Gaithersburg,
Maryland.















APPENDIX D
BOTTLE FEEDING QUESTIONNAIRE


Subject number:


Bottle Feeding History Questionnaire

1. How often were sweeteners (sugar, honey, molasses, Karo syrup,
chocolate syrup, etc.) added to milk/formula in your child's bottle
or sippy cup?

Never
Rarely (no more than once every 2-3 months)
Occasionally (about 1-2 times a month)
Weekly (about once a week)
Daily (almost every day)


2. How often was cereal or strained fruit added to milk/formula in
your child's bottle or sippy cup?

Never
Rarely (no more than once every 2-3 months)
Occasionally (about 1-2 times a month)
Weekly (about once a week)
Daily (almost every day)


3. How often was sweetened condensed milk used to make your
child's formula?

Never
Rarely (no more than once every 2-3 months)
Occasionally (about 1-2 times a month)
Weekly (about once a week)
Daily (almost every day)









4. How often were juice, Kool-aid, sweetened tea, chocolate milk
and/or soda given to your child in a bottle?

Never
Rarely (no more than once every 2-3 months)
Occasionally (about 1-2 times a month)
Weekly (about once a week)
Daily (almost every day)


5. How often was your child allowed to drink from a bottle or sippy
cup while they were in bed?
Never
Rarely (no more than once every 2-3 months)
Occasionally (about 1-2 times a month)
Weekly (about once a week)
Daily (almost every day)


6. If your child was breastfed, how often was your child allowed to
feed at the breast throughout the night as desired (i.e., sleep in the
bed and feed whenever they wanted to)?

Never
Rarely (no more than once every 2-3 months)
Occasionally (about 1-2 times a month)
Weekly (about once a week)
Daily (almost every day)


7. At what age was your child weaned from the bottle?

before 9 months
9-12 months
13-15 months
after 15 months
not sure
















APPENDIX E
THREE DAY FOOD, BEVERAGE AND SUPPLEMENT DIARY WITH
INSTRUCTIONS












Questions? Please call Claire Edgemon at 352-317-3907


3-day Food and Supplement Diary


Time
Consumed
List the time
at which the
item was
consumed.


Foods, Beverages and Supplements Consumed
List each food, beverage, snack, chewing gum or
supplement you consume. List only one item per
line.


Description
List the brand name and product
description or include the product
label or recipe for everything you
eat. Tell how the food was cooked
(fried, baked, etc). If you ate away
from home, list the name of the
restaurant or food shop. Be sure to
include information about things
that you add to your food before
you eat it, like margarine, salt,
sugar, milk, etc.


Amount Consumed
List the amount of each
food, beverage, snack,
chewing gum or
supplement you
consume. Tell how many
cups, ounces (oz),
teaspoons (tsp),
tablespoons (tbsp) you
eat or the weight or
number of portions or
pieces you eat.


Name:


Day 1









Directions for
24-hour Food, Beverage, and Supplement Diary

*Please record everything your child consumes in a 24 hour period, including all foods,
beverages, snacks, chewing gum and supplements.

If you have any questions, please call Claire Edgemon at 352-317-3907.

1. Please record your child's intake for a full 24 hour period on 3 nonconsecutive
days (at least one day between each of the days you record your child's intake).
Include at least one weekend day (Saturday or Sunday).

2. Please record the time of day when items are consumed; the foods, beverages,
snacks, chewing gum and supplements your child consumes; and the amounts of
each that your child consumes as soon after eating as possible. This will help
prevent you from forgetting foods, or over- or under- estimating what your child
has consumed.

3. In the column labeled "Time Consumed" record the time of day at which the
items are consumed.

4. In the column labeled "Foods and Beverages Consumed" record what your
child ate. Please be as specific as possible. For example, if your child consumed
milk: indicate skim, 1%, 2%, or whole. If your child consumed cereal, indicate
what kind of cereal. If your child consumed bread, indicate what kind of bread
(white, wheat, rye, oat bran, etc.). Don't forget to include condiments, such as
catsup, mustard, jelly, salad dressing, sauces, etc.

For example:

Time Foods, Beverages, Description Amount
Consumed Supplements Consumed Consumed
7:00 am Milk 1% low fat 1 cup
7:00 am Cornflakes Kellogg's 1 2 cups
7:00 am Bread Publix honey wheat 1 slice
7:00 am Jelly (on bread) Smucker's strawberry jam 1 teaspoon
7:00 am Sugar (on cereal) White granulated 2 teaspoons
8:30 am Gum Extra Winterfresh 1 piece
10:00 am Lollipop Orange flavored no brand 1 small

In the column labeled "Description" please list the brand name and give a product
description or include the product label or recipe whenever possible. Tell how the food
was cooked (fried, baked, etc). If your child ate away from home, list the name of the
restaurant or food shop. If your child consumes candy or gum, indicate what kind was
consumed (Hershey's Kiss, Extra Winterfresh, etc.). Be sure to include information
about things that were added to the food before it was eaten, like margarine, salt, sugar,
milk, etc. Please refer to the example above.









6. In the column labeled "Amount Consumed" please list the amount of each food
and beverage your child consumed. Tell how many cups, ounces (oz), teaspoons
(tsp), tablespoons (tbsp) your child ate or the weight or number of portions or
pieces your child ate.

7. A sample food diary is included to help you.
Sample:


Foods,
Beverages or
Supplements
Consumed
List each food
or beverage
your child
consumed. List
only one item
per line.


Description
List the brand name and
product description or
include the product label or
recipe for everything your
child ate. Tell how the food
was cooked (fried, baked,
etc). If your child ate away
from home, list the name of
the restaurant or food shop.
Be sure to include
information about things
that were added to the food
before they were eaten, like
margarine, salt, sugar, milk,
etc.


Amount Consumed
List the amount of each
food or beverage your
child consumed. Tell how
many cups, ounces (oz),
teaspoons (tsp),
tablespoons (tbsp) your
child ate or the weight or
number of portions or
pieces your child ate.


7:30 am Corn Flakes Kellogg's brand 1 cup
7:30 am Milk 2% 1/2 cup
7:30 am Banana, Small 5 inches
11:45 am Turkey Baked 2 oz
11:45 am Bread Whole wheat, toasted 2 slices
11:45 am Mayonnaise Hellmann's Light 1 tsp
11:45 am Tomato 2 slices
12 noon Apple With skin 1 medium
12 noon Pepsi Pepsi, regular 12 oz can
3:15 pm Ice cream Albertson's, chocolate 1 cup
6:30 pm Chicken Breast Grilled, no skin 3 oz.
6:30 pm Green beans Canned, prepared with 1 12 cup
tbsp. butter and 1 tsp. salt
6:30 pm Rice White, Boiled 1 cup
7:10 pm Candy Hershey's Kisses 5 pieces
8:00 pm Apple pie Store bought, bakery 1/5 pie
9:00 pm Children's Flintstone's Brand 1
multivitamin


1 cup = 8 fluid ounces (8 fl. oz.) = 237 ml
3 teaspoons = 1 tablespoon
4 tablespoons = cup
1 oz = 28 g (grams)


Time
Consumed









Estimating Portion Sizes


3 ounces of meat, poultry, or fish
is about the size and thickness of
a deck of playing cards


A medium-size piece of fruit
(e.g., apple or peach) is about
the size of a tennis ball


12 cup of ice cream, frozen yogurt,
yogurt, or cottage cheese is about
the size of a tennis ball


1 cup of mashed potatoes or
broccoli is about the size of your


1 teaspoon of butter, margarine,
or peanut butter is about the size
of the tip of your thumb


1 ounce of nuts or small candies
is about one handful


Ie091~ _


Adapted from: Southern Illinois University Carbondale Wellness Center Nutrition
Program 3-Day Recall. 2002. http://www.siu.edu/-shp/Acrobat2002/Recall.PDF




















APPENDIX F
YOUTH/ADOLESCENT QUESTIONNAIRE (YAQ)




PAGE ONE EATIG SURVEY -9S-1 HAVARD MEDICAL SCH

MARKING INSTRUCTIONS TheRIGHTway 0
to mark your
Use a NO. 2 PENCIL only, answer!
Do not use ink or ballpoint pen,
Darken in the circle completely. The WRONG way 0Q(
Erase cleanly any marks you wish to change. to markyour
Do not make any stray marks on this form. answers!


1. What is yur AGE?
OLass lan9 013
09 014
01o 015
Onil Oi
012 017
018 or older


Questionnaire refers to what you ate over the past year.


5. Do you nowtake vitamins like Fintstones, One-A-Day, etc.l?
ONo OYes -- Ify) o)How nny 02orless
vitmim pill do 03- 5
+ youtaeawmeek? 0 -9
0lOormore


6 How many teaspoons of sugr do
you ADD to your beverage or food
.ach day?
ONoneless tIan 1 teaspoon per day
01 2 teaspoons per day
03 -4 teaspoons per day
05 or more teaspoons per day


a Where do you usually eat breakfast?

OAthome
OAtsdhool
ODodt eat breakfast
OOer


b) For how 00 1 years
m VanVy-yea 02-4
h= you 05-9
5aMP 0 O10+ ears


7. Which nold brekfast oeral do you
usualy eat?


0 Never eat cold breakfast cereal



9. How many times ech week (including
weekdays and weeknds) do you usually eat
brlf omar d awa from home?
0 Never or almosinever
01 2 times per week
03 -4 times per week
05 or mere limes per week


Reprinted with permission of Helaine Rockett, Channing Laboratory, Boston, MA,
nhhrh@channing.harvard.edu, phone: 617-525-4207


2 Are you:
OMale
O Female


SIS




il@

~ ta


S1_
SI


C.





U 6


















S10. How manytimes each week linduding
weekdays and weekends) do you usually eat
S lunch orenared away from home?
- 0 Never or almost never
S 0 1 2 limes per week
M 03 -4 imesperweek
S 0 5 or more times per week


- 12 How many times each week weekdays and
weekends) do you usually eat dinner
S nrlared away from home?
M 0 Never or almost never
- 01 2 times per week
S 0 3 4 times per week
M 05 or orre times per week


How often do you have dinner that is ready
made, like frozen dinners, Spaghetti-O's,
microwave meals, etc.
0 Never/less than once per month
S1 2 times per week
0 3 4 times per week
05 or more times per week


16. How often do you eat food that is fried at
home, like fried chicken?

0 Never/less ban once per week
01 3 limes per week
04 6 limes per week
0 Daily


11. How many times each week do you usually
eat afte-school snacks or foods prepared
away from home?
ONever or almost never
01 2 limes per week
03 4 limes per week
05 or more times per week


13. How many times per week do you prepare
dinner for yourself (andlor others in your
house]?
0 Never or almost never
0 Less than once per week
01 -2 limes per week
03 4 limes per week
05 or more times per week


15. How many times each week (including
weekdays and weekends) do you eat late
night snacks preoared away from home?
0 Never/less than once per month
01 2 times per week
03 -4 limes per week
05 or more times per week


17. How often do you eat friedfood away from
home (like french fries, chicken nuggets)?

ONever/ess than once per week
01 3 times per week
04 6 times per week
O Daily


DIETARY INTAKE

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PAGE TIREE Ouesonnak r rNfers to what Tou ate over the ast year. HARVARD MEDICAL


BEVERAGES

18. Diet soda (1 can or glass)
ONeverless than 1 per month
01 3 cans per month
01 can per week
02 6 cans per week
01 can per day
02 or more cans per day


21. Iced Tea sweetened
(1 glass, can or bottle)
ONeverAess than 1 per month
01 3 glasses per month
01 4 glasses per week
05 6 glasses per week
01 or more glasses per day


24. Beer (1 glass,
bottle or can)
ONever/ess than 1 per month
01 3 cans per month
01 can per week
02 or more cans per week


FILL OUT ONE BUBBLE FOR EACH FOOD ITEM


19. Soda not diet
(1 can or glass)
ONeverAess than 1 per month
01 3 cans per month
01 can per week
02 6 cans per week
01 can per day
02 or more cans per day


22. Tea (1 cup)
ONeverness than 1 per month
01 3 cups per month
01 2 cups per week
03 6 cups per week
01 or more cups per day



25. Wine or wine coolers
(1 glass)
ONeverAess Ihan 1 per month
01 3 glasses per month
01 glass per week
02 or more glasses per week


20. Hawaiian Punch, lemonade,
Koolaid or other non-carbonated
fruit drink (1 gkass)
0 NeverAess than 1 per month
01 -3 glasses per month
01 glass per week
02 -4 glasses per week
05 6 glasses per week
01 glass per day
02 or more glasses per day


23. Coffee not decaf. (1 cup
0 Neverless than 1 per month
01 -3 cups per month
0 1 2 cups per week
03 -6 cups per week
0 1 or more cups per day



26 Liquor, like vodka or rum
(1 drink or shot)
ONeverless than 1 per month
01 3 drinks per monih
01 drink per week
02 or more drinks per week


DAIRY PRODUCTS


27. What TYPE of milk do
you usually drink?
OWhole milk
02% milk
01%milk
OSkimInontat milk
0 Dort know
F,,% .i,. -l


28. Milk Iglass or with cereal)
ONeverAess than 1 per month
01 glass per week or less
02 6 glasses per week
01 glass per day
02 3 glasses per day
04+glasses per day


29. Chocolate milk (glass)
O Never/less han 1 per month
0 1 3 glasses per month
01 glass per week
02 6 glasses per week
0 1 -2 glasses per day
03 or more glasses per day


ii. .--r-l i-~-l- I~i.---~1L;rl ~I--: 'li -iY-:l-.l~raY-PI*Yi- .T1~-i;F' ~II Itl-C--.~*r~.~r- l.r' r- I-~il'--':
















S30. Instant Breakfast Drink 31. Whipped cream 32. Yogurt (1 cup) Not frozen
- (1 padceti ONeverIess than 1 per month ONever/less than 1 per month
- ONever/less than 1 per month 01 3 times per month 01 3 cups per month
i 01 3 times per month Once per week 0 1 cup per week
- OOnce per week 02 4 times per week 02 6 cups per week
m 02 -4 times per week 05 or more times per week 01 cup per day
- 05 or more times per week 02 or more cups per day

S33. Cottage or ricotta cheese 34. Cheese (1 slice) 35. Cream cheese
m ONeverAess than 1 per month 0 Never/less than 1 per month ONeveriless than 1 per month
M 01 3 times per month 01 3 slices per month 01 3 times per month
- OOnce per week 01 slice per week 0 Once per week
- 02 or more times per week 02 6 slices per week 02 or more times per week
S0 1 since per day
- 02 or more slices per day


36. What TYPE of yogurt,
cottage cheese & dairy
products besided milk do
- you use mostly?

- ONontat
- OLowfat
- ORegular
S 0 Don'taknow
m


37. Butter (1 pat) 38. Margarine (I patty NOT butter
NOT margarine


ONeverdess than 1 per month
01 3 pats per month
O1 pat per week
02 6 pats per week
O1 pat per day
02- 4 pats per day
05 or more pats per day


ONever/less than 1 per month
01 3 pats per month
01 pat per week
02 6 pats per week
01 pat per day
02 -4 patsper day
0 5 or more pats per day


39. What FORM and BRAND of 40. What TYPE of oil does
margarine des your family your family use at home?
I usually use? OCanala oil
- ONone I WHAT SPECIFIC BRANDAIM TYPE Corn oil
S O Stick LK LPKE RKAY CON OIL SPADOL O Safflower oil
- OTub Oliveoil
- OSqueeze (liquid) OVegetable oil
- ODon'tknow


Lam blnk l you donl Lnw.


- MAIN DISHES

- 41. Cheeseburger (1)
i ONever/ess than 1
S 1 3 per month
- 0 One per week
- 02 4 per week
- 05 or more per wel
SE


per month



k


42. Hamburger 11)
ONeverAess than 1 per month
S1 3 per month
O One per week
02 4 per week
05 or more per week


43. Pizza (2 slices)
0 Never/ess than 1 per month
01 3 tmes per month
OOnce per week
02 4 times per week
05 or more times per week


- ...,.... ,*~.,,a-.n--~-,-. v~--, c-.,a-r4A. *.r4~,. ,...r4.r44,,44...-4 .,-. -40..--]


Tacos/burritos (1)
ONeverAess than 1 per month
01 -3 per month
OOne per week
02 4 per week
05 or more per week


45. Which taco filling do you
usually have:
0 Beef & beans
OBeef
O Chicken
0 Beans


46. Chicken nuggets (I1
0 Never/less than 1 per month
S1 3 times per month
OOnce per week
02 4 times per week
0 5 or more times per week


ass - _. ... .. .. T -1 .-- -- ,'


144



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47. Hot dogs (1) 48. Peanut butter sandwich 11) 49. Chicken or turkey sandwich III
ONeverAess than 1 per month (plain or with jlly, uff, etc.) 0 Neverless than 1 per month
01 3 per month ONeverless than 1 per month 01 3 per month
OOne per week 01 3 per month OOne per week
02 4 per week OOne per week 0 2 or more per week
05 or more per week 02- 4 per week
05 or more per week

50 Roast beef or ham 51. Salami, bologna, or other 52. Tuna sandwich ( 1
sandwich (1) deli meat sandwich (1) 0 Never/less tan 1 per month
O Neverless than 1 per month 0 NeverAess than 1 per month 01 3 per month
Ol 3 per month 01 3 per month OOne per week
0 One per week 0 One per week 02 or more per week
02 or more per week 02 or more per week


53. Chicken or turkey as 54. Fish sticks, fish cakes or fish 55. Fresh fish as main dish 11 serving)
main dish 11 sorvng) sandwich (1 serving) O Neverless than 1 per month
ONever/tess than 1 per month ONeverAess than 1 per month 01 3 times per month
01 3 times per month 01 3 times per month OOnce perweek
OOnce perweek OOnce per week 02 4 times per week
02 4 times per week 02 or more times per week 05 or more times per week
05 or more limes per week


56. Beef (steak, roast) or lamb 57. Pork or ham as main dish 58 Meatballs or meatloaf (1 serving)
as main dish (1 serving) (1 serving)


ONeverless than 1 per month
01 3 times per month
OOnce per week
02 -4 times per week
05 or more times per week


59. Lasagnalbaked ziti
(1 serving)
ONever/less than 1 per month
01 3 times per month
OOnoe per week
02 or more times per week



62. Eggs I11
ONever/less than 1 per month
01 3 eggs per month
OOne egg per week
02 4 eggs per week
Os or more eggs per week


ONeverAess lhan 1 per month
01 3 times per month
0 Once per week
02 -4 times per week
05 or more times per week


60. Macaroni and cheese
(1 serving)
0 NeverAess than 1 per month
01 3 times per month
0 Once per week
02 or more limes per week


%lJ mineess laI t per IIImoIIUI
01 3 times per month
OOnce per week
02 4 times per week
05 or more times per week



61. Spaghetti with tomato sauce
(1 serving
0 Never/less than 1 per month
01 3 times per month
0 Once per week
02 -4 times per week
05 or more limes per week


63. Liver: beef. calf, chicken 64. Shrimp, lobster, scallops
or pork (1 serving) (1 serving


ONeverAess than 1 per month
OLess than once per month
OOnce per month
02 -3 times per month
0 Once per week or more


ONever/less than 1 per month
01 3 times per month
0 Once per week
02 or more times per week

















65 French toast 12 slices)
ONeverless than 1 per month
01 3 times per month
OOnce per week
02 or more limes per week


66. Grilled cheese (1)
ONever/less than 1 per month
01 3 limes per month
OOnce per week
02 or more times per week


67. Eggrolls 11)
0 Never/less than 1 permonh
01 3 times per month
0 Once per week
02 or more times per week


MISCELLANEOUS FOODS


68. Brown gravy
ONeverfess than 1 per month
OOnce per week or less
02 -6 times per week
OOnce per day
02 or more limes per day



71. Cream milk) soups or
chowder 11 bowl)
ONeveri/ess than 1 per month
01 3 bowls per month
01 bowl per week
02 -6 bowls per week
0 1 or more bowls per day



74. Salad dressing (not
low calorie)
ONeverless than 1 per month
01 3 limes per month
OOnce per week
02 6 times per week
OOnoe or more per day



77. When you have chicken or
turkey, do you eat the skin?
OYes
ONo
0 Sometimes


69. Ketchup
ONever/less than 1 per month
01 3 times per month
0 Once per week
02 4 limes per week
05 or more times per week



72. Mayonnaise
ONeverless than 1 per month
01 3 times per month
0 Once per week
02 6 limes per week
OOnce per day


75. Salsa
ONever/less than 1 per month
01 3 limes per month
OOnce per week
02 6 limes per week
OOnce or more per day


70. Clear soup Iwith rice,
noodles, vegetables) I bowl
O Never/less than 1 per month
0 1 3 bowls per month
01 bowl per week
02 or more bowls per week



73. Low calorielfat salad dressing
0 Never/less than 1 per month
01 3 times per month
O Once per week
02 6 times perweek
OOnce or more per day


76 How much Fat on your
beef, pork, or lamb do
you eat?
O Eat all
O Eat some
O Eat none
0 Don't eat meat


'''~';'' "~"~""*~' ~''''~"~'

















BREADS & CEREALS

78 Cold breakfast real
(1 bowl)
0 Never/less than 1 per month
01 3 bowls per month
0 1 bowl per week
0 2 -4 bowls per week
0 5 -7 bowls per week
02 or more bowls per day



81. Dark bread 11 slice)
0 Never/less than 1 per month
01 slice per week or less
0 2 -4 slices per week
0 5 -7 slices per week
0 2 3 slices per day
04+ slices per day



84. Cornbread (1 square)
0 Never/less than 1 per month
01 3 times per month
0 Once per week
02 4 times per week
05 or more per week



87. Noodles, pasta
0 Never/less than 1 per month
01 3 times per month
0 Once per week
02 -4 times per week
05 or more times per week




90. Pancakes (2) or
waffles (11
0 Never/less than 1 per month
01 3 limes per month
0 Once per week
02 or more times per week


79. Hot breakfast cereal, like
oatmeal, grits (I bowl
0 Never/less than 1 per month
01 3 bowts per month
01 bowl per week
02 4 bowls per week
05 7 bowls per week
02 or more bowls per day



82 English muffins or
bagels (1)
0 Never/less than 1 per month
0 1 3 per month
01 per week
02 -4 per week
05 or more per week



85. Biscuitlroll (1)
0 Never/less than 1 per month
01 3 per month
01 per week
02 4 per week
05 or more per week



88. Tortilla no filling (1)
0 Never/less than 1 per month
01 3 per month
01 per week
02 -4 per week
05 or more per week


91. French fries Ilarge order)
0 Never/less than 1 per month
0 1 3 orders per month
01 order per week
02 4 orders per week
05 or more orders per week


80. White bread, pita broad,
or toast II slice)
O Neveress than 1 per month
01 slice per week or less
0 2 -4 slices per week
05 7 slices per week
02 3 slices per day
04+ slices per day



83. Muffin 11)
0 Never/ess than 1 per month
0 1 3 muffins per month
0 1 muffin per week
0 2 4 muffins per week
05 or more muffins per week


86 Rice
0 Never/ess than 1 per month
01 3 times per month
0 Once per week
0 2 4 times per week
0 5 or more times per week



89. Other grains, like kasha,
couscous, bulgur
0 NeverAess than 1 per month
01 3 times per month
OOnoe per week
02 or more times perweek


92. Potatoes baked, boiled, mashed
0 Neverless than 1 per month
01 3 times per month
0 Once per week
0 2 4 limes per week
05 or more times per week















FRUITS & VEGETABLES


93. Raisins (small pack)
0 Never/less han 1 per month
01 3 limes per month
0 1 per week
S2 4 limes per week
05 or more times per week



96. Cantaloupe, melons (1/4
melon)
O Never/less than 1 per month
01 3 limes per month
01 per week
02 or more limes per week



99. Oranges 111, grapefruit 11/21
0 Never/less than 1 per month
01 3 per monlh
S1 per week
02 6 per week
01 or more per day


102. Orange juice (1 glass
ONever/less than 1 per month
01 3 glasses per month
01 glass per week
02 6 glasses per week
01 glass per day
02 or more glasses per day


94. Grapes (bunch)
ONever/ess than 1 per month
0 1 3 times per month
O Once per week
02 -4 times per week
05 or more tmes per week



97. Apples (11 or applesauce
ONeveless than 1 per month
01 3 per month
01 per week
02 6 per week
01 or more per day


100. Strawberries


103.


95. Bananas (1)
O Neveriless than 1 per month
0 1 3 per month
01 per week
02 -4 per week
05 or more per week



98. Pears I1)
ONeverAess than 1 per month
0 1 3 per month
01 per week
02 6 per week
01 or more per day



101. Peaches, plus, apricots 11)


ONever/less than 1 per month ONeverless than 1 per month
01 3 times per month 0 1 3 per month
O Once per week 1 per week
02 or more times per week 02 or more per week





Apple juice and other fruit 104.Tomatoes (1)
iuloes l glass) ONever/less than 1 per month
ONeverAess than 1 per month 01 3 per month
01 3 glasses per month 01 per week
01 glass per week 02 6 per week
02 6 glasses per week 01 or more per day
01 glass per day
02 or more glasses per day


105.Tomato/spaghetti sauce
ONever/less than 1 per month
01 3 limes per month
0 Once per week
02 4 limes per week
05 or more times per week


106. Tofu
ONever/ess than 1 per month
0 1 3 times per month
0 Once per week
02 -4 'lmes per week
05 or more times per week


107. String beans
ONeverless than 1 per month
01 3 times per month
OOnce per week
02 -4 limes per week
05 or more times per week













108. Beans/lntils/soybeans 1
ONever/less than 1 per month
OOnce per week or less
02 6 times per week
O Once per day


111. Com
ONever/less than 1 per month
01 3 times per month
0 Once per week
02- 4 times per week
05 or more times per week


114. Spinach
0 Never/less than 1 per month
01 3 limes per month
0 Once a week
02 -4 times per week
05 or more times per week


09. Broccoli


ONever/less than 1 per month
01 3 times per month
OOnce per week
02 4 limes per week
05 or more times per week



112. Peasor Erma beans
ONever/ess than 1 per month
01 3 times per month
0 Once per week
02 4 times per week
05 or more times per week


115. Greens/kale
ONever/less than 1 per month
01 3 times per month
0 Once per week
02 4 times per week
05 or more times per week


110. Beats [not greens)


ONever/less than 1 per month
OOnce per week or less
02 or more times per week


113. Mixed vegetables
ONever/less than 1 per month
01 3 times per month
0 Once per week
02 4 limes per week
05 or more times per week


116. Greenred peppers
ONever/less than 1 per month
01 3 limes per month
OOnce a week
02 4 times per week
05 or more times per week


117. Yams/sweet potatoes (1)
0 Never/less than 1 per month
01 3 times per month
0Once a week
02 4 times per week
05 or more times per week


118. Zucchini, summer squash, 119. Carrots, cooked
eggplant 0Never/less tha
ONever/less than 1 per month 01 3 times per
01 3 limes per month Once per weet
SOnce per week 02 4 times per
02 4 limes per week 05 or more time
05 or more times per week


n 1 per month
month

week
s per week


120. Carrts, raw
ONever/less than 1 per month
01 3 times per month
OOnce per week
02 4 limes per week
05 or more times per week


121. Celery
0 Never/less than 1 per month
01 3 limes per month
OOnce per week
02 4 times per week
05 or more times per week


122. Lettuce/tossed salad
0 Never/less than 1 per month
01 3 times per month
0 Once per week
02- 6 limes per week
OOne or more per day


123. Coleslaw
0 Never/less than 1 per month
01 3 times per month
0 Once per week
02 or more times per week


124. Potato salad
0 Never/less than 1 per month
01 3 times per month
OOnce per week
02 or more times per week


1 ;-.ll~r~.-1:::": ~-i'r "i~--- --r:-~ L-r--l;_-i~-ill-i^1Ll(?ill liL -i*lU iS'--l? L--.ri:;l Il-~.ill~i ;In~.i~:-:~;P:i-il' :U~: -li: II



























SNACK FOODS/DESSERTS


125. Fill in the number of snacks (ood or drinks) eaten on school
days and weekends/vacation days.


School Day
I I i


Snacks


VacalonfWooe nd Dayc


126. Potato chips (1 small bag) 127. Corn chips/Doritos 128. Nachos with cheese (1 serving)
ONever/less than 1 per month (small bag) 0NeverAess than 1 per month
01 3 small bags per month ONever/less than 1 per month 01 3 times per month
0 One small bag per week 01 3 small bags per month O Oce per week
02 6 small bags per week OOne small bag per week 02 or more times per week
01 or more small bags per day 02 6 small bags per week
01 or more small bags per day


129. Popcorn (1 small bag 13
O Never/less than 1 per month
01 3 small bags per month
01 -4 small bags per week
05 or more small bags per week


132. Fun fruit or fruit rollups
(1 pack)


0 Never/less than 1 per month
01 3 packs per month
01 4 packs per week
05 or more packs per week


0. Pretzels 11 small bag) 13
ONever/less than 1 per month
01 3 small bags per month
01 small bags per week
02 or more small bags per week


133. Graham crackers


ONever/less than 1 per month
01 3 times per month
01 4 limes per week
05 or more times per week


1. Peanuts, nuts (1 small bag)
ONeverless than 1 per month
01 3 small bags per month
01 4 small bags per week
05 or more small bags per week


134. Crackers, like saltines or
wheat thins


O NeverAess than 1 per month
O 1 3 limes per month
0 1 4 limes per week
05 or more times per week


'` '-`-"'" "~ '-'`~U~L~L~L~-e














135. Poptarts (1)
ONever/less than 1 per month
01 3 poptarts per month
01 6 poptarts per week
01 or more poptarts per day


138 Danish, sweetrolls,
pastry (1)
ONever/less than 1 per month
0 1 3 per month
01 per week
02 -4 per week
0 5 or more per week


141. Brownies (1)
ONever/less than 1 per month
01 3 per month
0 1 per week
02 -4 per week
05 or more per week


136. Cake (1 slice)
ONeveriless than 1 per month
O 1 3 slices per month
01 slice per week
02 or more slices per week


139. Donuts (1)
O Never/less than 1 per month
01 3 donuts per month
01 donut per week
02 6 donuts per week
01 or more donuls per day



142 Pie 0I slice)
0 NeverAess than 1 per month
0 1 3 slices per month
0 1 slice per week
02 or more slices per week


137. Snack cakes, Twinkies (1 package)
O Neverless than 1 per month
0 1 3 per month
0 Once per week
02 6 per week
0 1 or more per day


140. Cookies (1)
ONever/less than 1 per month
01 3 cookies per month
0 1 cookie per week
02 6 cookies per week
01 3 cookies per day
04 or more cookies per day


143. Chocolate (1 bar or packet)
like Hershey's or M & Ms
0 Never/ess than 1 per month
01 3 per month
01 per week
02 6 per week
0 1 or more per day


144. Other candy bars (Milky 145. Other candy without
Way, Snickers) chocolate (Skittls)
......... ...... pack)


J NeBverliess Ian 1 per monu i
01 3 candy bars per month
01 candy bar per week
02 4 candy bars per week
05 or more candy bars per week


147. Pudding
ONever/less than 1 per month
01 3 times per month
0 Once per week
02 -4 times per week
n0V C'- s k


ONever/less than 1 per month
01 3 times per month
O Once per week
02 4 limes per week
05 or more limes per week


148, Frozen yogurt
ONever/less than 1 per month
01 3 times per month
0 Once per week
02 -4 times per week
05 Qi k


146. Jello
O Never/less than 1 per month
01 3 times per month
OOnce per week
02 4 times per week
05 or more times per week


149. Ice cream
0 Never/less than 1 per month
01 3 times per month
OOnce per week
02 4 tmes per week
n0r ti k,


150. Milkshake or frappe (1)
ONever/less than 1 per month
01 3 per month
01 per week
02 or more per week


151. Popsides
O Never/less than 1 per month
01 3 popsides per month
01 popsicle per week
02 -4 popsides per week
05 or more popsices per week


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r a more me per wee or more mes per wee or m e









152. Please list any other foods that you usually eat at least once nar week that are not listed (for
example, coconut, hummus, falafel, chili, plantains, magoes, etc...)
FOODS HOW OFTEN?
a) _a)

c) c)
03iai~ 03~jl I~II '''''~~~~~


THANK YOU

FOR

COMPLETING

THIS

SURVEY!















LIST OF REFERENCES


1. Anliker JA, Bartoshuk L, Ferris AM, Hooks LD. (1991) Children's food
preferences and genetic sensitivity to the bitter taste of 6-n-propylthiouracil
(PROP). Am J Clin Nutr. 54: 316-320.

2. Duffy VB, Peterson JM, Dinehart ME, Bartoshuk LM. (2003) Genetic and
environmental variation in taste: Associations with sweet intensity, preference,
and intake. Top in Clin Nutr 18: 209-220.

3. Kaminski LC, Henderson SA, Drewnowski A. (2000) Young women's food
preferences and taste responsiveness to 6-n-propylthiouracil (PROP). Physiol
Behav 68: 691-697.

4. Duffy VB, Davidson AC, Kidd JR, Kidd KK, Speed WC, Pakstis AJ, Reed DR,
Snyder DJ, Bartoshuk LM. (2004) Bitter receptor gene (TAS2R38), 6-n-
propylthiouracil (PROP) bitterness and alcohol intake. Alcohol Clin Exp Res 28:
1629-1637.

5. Looy H, Weingarten HP. (1992) Facial expressions and genetic sensitivity to 6-n-
propylthiouracil predict hedonic response to sweet. Physiol Behav 52: 75-82.

6. Burt BA, Eklund SA, Morgan KJ, Larkin FE, Guire KE, Brown LO, Weintraub
JA. (1988) The effects of sugars intake and frequency of ingestion on dental
caries increment in a three-year longitudinal study. J Dent Res 67: 1422-1429.

7. Duffy VB, Bartoshuk LM. (2000) Food acceptance and genetic variation in taste.
J Am Diet Assoc 100: 647-655.

8. Drewnowski A, Henderson SA, Hann CS, Berg WA, Ruffin MT. (2000) Genetic
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BIOGRAPHICAL SKETCH

Claire Allinda Lewis Edgemon was born in Houston, Texas, on June 12, 1970. In

1992, she graduated with a Bachelor of Arts degree in biology from Austin College in

Sherman, Texas. She spent 2 years teaching English at a community center in Senegal,

West Africa. In 1999, she graduated from Golden Gate Baptist Theological Seminary in

Mill Valley, California, with a Master of Divinity degree. After living in Djibouti, East

Africa, for 2 years where she worked for a relief and development agency, she pursued

her interest in nutrition and dietetics and graduated from the University of Florida with a

Bachelor of Science degree in food science and human nutrition, specializing in dietetics.

She received the American Dietetics Association's Outstanding Dietetics Student Award

for a Didactic Program in Dietetics in 2003. That same year she entered the University of

Florida's combined Master of Science-Dietetic Internship program. Upon completion of

her Master of Science degree, she will take the national examination for registered

dietitians to complete the last step in earning the Registered Dietitian credential.