Artigos

INTRODUCTION
Inadequate food consumption is a recognized risk factor for the development of non-communicable chronic diseases, such as obesity, cardiovascular disease and type 2 diabetes1,2. Consequently, food consumption has become a focus of investigation in numerous epidemiological studies, with an emphasis on defining healthy and unhealthy food markers3-5. In Brazil, the Ministry of Health launched a Food-Based Dietary Guidelines for the Brazilian Population in 2014, which established recommendations for the consumption of fresh foods and traditional Brazilian cuisine while also advocating for the reduction of ultra-processed foods, snacks, sweetened drinks, and soft drinks6.
Although socioeconomic factors, particularly income, often influence food consumption, oral health conditions should also be considered in this context. These factors can significantly affect masticatory function, which in turn impact the food consumption of essential nutrients7 such as fiber8 and protein9, for example. In Brazil, the most prevalent oral diseases among adults from 35 to 44 years old are tooth decay (37,5%) and periodontal disease (19,4%)10-12. Other significant oral health issues with high prevalence among Brazilian population are tooth loss, lesions in the oral mucosa, and oropharyngeal neoplasms13.
There is a notable synergy between oral health and dietary intake. Studies indicate that individuals often experience difficulties in chewing hard foods such as fruits, raw vegetables, and meat, leading to a preference for cooked foods with softer textures14. These softer foods, although easier to chew, are often richer in calories and high in fat15,7. This preference is particularly observed in individuals with periodontal diseases, tooth loss, and those using dental prostheses, where long-term dietary adaptations may result in changes in nutritional status, potentially leading to malnutrition, regardless of age15.
Masticatory function, tooth decay and periodontal disease can influence how individuals assess their own oral health, especially when combined with sociodemographic factors such as income, education and frequency of dental visits16. Consequently, oral health status, as evaluated through self-assessment, emerges as an essential measure. Self-assessment offers a low-cost method to evaluate the oral health of individuals and populations, despite its limitations16. It reflects individuals’ perceptions of their health status and functional capacity, thereby contributing autonomously to lifelong satisfaction and well-being17. Additionally, self-assessment serves as a valuable health indicator, reflecting clinical conditions and other morbidity and mortality metrics16,17. Previous studies showed that self-perception of oral health is significantly associated with social factors18,16,19, indicating that poor self-perception is linked to low education, low income, poor housing conditions, and income inequality19-21.
From a public health perspective, the relevance of oral health and food consumption is significant, as both sciences exhibit a multidirectional synergy15,22. Oral infectious diseases (acute and chronic) and other diseases with oral manifestations impact the functional capacity to eat, affecting diet and nutritional status23. Similarly, nutrition and food consumption influence the integrity and development of the oral cavity, as well as the progression of oral diseases22,23. Therefore, studies evaluating the relationship between oral health and food consumption are particularly important. Thus, here we aimed to investigate the association between self-perceived oral health and indicators of healthy and unhealthy food consumption in Brazilian adults and older adults, using data from the last two editions of the National Health Survey (NHS).
METHODS
Study design and data source
This is a cross-sectional study conducted using data from the two editions of the NHS (2013 and 2019; PNS, acronym in Portuguese) carried out by the Brazilian Institute of Geography and Statistics (IBGE, acronym in Portuguese) and the Ministry of Health. The NHS aims to produce data related to access to and use of health services and the health conditions of the Brazilian population24-26. In both surveys’ editions, participants were eligible if they were aged 18 years or older (in 2013) or 15 years or older (in 2019), residing in urban and rural areas of the five geographical regions of the country (North, Northeast, Midwest, Southeast, and South). The dataset is publicly available at the IBGE’s website: https://www.ibge.gov.br/estatisticas/downloads-estatisticas.html.
The probabilistic sample of the target population in both editions of the NHS was obtained through clusters divided into three stages: (i) selection of primary sampling units, performed by simple random sampling, defined by the number of permanent private households; (ii) selection of households recruited from the first stage, and (iii) selection of one resident aged 18 years or older (in 2013) or 15 years or older (in 2019) from the sample household. To calculate the necessary sample size to estimate the parameters of interest at different levels of geographical disaggregation, aspects of estimating proportions with a 95% confidence level were considered. The effect of the sampling plan due to the sample having clusters at multiple stages, the number of households selected per primary sampling units, and the proportion of these households with individuals in the age range of interest for the survey were also considered in the sample size calculation24,25.
Data collection was conducted by IBGE, employing a structured questionnaire consisting of 20 blocks in 2013 and 26 blocks in 2019, covering information on work and social support, perception of health status, lifestyle, non-communicable chronic diseases, among others. Interviews were conducted in the 26 Brazilian states and the Federal District, resulting in specific numbers of interviewees in each federative unit. In the 2013 NHS, 62,986 interviews were conducted, and in the 2019 edition, the total number was 90,846, with 88,531 individuals who aged 18 years or older24,25,27. For the present analysis, only individuals aged 20 years or older were included. Thus, for the 2013 survey, 57,962 individuals were analyzed, and in 2019, a total of 86,510 individuals were included.
Food consumption
Food consumption indicators (study outcome) were extracted from the questions referring to food items available in the NHS datasets. In both editions, weekly food consumption was assessed through the following question: “On how many days of the week do you usually eat/drink______?” The food items included were: (i) beans; (ii) greens or vegetables (excluding potatoes, cassava, yams, or taro) such as lettuce, tomato, kale, carrot, chayote, eggplant, zucchini; (iii) fruits; (iv) milk (from animal sources – cow, goat, buffalo); (v) chicken/poultry meat; (vi) red meat (beef, pork, goat, sheep); (vii) soft drinks and sugar-sweetened beverages (such as boxed/canned juice or powdered drinks); (viii) sweets (filled cookies/crackers, chocolate, gelatin, candies); and (ix) substitution of main meals by snacks (sandwiches, savory pastries, pizza, hot dogs) (Table 1). The response options ranged from zero (never or less than once a week) to seven days a week.
For the present study, the food items were categorized into two groups: healthy (beans, raw and cooked vegetables, fruits, milk, and chicken)4,28 or unhealthy (red meat, soft drinks and sugar-sweetened beverages, sweets, and substitution of main meals with snacks)4,29. For analytical purposes, the healthy indicators were categorized based on the recommendation for a weekly consumption of at least five times a week (beans, raw and cooked vegetables, fruits, milk, and chicken). The unhealthy indicators items were categorized based on their recommended frequency of consumption. To prevent weight gain and reduce cardiometabolic risk, red meat, soft drinks, sugar-sweetened beverages, and sweets should ideally be consumed no more than four times per week4. These foods are energy-dense and high in saturated fats, sodium, added sugars, and trans fats29. Therefore, consumption of these items four or more times per week was defined as regular consumption. For the replacement of main meals by snacks, regular substitution was defined as one or more times per week4,30.
Self-perception of oral health
The main exposure variable was self-perception of oral health, obtained through the following question: “In general, how do you rate your oral health (teeth and gums)?” with the response options: very good, good, fair, poor, and very poor. Subsequently, the responses were grouped into three categories (very good/good, fair, poor/very poor)17,31-33.
Socioeconomic, demographic, and health characteristics
Socioeconomic, demographic, and health characteristics were included as potential confounding factors in the relationship between oral health and dietary consumption. The following variables were considered: geographic region (North, Northeast, Midwest, Southeast, and South), area of residence (urban and rural), sex (male and female), age group (20-39, 40-59, ?60 years old), skin color (white, brown, black, yellow, and indigenous), education level (obtained in completed years of formal education and subsequently categorized into no schooling (illiterate), incomplete primary education, complete primary education, complete secondary education, and complete higher education), per capita household income (divided into quintiles: ?1/4 of the minimum wage - MW, 1/4 to 1/2, 1/2 to <1, 2 to <5, and ?5 – in 2013: R$678,0034 and 2019: R$998,0035), last dental visit (up to 1 year, more than 1 to 3 years, more than 3 years, and never visited), smoking status (non-smoker, former smoker, and current smoker), alcohol consumption (never, less than once a month, and more than once a month), previous diagnosis of type 2 diabetes (yes, no), arterial hypertension diagnosis (yes, no) and cardiovascular disease - heart attack, angina and heart failure (yes, no).
Statistical analysis
The socioeconomic and demographic characteristics of both editions of the NHS were described using relative frequencies and their respective 95% confidence intervals. Associations between oral health and these characteristics were assessed using Pearson's chi-square test for heterogeneity, with a significance level of less than 5% and a corresponding 95% confidence interval.
The associations between the regular consumption of each food consumption indicator and oral health were evaluated using unadjusted and adjusted Poisson regression models. For the adjusted model, we developed a theoretical framework based on the study design (geographic region and area of residence), determinants of the exposure and outcomes (sex, age, skin color, educational level, and per capita household income), chronic disease (diabetes, hypertension, cardiovascular disease), health related-behaviors (smoking status, alcohol consumption, and last dental visit), the exposure of interest (self-perception of oral health), and outcomes (food consumption) (Figure 1). The results were presented as prevalence ratios and their respective 95% confidence intervals, with a significance level of 5%. Akaike’s information criteria (AIC) and Schwarz’s Bayesian information criteria (BIC) tests were performed to confirm the quality of the analyses in the adjustment model. All analyses were performed using Stata® 15.0 software36, considering the complex sampling design of the NHS.
Ethical aspects
The National Commission for Ethics in Research (CONEP, acronym in Portuguese) approved both editions of the NHS in June 2013 and August 2019, under protocol numbers 328.159 (2013) and 3.529.376 (2019). During the household interviews, all participants signed an Informed Consent Form, regarding ethical principles. As this study involved secondary data analysis, no additional ethical approval was required.

RESULTS
In both surveys, most participants were women, lived in urban areas, and nearly half resided in the Southeast region of the country. The proportion of participants aged 60 years or older increased from 19% in 2013 to 22.5% in 2019. About one-third of the participants had completed high school, and almost a quarter reported a per capita income of 2 to <5 MW. Regarding health-related behaviors, dental visits within the last year increased from 43.9% to 48.9%, smoking decreased from 15% to 12.7%, and alcohol consumption more than once a month increased from 26.6% to 30.1%. In terms of chronic diseases, hypertension prevalence increased from 23% to 26.8%, diabetes from 7.3% to 8.9%, and cardiovascular diseases prevalence increased from 4.3% to 5.5% (Table 2).
In 2013, most participants reported regular consumption of beans, raw and cooked vegetables, and milk (71.9%, 55.2%, and 50,5%, respectively), while only 42% reported consuming fruits regularly, and 13.7% chicken/poultry meat. The highest frequency of unhealthy indicators was for the regular consumption of red meat (50.5%) and the replacement of main meals with snacks (41.3%), followed by soft drinks and sugar-sweetened beverages (27.6%) and sweets (26.1%). In 2019, the regular consumption of beans (68.4%), and milk (45.6%) reduced, while chicken/poultry meat (17.5%) consumption increased. The regular consumption of fruits (45.6%) increased, and the consumption of raw and cooked vegetable remained stable. The replacement of main meals with snacks and the regular consumption of red meat (41.3%), sweets (18.7%) and soft drinks and sugar-sweetened beverages (24.7%) reduced (data not shown).
In 2013, the percentage of individuals who perceived their oral health as “very good/good” was 67.1%, while 26.9% reported it as “fair” and 6% as “poor/very poor”. In 2019, there was a slight improvement in the self-perception of oral health: 69.5% reported it as “very good/good”, 25.2% as “fair”, and 5.3% as “poor/very poor” (Table 3).
The adjusted associations between self-perception of oral health and the indicators of food consumption showed that in 2013, participants who self-perceived their oral health as “poor/very poor” had a lower prevalence of regular consumption of raw and cooked vegetables (adj PR= 0.92, 95% CI: 0.86;0.98), fruits (adj PR=0.82, 95% CI: 0.75;0.90), and milk (adj PR=0.86, 95% CI: 0.80;0.93) compared to those who perceived their oral health as “very good/good”. None of unhealthy indicators showed a significant association with self-perceived oral health (Figure 2 and Supplementary table 1).
In 2019, participants who perceived their oral health as “poor/very poor” had a lower prevalence of regular consumption of raw and cooked vegetables (adj PR= 0.83, 95% CI: 0.78;0.88), fruits (adj PR= 0.82, 95% CI: 0.76;0.88) and milk (adj PR= 0.87, 95% CI: 0.82;0.93), and a higher prevalence of consuming soft drinks and sugar-sweetened beverages (adj PR=1.13, 95% CI: 1.02;1.24), sweets (adj PR=1.15, 95% CI: 1.03;1.29), and substituting main meals with snacks (adj PR=1.18, 95% CI: 1.06;1.32), compared to those who perceived their oral health as “very good/good”. Individuals with “fair” self-perceived oral health had a lower prevalence of regular consumption of red meat (adj PR=0.95, 95% CI: 0.91;0.98) (Figure 2 and Supplementary table 1).

DISCUSSION
The present investigation revealed that adults and older adults who perceived their oral health as “poor/very poor” presented a lower prevalence of regular consumption of raw and cooked vegetables, fruits and milk in both editions of NHS. In a 6-year interval, despite the decrease in the prevalences of unhealthy food consumption indicators observed in the population, poor self-perception of oral health become associated with a higher prevalence of consuming soft drinks and sugar-sweetened beverages, and sweets, as well as replacing main meals with snacks. These findings were observed after adjustment for socioeconomic, demographic, chronic disease, and behavior confounders, as well as geographic region and area of residence to control for study design.
It is challenging to compare our findings with the current literature since most studies addressing self-perception of oral health associate it with other health outcomes. Dietary aspects are usually explored in terms of chewing difficulty rather than food consumption per se37,38. Previous studies in oral health have focused on tooth loss14,39,40 and functional dentition41,42, reporting findings consistent with our study. Individuals with tooth loss who experienced chewing difficulties tend to avoid harder foods (such as raw vegetables and meat), and preferred softer-textured foods that cause less discomfort15. Another study using the 2019 NHS data found that adults with poor self-perception of oral health were five times more likely to have chewing difficulties32. Similarly, Nakamura et al. (2019) reported that individuals with fewer teeth consumed less meat and vegetables than those with more teeth. Functional dentition also appeared to play a role on the association between oral health and food consumption, as the number of teeth present is positive associated with the consumption of fruits, vegetables, meat, fish, eggs, and other foods39. Silva & Oliveira (2018) had previously explored the social context factors associated to self-perception of oral health using data from the 2013 NHS. The authors observed that individuals with healthier eating habits (such as the consumption of salads, vegetables, and fruit juice), regardless of regular frequency, tended to have better oral health and belonged to the highest socioeconomic strata (A or B)18.
It is essential to recognize that self-perceived oral health provides a simple and direct method for capturing perceptions of overall health. This approach is considered valid, reliable, and economical for assessing oral health31. Oral diseases are associated with factors such as oral hygiene, smoking, stress, treatment needs, dental pain and diet43-45. Regarding diet, difficulties in chewing can influence food preferences, often leading to the selection of softer foods that may have lower nutritional value compared to those rich in vitamins and fiber, such as hard fruits and vegetables46. Research shows that positive health behaviors are directly influenced by psychosocial factors, including intention, social influences and action planning. Furthermore, a complex interplay of biological, behavioral and social factors determines the disease prevalence, with socioeconomic status playing a significant role in oral health outcomes44. Studies indicate that individuals with lower income or educational levels are more likely to experience higher rates of chronic periodontitis47 and cavities48.
In the current study, we also observed that less than half of the analyzed sample regularly consumed raw and cooked vegetables, fruits, and milk in both editions of the survey. This finding reflects the nutritional transition observed in recent decades among the Brazilian population, characterized by an increased prevalence of overweight and obesity alongside a decline in malnutrition. In addition to shifts in housing and sanitation access, employment levels, income, information, and education, eating habits play a critical role in this context49. Notable trends include greater access to and consumption of ultra-processed foods, accompanied by a decrease in the consumption of fresh foods, such as vegetables and fruits50. Fruits and vegetables are associated with better oral health, as they contribute to lower cavity levels50,51 and help reduce bacterial plaque through natural protective factors that act as anticariogenic agents. Additionally, most of these foods are rich in fiber, which stimulates salivary flow52. Another factor contributing to this trend may be the declining price of ultraprocessed foods53. In some high-income countries, ultra-processed foods tend to be cheaper than natural or minimally processed foods53. However, this relationship is less clear in Brazil, one of the world's largest food producers, which could ensure a greater supply and lower prices of fresh foods54. Between 1995 and 2017, the price of ultra-processed foods initially increased but showed a slight decline in the remaining period. Projections for 2030 suggest a further reduction in the price of ultra-processed foods and an increase in the price of unprocessed or minimally processed foods starting in 202655. Until the early 2000s, fresh foods were generally cheaper than ultra-processed ones56. However, recent estimates indicate a shift in this scenario, with declining prices of ultra-processed foods55, contributing to their high consumption and exacerbating inequalities in food consumption.
The main strength of the current study is the use of representative health survey conducted in Brazil with data about oral health and food consumption available. The NHS is a secondary public data capable of providing a broad view of the health aspects of the Brazilian population. The data harmonization process for the two editions of the NHS enabled the analysis of the population context in a 6-year interval, rather than at a single point in time. Additionally, potential confounders were collected and controlled in a robust analysis.
Despite the strengths, the study has limitations need to be acknowledged. First, its cross-sectional design raises concerns regarding the potential reverse causality, since both exposure and outcome variables were assessed at a single point in time. Second, the instrument applied to evaluate dietary consumption data restricts the comprehensive assessment of the population’s dietary intake. Although this instrument encompasses only a limited number of food items, the risk of memory bias remains, and the retrospective questioning over the preceding week requires cognitive abilities to approximate average consumption. Third, the subjectivity nature inherent in self-perception of oral health warrants careful consideration. Such perception is prone to fluctuation over an individual’s lifespan, influenced by contextual factors, such as psychological state and presence of unexpressed emotions57,32.
We identified that poor oral health was associated to worse food consumption. Specifically, our findings showed that individuals who assessed their oral health as poor or very poor presented lower consumption of healthy foods, in parallel with a higher intake of unhealthy foods, particularly evident in the most recent edition of the survey, conducted in 2019. Given the demographic group evaluated, the adverse impact of a poor oral health and an unhealthy dietary habit has a high significance, with implications extending to non-communicable chronic disease. Our findings contribute to the relationship between oral health and indicators of healthy and unhealthy food consumption, emphasizing the importance of integrated public health interventions and initiatives to prevent non-communicable chronic diseases.

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