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Nutrition Unit
Dupuytren University Hospital
and
Research Unit EA 3174
Faculty of Medicine
87042 Limoges cedex
France
E-mail: nutrition{at}unilim.fr
Dear Sir:
We read with interest the article by Lee et al (1) in a recent issue of the Journal. As emphasized by the authors, edentulism is frequent in the elderly (2) and could cause reduced nutritional intake. Edentulism has been implicated as a factor causing malnutrition in elderly patients (3). One of the surprising results of Lee et al's study was the lack of significant difference between edentate and dentate participants in energy intake, except when the analysis was broken down by race. However, I believe that the study had the following problems:
1) Edentulism was attested only by "self-reported information regarding whether a participant had any remaining natural teeth. Participants were also asked whether they wore dentures and whether they had chewing pain" (page 296, "Oral heath" paragraph). This method does not provide reliable recording of the number and type of teeth lost; it is a problem noted by the authors in the discussion (page 301, first lines) but is of such central importance that it may raise questions about the study's overall validity.
2) Improved nutritional status was suggested by the percentage of persons who experienced a weight gain of >5% of baseline weight in 1 y (page 298, last sentence). I believe that this criterion is misleading because it may be unlinked with the more meaningful data of the mean weight gain of the participants. Without more data, it is not possible to conclude that the edentate participants had greater weight gains than did the dentate participants, as suggested on page 299 (right column, lines 23–25). It would also be important to know the criteria used in the multiple linear regression analysis presented in the last lines of page 298.
3) In the multiple linear regression analysis of mean energy intake (page 299, Table 2), it is notable that mean energy intake was not adjusted for certain nutritional values, such as weight or, even better, fat-free mass (FFM). This is important because nutritional balance is not obtained with the same energy intake in a participant with a high FFM as in a participant with a low FFM, ie, body composition can play a role. With such an adjustment, the race-linked mean energy intake difference might lessen or disappear. Without this adjustment factor, we think that it is very difficult to know whether mean energy intake differs between edentate and dentate participants.
4) There is insufficient discussion of the contrast of the higher appetite reported for dentate subjects than for edentate subjects (page 297, Results, line 6) and yet no apparent difference in energy intake.
In conclusion, the article by Lee et al is an interesting approach to dietary intake in the elderly in relation to dental status and suggests a difference in mean energy intake more on the basis of race than on the basis of edentulism. However, additional methodologic retooling may yield a further level of understanding.
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