ORIGINAL ARTICLE: OBSERVATIONAL STUDIES
|Year : 2019 | Volume
| Issue : 3 | Page : 232-236
Influence of gratification behavior on early childhood caries and body mass index in preschool children
Battula Purnima, KS Uloopi, C Vinay, Rayala Chandrasekhar, Kakarla Sri RojaRamya
Department of Pedodontics and Preventive Dentistry, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
|Date of Web Publication||30-Sep-2019|
Dr. Battula Purnima
Department of Pedodontics and Preventive Dentistry, Vishnu Dental College, Bhimavaram - 534 202, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Early childhood caries (ECC) and obesity are becoming major public health problems in children. Apart from biological and social risk factors, gratification response, a psychological behavior, may also have a large influence on body mass index (BMI) and occurrence of ECC in preschool children. Aim: The study aimed to ascertain the impact of delayed gratification as a behavioral risk factor for the occurrence of ECC and obesity in preschool children of age 5–6 years. Settings and Design: Comparative cross-sectional study. Materials and Methods: Fifty children with ECC (Group I) and 50 caries-free children (Group II) were included to participate in a task similar to the famous Stanford marshmallow experiment to assess their ability to delay gratification. BMI was calculated by obtaining the biometric measures of height and weight. Body weight status was determined using BMI for age percentile growth charts revised by the Indian Academy of Pediatrics, 2015. Children's caries experience and BMI status were associated with their gratification response. Statistical Analysis: Statistical analysis was performed using Fisher's exact test and Chi-square test. Results: Higher percentage of children with ECC delayed their gratification (54%) than caries free (40%). Children who exhibited instant gratification (37%) had a higher BMI when compared to those who delayed their gratification (25%). Conclusion: Children with ECC were more self-controlled, and children with high BMI were more impulsive. Hence, delayed gratification for cariogenic reward is a behavioral risk factor for ECC, whereas instant gratification is an alarming risk factor for higher BMI in preschool children.
Keywords: Body mass index, delayed gratification, early childhood caries, obesity
|How to cite this article:|
Purnima B, Uloopi K S, Vinay C, Chandrasekhar R, RojaRamya KS. Influence of gratification behavior on early childhood caries and body mass index in preschool children. J Indian Soc Pedod Prev Dent 2019;37:232-6
|How to cite this URL:|
Purnima B, Uloopi K S, Vinay C, Chandrasekhar R, RojaRamya KS. Influence of gratification behavior on early childhood caries and body mass index in preschool children. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2019 Nov 13];37:232-6. Available from: http://www.jisppd.com/text.asp?2019/37/3/232/268187
| Introduction|| |
Gratification is the emotional satisfaction of happiness in reciprocation to the accomplishment of a goal or desire. Similar to all emotions, it is an incentive of behavior and plays a prime role in the entire range of human social systems. In psychological models, gratification is believed to be governed by “pleasure principle” which is primarily the motive power that compels human beings to gratify their wishes, needs, and urges. Delayed gratification or deferred gratification is a psychosocial ability that involves being able to resist the temptation for a smaller and more immediate reward to receive a larger and more enduring reward later.
Early childhood caries (ECC) and obesity (high body mass index [BMI]) are multifactorial diseases associated primarily with biological and social risk factors. However, currently, the behavioral risk factors have been focused on the etiology of ECC and high BMI. Hence, the psychosocial behavior, i.e., inability to delay gratification in preschool children may also have a large influence on the BMI and occurrence of ECC.
Many studies have evaluated the association of delayed gratification with obesity, BMI, depression levels, and impulsive behavior in children.,,, But hitherto, there is a dearth of literature to evaluate the association between delayed gratification and occurrence of ECC in preschool children.
Hence, this current study was conducted with an aim to ascertain the impact of inability to delay gratification as a behavioral risk factor for the occurrence of ECC and obesity in preschool children of 5–6 years' age.
| Materials and Methods|| |
The present comparative cross-sectional study was conducted using the purposive sampling procedure. Ethical clearance was obtained from the Institutional Ethical Review Board (VDC/IEC/2016/32). The present study included 100 children of 5–6 years' age and they were recruited from the private schools. Necessary permission was obtained from the respective school authorities. Written informed consent was obtained from parents of the participating children after explaining the study in detail.
Based on the caries experience, children were equally categorized into two groups, i.e., children with ECC (Group I-50) and caries free (Group II-50). Then, each group is further equally divided into two subgroups based on the gender. The ability to delay gratification was evaluated implementing the famous Stanford marshmallow experiment with few modifications. Each child was taken to an isolated room having a video camera with live recording.
One chocolate was presented to the child and he/she was offered with two options. Either the child can have the given chocolate immediately (or) can wait for 8–10 min to receive a larger reward of two chocolates, i.e., the message was small reward now and larger reward later. Then, the investigator exits from the room leaving the child with the chocolate. The child who breaks down and eats the first given chocolate was considered to exhibit instant gratification and was not rewarded with the second chocolate and if the child waits for 10 min to receive a larger reward, he/she was considered to delay gratification and rewarded with two chocolates. To prevent detrimental effect due to unnecessary exposure to cariogenic food and to avert from the ethical issue, children who exhibited instant gratification and have gulped the first given chocolate were mandated to perform mouth rinsing.
Height was measured using a stadiometer, and a weighing machine was used to record the weight. Then, BMI was calculated using the standard metric system formula for BMI according to CDC (Centers for disease control), i.e., BMI = weight in kg/height in m2. The obtained BMI value was plotted in the BMI for age percentile growth charts revised by the Indian Academy of Pediatrics. X-axis in the growth chart depicts age and Y-axis represents the BMI of the child. The interpretation of BMI status of each child was done according to the percentiles. If the plotted BMI value for the age is below the 3rd percentile, then the BMI status of the child is considered as underweight and if it is between 5th percentile and 50th percentile, then it is considered as a healthy weight. Twenty-five adult equivalent and 27 adult equivalent are considered as a risk for overweight and risk for obesity, respectively. In the present study, risk for overweight and risk for obesity percentiles were considered as high-BMI categories. Children's caries experience and BMI status were associated with their gratification response.
| Results|| |
All analyses were done using the Statistical Package for the Social Sciences software version 21.0 (Armonk, NY, USA: IBM Corp). Nonparametric tests were used for the analysis as the obtained data did not show normal distribution. For categorical data, the descriptive statistics number and percentage were presented. The association between ECC and gratification response was evaluated using the Chi-square test. Fisher's exact test was applied to the data to assess the association between BMI and gratification response. All tests were two-sided at α = 0.05 level of significance. Statistical significance was computed at P ≤ 0.05 as statistically significant and ≤ 0.001 as highly significant.
At the end of the study, no individuals were lost from the sample, and there was no missing data for any of the listed variables. The mean age (years) of the children included in the study was 5.55 ± 0.5, and the mean height (m) and weight (kg) of the participants were 1.09 ± 0.06 and 18.3 ± 3.09, respectively [Table 1].
A total of 27 children (boys = 15 and girls = 12) with ECC delayed their gratification, whereas 20 children (boys = 9 and girls = 11) exhibited instant gratification. A total of 23 caries-free children (boys = 10 and girls = 13) delayed their gratification, whereas 30 children (boys = 16 and girls = 14) exhibited instant gratification [Table 2]. Distribution of sample according to their body mass index status and gratification response is shown in [Table 3].
|Table 2: Distribution of children according to their gratification response|
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|Table 3: Distribution of sample according to their body mass index status and gratification response|
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Caries experience and gratification response
Preschool children with ECC (54%) outperformed their counterparts (36%) on measures of delaying gratification [Table 4]. On comparing boys and girls with ECC in relation to their gratification response, predominant percentage of boys (60%) delayed their gratification than girls (48%) [Table 5]. Moreover, among caries-free boys and girls, a higher percentage of boys (64%) exhibited instant gratification than girls (56%) [Table 6].
|Table 4: Intergroup association between early childhood caries and gratification response in children|
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|Table 5: Intragroup association of gratification response among boys and girls with early childhood caries|
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|Table 6: Intragroup association of gratification response among caries-free boys and girls|
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Body mass index and gratification response
A higher percentage of children regardless of their caries experience and gratification response had a healthy weight. A predominant number of children who exhibited instant gratification (n = 16) were at risk for overweight when compared to children with delayed gratification (n = 12) [Table 7]. Majority of girls with ECC who exhibited delayed gratification had a high BMI (risk for overweight [33%]) [Table 8]. Caries-free girls who exhibited instant gratification had a high BMI (risk for overweight [42%]) [Table 9].
|Table 7: Intergroup association between body mass index and gratification response in children|
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|Table 8: Intragroup association between body mass index and gratification response among boys and girls with early childhood caries|
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|Table 9: Intragroup association between body mass index and gratification response among caries-free boys and girls|
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| Discussion|| |
The ability to delay gratification develops as children mature and learn to forgo less valued, short-term pleasures in favor of pursuing valued long-term goals. The past literature has linked the ability to delay gratification to other positive outcomes, including academic success, physical and psychological health, and social competence. A person's ability to defer gratification relates to other similar skills such as patience, impulse control, self-control, and willpower, all of which are involved in self-regulation.
ECC and high BMI in preschool children, both being pathological conditions with a psychological basis, have also been particularly associated with the inability to defer gratification. In the present study, the association of gratification response with ECC and BMI were evaluated because a child's dietary habits are a significant contributor to dental caries and obesity.
It was hypothesized that preschool children with ECC are more impulsive toward sugary food and would be less likely to delay their gratification. Further, it was also hypothesized that children who are more impulsive toward food and exhibit instant gratification will have a higher BMI.
In the present study, children with ECC were more self-controlled to have a larger reward of two chocolates and delayed their gratification, whereas caries-free children were more impulsive and exhibited instant gratification. Children with ECC are ravenous and have a strong urge to acquire more sugary food (two chocolates); and hence, to perceive a higher amount of sugary food they might have delayed their gratification. However, it is well-known from the Stephen's curve that high caries experience is due to increased frequency in intake of sugary food but not solely by the amount of sugar consumed. This can be justified by an explanation that children with ECC who delayed their gratification and acquired two chocolates were not insisted to have both the rewarded chocolates simultaneously. They were just rewarded, and it depends on the child's choice either to eat both the chocolates at once or in divided times. Hence, the child out of joy may enjoy one chocolate then itself immediately and preserve the second chocolate to have some time later, which justifies the infrequent consumption of cariogenic sugary food, which may lead to higher caries score.
In contrary to the results of the present research, studies reported that children with higher deft index values were unable to defer gratification than those with lower deft values. Author's explanation is that as young children lack the ability to resist their temptation for refined carbohydrate food, they tend to consume these cariogenic foods by their wish irrespective of frequency, duration, and intensity which render them to get exposed to a higher risk of developing caries.
The present research provides experimental data that tend to support previous studies in the literature, finding a marked association between the inability to defer gratification and high BMI or overweight/obesity. It is well-known that impulse control or self-control is a “treasured ability” and largely depends on cognition of the child. Hence, preschool children tend to have lower cognition, fail to control their impulsive behavior toward food and consume more cariogenic and carbohydrate-rich food, which ultimately leads to a higher BMI.
Several cross-sectional studies also have found that obese children are more impulsive than healthy weight children., For the reason that increased activity in dopaminergic pathways is related to increased impulsivity and a corresponding reduced ability to control impulses for many behaviors. Obese children receiving 1-year multidisciplinary residential treatment for obesity are more sensitive to immediate reward than to punishment and have less inhibitory control than the normal weight children. Furthermore, they are less successful in losing weight during the treatment, as impulsive children have difficulty in the following treatment instructions and strict eating rules.
Neuroimaging studies in obesity suggest that lower prefrontal cortex activity affects inhibitory control and in turn the BMI status. A study in the journal of the Frontiers in Neuroscience revealed that overweight people had less white matter a component of the brain that connects areas of gray matter in the “salience network,” which many researchers described as the “seat of motivation, willpower, self-discipline, and the ability to persevere through physical and emotional challenges.” Overweight and obese people may be neurologically predisposed to overeating and may behave more impulsively.
| Conclusion|| |
All children are born pure egocentric and they perceive their needs to the exclusion of all others. Only through socialization, they do learn that some forms of gratification must be deferred and others denied. In the present study, children with ECC were more self-controlled, and children with high BMI were more impulsive. Hence, delayed gratification for cariogenic reward is a behavioral risk factor for ECC, whereas instant gratification is an alarming risk factor for higher BMI in preschool children.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]