Food insecurity is a public health concern that refers to limited or uncertain access to adequate nutritious foods (Seligman, Laraia, & Kushel, 2009). It is considered to be a socioeconomic problem, as families with a low income exhibit greater susceptibility (Garasky & Stewart, 2007). Studies have established that low-income families and those with single parent are more prone to food insecurity (Garasky & Stewart, 2007). In the United State, approximately half of all poor families and one out of seven non-households, show some state of food-insecurity (Bowen, Bowen, & Barman-Adhikari, 2016). This problem results in decreased variety and quantity of food, and is accompanied by a decline of nutritional quality of the diet (Gary Bickel, Nord, Price, Hamilton, & Cook, 2000). Individuals with economic instability resort to a diet high in carbohydrates and lipids, both of which have adverse effects on health (Mohamadpour, Sharif, & Keysami, 2012). Studies have shown that individuals with food insecurity are more vulnerable to obesity, diabetes, inflammation, and heart disease (Gowda, Hadley, & Aiello, 2012). Furthermore, children in food-insecure families are more susceptible to psychosocial, cognitive, and behavioral problems (Alaimo, Olson, & Frongillo, 2001; Howard, 2011) as well as, asthma (Kirkpatrick, McIntyre, & Potestio, 2010), nutrients(Kaiser et al., 2003) and growth-related deficiencies (Hernandez & Jacknowitz, 2009).
Oral health is connected to food insecurity, as the gums can deteriorate from insufficient (Huang, Matta Oshima, & Kim, 2010) food and lack of certain nutrients (Santin, Martins, Pordeus, Fraiz, & Ferreira, 2014). In particular, periodontal disease is associated with a lack of vitamin D and calcium (Goodman, Martinez, & Chavez, 1991; Krall, 2001); scorbutic gingivitis is related to with a deficiency of vitamin C (Chapple, Milward, & Dietrich, 2007; Marsh, 1994; Nishida et al., 2000). Women in the United States are more likely to live in impoverishment than men, which raises their risk of being food insecure. Sixty one percent of poor adult populations in the United States are women (Olson, 2005). Role of women in feeding their families make them vulnerable to the food-insecurity consequences. Also, adequate evidence supports the argument that women generally have a positive effect on household food security and nutrition (Quisumbing, Brown, Feldstein, Haddad, & Peña, 1995). Women normally spend a high percentage of their income on food and health care for children and general household consumption (Guyer, 1988). As income is a critical factor in the ability of a family to obtain sufficient and nutritious food, poverty increases food insecurity. Thus, poverty and gender disparities together pose a greater threat than poverty alone (Quisumbing et al., 1995). To date no study has examined the effect of food insecurity on the prevalence of periodontal disease in low-income women.
Thus, The aim of present study was to discern relationships between food security status on prevalence and severity of periodontal disease in low-income women. In other words, how food insecurity affects the prevalence and severity of periodontal disease? Methods Participant: Participants will be 220 women with an income of less than 250% of Federal Poverty Level, ages 18-50, and who have received a dental treatment within the last 5 years. The women will be recruited from housing units and recreation centers. Exclusion criteria are: pregnancy, lactation, smoking, systemic illness that could affect participation in the study. The risks and benefits of the study will be explained, informed consent will be obtained. A 20$ gift card will be provided to the participants who complete the demographics, Food Insecurity Survey Module, and periodontal examination. Design: Participants will provide written consent, and the 10-minute U.S. Adult Food Security Survey Module and a demographic questionnaire will be obtained. After completion of the survey, study participants will be undergo a periodontal examination. The Food insecurity scale will determine the level of food insecurity for the past 12 months. Household income will be defined as a categorical variable that demonstrates that the income to poverty ratio based on the U.S. Census measurement of poverty.
The income to poverty ratio will be computed by dividing household income (per number of household members) by the federal poverty threshold. Based on the Census Bureau, a household income > 100%, but < 125% of poverty, will be recognized “near poverty.” Households with incomes ≤ 100% are considered “in poverty,” and household incomes < 50% of their poverty threshold will be categorized as “severe” or “deep poverty.” U.S. Household Food Security Survey Module: Food security status will be evaluated by the 10-item validated U.S. Household Food Security Survey Module. Responses of “yes,” “often,” “sometimes,” “almost every month,” and “some months but not every month” are coded as affirmative. The sum of affirmative responses to a specified set of items is referred to as the household’s raw score on the scale comprising those items. Raw scores 6-10 indicate very low food security, 3-5 scores denote low food security, 1-2 categorized as marginal food insecurity, and zero demonstrate high food security among adults. (G Bickel, Nord, & Hamilton, 2006). Households with high or marginal food security will be classified as food secure. Those with low or very low food security will be classified as food insecure. Clinical examination Periodontal examination will be performed by a trained dental hygienist. The periodontal status of all teeth, excluding third molars, will be measured using probing pocket depth (PPD), clinical attachment loss (CAL), and Bleeding on Probing (BOP) (ref). Sterile dental mirrors and WilliamsÕ periodontal probes will be used to measure PPD and CAL. PPD and CAL measurments will be assessed at six sites (mesio-facial, mid-facial, disto-facial, mesio-lingual, mid-lingual and disto- lingual) per tooth for all teeth, except third molars. The mean BOP will be estimated as a percentage number of bleeding gingival units regarding the total number of bleeding sites measured for each individual (Gerber, Tan, Balmer, Salvi, & Lang, 2009).
The percentage of the PDD and CAL of individuals will be estimated by dividing the number of sites meeting the criteria by the total number of unites measured. Total severity of periodontal disease will be specified using a Periodontal Severity Index (PSI) (Beltrán‐Aguilar, Eke, Thornton‐Evans, & Petersen, 2012). Mild periodontitis will be described as two or more teeth with a site of CAL ≥3 mm and two or more teeth with PPD ≥4 mm or one tooth with PPD ≥5 mm. Subjects with two or more sites with CAL ≥4 mm or with two or more sites with PPD ≥5 mm will be considered to have moderate periodontal disease. Participants with two or more teeth with sites of CAL ≥6 mm and one or more teeth with sites of PPD ≥5 mm reflectes severe periodontitis (Holtzman, Atchison, Macek, & Markovic, 2017). Statistical Analysis Bivariate analyses will be conducted using Chi-square tests to assess associations of demographic variables and periodontal disease with food insecurity. Multiple regressions will be used to assess the effect of food insecurity on the presence of periodontal disease, while control for oral health and socioeconomic status (Frequency of brushing, flossing, dental visits, time since last dental visit, drinking, income level). All analyses will be calculated using version 22.0 (Armonk, NY). All statistical tests will be two-sided. P-values