Journal of Taibah University Medical Sciences (2022) 17(5), 818e825

Taibah University

Journal of Taibah University Medical Sciences

[Link]

Original Article

Effects of orthodontic treatment on body mass index, food habits and

self-esteem of patients: A prospective single-arm cohort study
Vimala Gnanasambandam, MDS a and Sangeetha M. Gnaneswar, MDS b, *
a
Department of Orthodontics, Tamilnadu Government Dental College and Hospital, Chennai, India
b
Department of Orthodontics, SRM Dental College, SRM University, Chennai, India

Received 7 September 2021; revised 19 January 2022; accepted 7 February 2022; Available online 19 February 2022

‫ﺍﻟﻤﻠﺨﺺ‬ Abstract

‫ ﻏﺎﻟﺒﺎ ﻣﺎ ﻧﻮﺍﺟﻪ ﺍﻟﻤﺮﺿﻰ ﺍﻟﻘﻠﻘﻴﻦ ﺣﻮﻝ‬،‫ ﺃﺛﻨﺎﺀ ﻋﻼﺝ ﺗﻘﻮﻳﻢ ﺍﻷﺳﻨﺎﻥ‬:‫ﺃﻫﺪﺍﻑ ﺍﻟﺒﺤﺚ‬ Objectives: During orthodontic treatment, patients are
‫ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ ﻏﻴﺮ ﻣﻜﻠﻒ ﻭﻃﺮﻳﻘﺔ‬.‫ﺍﻧﺨﻔﺎﺽ ﺗﻨﺎﻭﻝ ﺍﻟﻄﻌﺎﻡ ﻭﻓﻘﺪﺍﻥ ﻭﺯﻥ ﺍﻟﺠﺴﻢ‬ often apprehensive about reduced food intake and loss of
‫ ﻳﻬﺪﻑ ﻫﺬﺍ ﺍﻟﺒﺤﺚ ﺇﻟﻰ‬.‫ﺳﻬﻠﺔ ﺍﻟﺘﻨﻔﻴﺬ ﻟﻔﺤﺺ ﻭﺩﺭﺍﺳﺔ ﺍﻟﺘﻐﻴﺮﺍﺕ ﻓﻲ ﻓﺌﺎﺕ ﺍﻟﻮﺯﻥ‬ body weight. Body mass index (BMI) assessment is an
‫ ﻭﺍﺣﺘﺮﺍﻡ‬،‫ﻣﻌﺮﻓﺔ ﻣﺎ ﺇﺫﺍ ﻛﺎﻧﺖ ﻫﻨﺎﻙ ﺗﻐﻴﻴﺮﺍﺕ ﻃﻮﻳﻠﺔ ﺍﻷﺟﻞ ﻓﻲ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ‬ inexpensive, easy method for screening and studying
.‫ ﻭﺍﻟﻌﺎﺩﺍﺕ ﺍﻟﻐﺬﺍﺋﻴﺔ ﻟﻠﻤﺮﺿﻰ ﺧﻼﻝ ﺍﻟﺴﻨﺔ ﺍﻷﻭﻟﻰ ﻣﻦ ﻋﻼﺝ ﺗﻘﻮﻳﻢ ﺍﻷﺳﻨﺎﻥ‬،‫ﺍﻟﺬﺍﺕ‬ changes in weight categories. This research aimed to
determine whether long-term changes in BMI, self-
‫ ﻣﺮﻳﻀﺎ ﻳﺨﻀﻌﻮﻥ ﻟﻌﻼﺝ‬120 ‫ ﺗﻢ ﺣﺴﺎﺏ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ ﻟﻌﺪﺩ‬:‫ﻃﺮﻕ ﺍﻟﺒﺤﺚ‬ esteem, and food habits occur in patients during the
‫ ﺗﻢ ﺟﻤﻊ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻓﻲ ﺑﺪﺍﻳﺔ ﻭﻧﻬﺎﻳﺔ ﺷﻬﺮ ﺍﻟﻌﻼﺝ ﺍﻷﻭﻝ ﻭﺍﻟﺜﺎﻧﻲ ﻭﺍﻟﺜﺎﻟﺚ‬.‫ﺗﻘﻮﻳﻢ ﺍﻷﺳﻨﺎﻥ‬ first year of orthodontic treatment.
‫ ﺗﻢ ﺍﺳﺘﺨﺪﺍﻡ ﻣﻘﻴﺎﺱ ﺭﻭﺯﻧﺒﺮﻍ ﻟﺘﻘﺪﻳﺮ ﺍﻟﺬﺍﺕ ﻟﺘﻘﻴﻴﻢ ﻣﺴﺘﻮﻯ‬.‫ﻭﺍﻟﺴﺎﺩﺱ ﻭﺍﻟﺜﺎﻧﻲ ﻋﺸﺮ‬
‫ ﺗﻢ ﺍﺳﺘﺨﺪﺍﻡ ﻣﻘﻴﺎﺱ ﺗﻘﻴﻴﻢ ﺍﻟﻌﺎﺩﺓ ﺍﻟﻐﺬﺍﺋﻴﺔ ﻟﺪﺭﺍﺳﺔ ﺍﻟﺘﻐﻴﺮﺍﺕ ﻓﻲ ﻋﺎﺩﺍﺕ‬.‫ﺍﺣﺘﺮﺍﻡ ﺍﻟﺬﺍﺕ‬ Methods: BMI was calculated for 120 patients undergo-
.‫ﺍﻷﻛﻞ‬ ing orthodontic treatment. Data were collected at base-
line, and after the end of the first, second, third, sixth, and
‫ ﻣﻦ ﺍﻟﻤﺮﺿﻰ ﺍﻧﺨﻔﺎﺽ ﻓﻲ ﻣﺆﺷﺮ‬٪43.4 ‫ ﻛﺎﻥ ﻟﺪﻯ‬،‫ ﺷﻬﺮﺍ‬12 ‫ ﻓﻲ ﻧﻬﺎﻳﺔ‬:‫ﺍﻟﻨﺘﺎﺋﺞ‬ twelfth months. Rosenberg’s self-esteem scale was used
‫ ﻭﺣﺎﻓﻆ‬،‫ ﻟﺪﻳﻬﻢ ﺯﻳﺎﺩﺓ ﺧﻔﻴﻔﺔ ﺇﻟﻰ ﻣﻌﺘﺪﻟﺔ ﻓﻲ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ‬٪45.8‫ ﻭ‬،‫ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ‬ for scoring self-esteem. The Food Habit Assessment Scale
‫ ﻟﻢ ﺗﻜﻦ ﺍﻟﺘﻐﻴﻴﺮﺍﺕ‬.‫ ﻣﻦ ﺍﻟﻤﺮﺿﻰ ﻋﻠﻰ ﻣﺴﺘﻮﻳﺎﺕ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ ﻟﺪﻳﻬﻢ‬٪10.8 was used to study changes in eating habits. Statistical
‫ ﻛﺎﻧﺖ ﺗﻐﻴﻴﺮﺍﺕ ﺍﺣﺘﺮﺍﻡ ﺍﻟﺬﺍﺕ ﺫﺍﺕ ﺩﻻﻟﺔ ﺇﺣﺼﺎﺋﻴﺔ ﻟﻜﻼ‬.‫ﺫﺍﺕ ﺩﻻﻟﺔ ﺇﺣﺼﺎﺋﻴﺔ‬ analysis was performed with repeated measures ANOVA
.‫ ﺍﻟﺘﻐﻴﻴﺮﺍﺕ ﻓﻲ ﺍﻟﻌﺎﺩﺍﺕ ﺍﻟﻐﺬﺍﺋﻴﺔ ﻛﺎﻧﺖ ﺫﺍﺕ ﺩﻻﻟﺔ ﺇﺣﺼﺎﺋﻴﺔ ﺃﻳﻀﺎ‬.‫ﺍﻟﺠﻨﺴﻴﻦ‬ followed by Tukey HSD post-hoc test for BMI scores and
KruskaleWallis test followed by Dunn’s multiple com-
‫ ﺍﻧﺨﻔﺎﺽ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ ﻛﺎﻥ ﻓﻲ ﺍﻷﺷﻬﺮ ﺍﻟﺜﻼﺛﺔ ﺍﻷﻭﻟﻰ ﻭﺗﻌﺎﻓﻰ‬:‫ﺍﻻﺳﺘﻨﺘﺎﺟﺎﺕ‬ parison post-hoc tests for the Rosenberg scale and food
‫ ﺃﻇﻬﺮﺕ ﺩﺭﺟﺎﺕ ﺍﺣﺘﺮﺍﻡ ﺍﻟﺬﺍﺕ ﺗﺤﺴﻨﺎ‬.‫ﺗﺪﺭﻳﺠﻴﺎ ﺑﻨﻬﺎﻳﺔ ﺍﻟﺴﻨﺔ ﺍﻷﻭﻟﻰ ﻣﻦ ﺍﻟﻌﻼﺝ‬ habits questionnaire.
.‫ ﻋﺎﺩ ﺍﻟﻤﺮﺿﻰ ﺇﻟﻰ ﺍﻟﻌﺎﺩﺍﺕ ﺍﻟﻐﺬﺍﺋﻴﺔ ﻗﺒﻞ ﺍﻟﻌﻼﺝ ﺑﻨﻬﺎﻳﺔ ﺍﻟﺴﻨﺔ‬.‫ﻛﺒﻴﺮﺍ ﻓﻲ ﻛﻼ ﺍﻟﺠﻨﺴﻴﻦ‬
Results: At the end of 12 months, 43.4% of patients had
‫ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ؛ ﺍﻟﻌﺎﺩﺍﺕ ﺍﻟﻐﺬﺍﺋﻴﺔ؛ ﺗﻘﺪﻳﺮ ﺍﻟﺬﺍﺕ؛ ﺃﺟﻬﺰﺓ‬:‫ﺍﻟﻜﻠﻤﺎﺕ ﺍﻟﻤﻔﺘﺎﺣﻴﺔ‬ a decrease in BMI, 45.8% had a mild to moderate in-
‫ﺗﻘﻮﻳﻢ ﺍﻷﺳﻨﺎﻥ ﺍﻟﺜﺎﺑﺘﺔ؛ ﺗﻘﻮﻳﻢ ﺍﻷﺳﻨﺎﻥ؛ ﺍﻟﺪﺭﺍﺳﺔ ﺍﻟﻤﺴﺘﻘﺒﻠﻴﺔ‬ crease in BMI, and 10.8% of patients maintained their
BMI levels. The changes were not statistically significant.
Self-esteem changes were statistically significant for both
genders. Changes in food habits were also significant.
* Corresponding address: Department of Orthodontics, SRM
Dental College, SRM University, Ramapuram, Chennai, 600089
Conclusion: BMI decreased for the first 3 months and
India.
E-mail: sangsortho@[Link] (S.M. Gnaneswar) gradually recovered by the end of the first year of treat-
Peer review under responsibility of Taibah University. ment. Self-esteem scores showed a significant improve-
ment in both genders. Patients reverted to pre-treatment
food habits by the end of the year.

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1658-3612 Ó 2022 Taibah University.

Production and hosting by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license ([Link]
licenses/by-nc-nd/4.0/). [Link]
 V. Gnanasambandam and S.M. Gnaneswar 819

Keywords: Body mass index; Food habits; Orthodontic ap- power and size of the sample, we used G-power software
pliances-fixed; Orthodontics; Prospective study; Self-esteem (Heinrich-Heine-University, Dusseldorf, North Rhine-
Westphalia, Germany). On the basis of the inputs, error
Ó 2022 Taibah University. probability ¼ 0.05, effect size f ¼ 0.50, power (1-* err
Production and hosting by Elsevier Ltd. This is an open
prob) ¼ 0.95, and number of groups ¼ 6, we determined that
access article under the CC BY-NC-ND license (http://
[Link]/licenses/by-nc-nd/4.0/). the required sample size was 90 with a power of 0.96. A
convenience sampling method was applied to determine the
required sample size.

Introduction Inclusion criteria

Orthodontic treatment offers several benefits, such as Patients 16e25 years of age who planned to undergo or-
improvement in facial esthetics; oral functional efficiency; thodontic treatment to correct malocclusion were included.
and an overall enhancement of individuals’ self-esteem, self-
confidence, and work performance.1 Beyond the discomfort Exclusion criteria
caused by brackets, arch wires, and auxiliary springs, mild
to moderate pain is also experienced after separators are Patients with a history of previous orthodontic treatment;
placed and after every activation.2 Patients are instructed patients with any systemic disease, physical disability, or
to avoid or reduce consumption of hard, sticky, and stress; patients taking any long term medications for obesity,
fibrous foods to avoid breakage of the appliance and such as sibutramine, orlistat, or metformin; patients
prevent dental caries, and for ease of maintenance of better receiving steroid therapy; athletes, patients enrolled in a gym
oral hygiene. As a result of these protocols, both parents or following a diet for weight reduction; and patients who
and patients complain about food restrictions and are acquired a systemic disease during orthodontic treatment
apprehensive about weight loss during orthodontic were excluded.
treatment, thus potentially affecting patient compliance. A total of 250 patients 16e25 years of age with planned
Clinicians and patients cite these negatives as major fixed orthodontic treatment at the Department of Ortho-
concerns.3 dontics, Government Dental College and Hospital, South
The body mass index (BMI) is an easy and inexpensive India, were screened (Figure 1). Initially, 148 patients were
way to screen and study changes in weight categories that enrolled in the study. At the end of 2 months, ten patients
may result in health problems. The World Health Organi- had joined sports activities, and five had joined a gym for
zation uses BMI as the standard for recording obesity sta- weight loss. At the end of 5 months, nine patients had
tistics. In the early nineteenth century, Adolphe Quetelet, a missed their follow-ups because of exams or vacations, and
Belgian astronomer and mathematician, developed the basis four patients had become ill. Those patients were excluded
of the BMI. Ancel Keys coined the modern term “body mass from the study. The final sample size was 120, with 60 males
index” in the 1970s.4 An estimated 39% of the global adult and 60 females (Table 1). Informed consent was obtained
population was overweight or obese in 2014, representing a from all patients.
doubling since 1975.5 The concept that childhood and
adolescent BMI changes may predict adult obesity as well Data collection
as adult fat mass and distribution is interesting, given that
BMI can easily be calculated from standardized growth BMI
charts, which include height and weight. Studies have The data collected were height in centimeters to the
reported that both BMI and obesity track from childhood nearest 0.5 cm, measured with an audiometer (Seca 217, CA
to adulthood; the closer to adulthood, the stronger the 91710, Chino, USA), and weight in kilograms to the nearest
tracking.6,7 BMI for children and teenagers is age and sex 0.5 kg, measured with a weighing machine (Seca 813, CA
specific and is often referred to as BMI-for-age. It is also 91710, Chino, USA). We used the standard equation given
associated with individual well-being on both a physical and by the US Centers for Disease Control and Prevention
emotional level.8 ([Link]) to calculate BMI (weight in kilograms/square of
Studies on BMI changes during orthodontic treatment height in meters). The interpretation of BMI for adults and
have been conducted for only short periods (1e3 months).9e11 teens was performed according to the growth charts given by
Very few data have indicated long-term follow up of BMI the CDC12 (Table 2).
levels. Therefore, this cohort study was conducted to scien-
tifically validate the changes in BMI and to clarify patients’ Self-esteem
qualms about weight loss. The aim of this study was to Self-esteem was scored with the Rosenberg Scale.13 This
determine whether long-term changes occur in the BMI, self- scale consists of five positive and five negative items. The
esteem, and food habits of the patients during the first year of score ranges from 0 to 30. Scores between 15 and 25
orthodontic treatment. suggest a normal range. Scores below 15 indicate low selfe
esteem.
Materials and Methods
Food habits
The study was approved by our Institutional Ethics Changes in food habits were studied with a modified
Committee (ref. No. 0425/DE/2010). To determine the food habits assessment (FHA) questionnaire.14 This
820 BMI in orthodontic patients

closed-ended questionnaire consists of 15 items evaluating Statistical analysis

eating difficulties. Our decision to use a closed-ended
model was based on having a well-defined variable or a Data were entered in Excel sheets for statistical analysis in
construct and the ease of converting the results into SPSS software (version 22, IBM corporation). The BMI
numbers for analysis in a spreadsheet. From 0 to 30, the values were assessed for normality with the ShapiroeWilk
scoring was yes ¼ 2 and no ¼ 1. Higher values denoted test and Levine’s test for homogeneity of variance.
more difficulties in eating. Repeated measures ANOVA followed by Tukey’s HSD post-
Data were collected at the beginning of the treatment hoc test was used to assess the significant differences at the
(pre-treatment), and at the end of the 1st, 2nd, 3rd, 6th, and indicated time intervals (T0, T1, T2, T3, T4, and T5). The
12th months, denoted T0, T1, T2, T3, T4, and T5, Rosenberg scale and FHA questionnaire scores for female
respectively. and male participants during the different treatment in-
tervals did not pass normality tests, and the test for signifi-
Primary outcome measure cance (P ¼ 0.05) was performed with the KruskaleWallis test
The primary outcome was the BMI score, calculated from and Dunn’s multiple comparisons post-hoc test.
the height and weight of the patients measured at various
intervals (T0 to T5).
Results
Secondary outcome measure
The secondary outcomes were the self-esteem scores and BMI
FHA questionnaire scores measured with the Rosenberg
scale and the FHA questionnaire from T0 to T5. Of 120 patients, 50% had normal BMI, 44.2% were un-
derweight, 5.8% were overweight, and none were obese at
Bias the pre-treatment level. At the end of the study period, 55%
To avoid selection bias, we included only orthodontic of patients had normal BMI, 40% were underweight, 5%
patients. The use of standard measurement instruments, were overweight, and none were obese (Table 3). A total of
World Health Organization classification of BMI, Rosen- 51.3% of females and 35.5% of males had a decrease in
berg scale, and a validated questionnaire minimized infor- their BMI with respect to pre-treatment levels. A total of
mation bias (misclassification bias). The scores and 41.3% of females and 50.3% of males showed increases in
calculations were rechecked at random by two blinded cli- their BMI levels. A total of 7.4% of females and 14.2% of
nicians to eliminate measurement bias. males did not show changes in their BMI levels. Overall,
In this study, a confounding factor was the height of the 43.4% of patients had a decrease in BMI, 45.8% had a mild
patients. Changes in height can occur due to growth in pa- to moderate increase in BMI, and 10.8% maintained their
tients 16e19 years of age, thus influencing the BMI values. BMI at the end of 12 months of orthodontic treatment. The
To reduce the confounding factor, patients 20e25 years of BMI showed a biphasic tendency in both genders (Table 4).
age who were in the post growth period with relatively stable The BMI began to decrease immediately after T0 and
height were also included. continued to decrease up to 3 months (T1 and T2).

Figure 1: Sampling flowchart.

 V. Gnanasambandam and S.M. Gnaneswar 821

Table 1: Demographics of the participants. Table 4: Average values of BMI, Rosenberg scale (RBS), and
Overall age distribution 16e25 years food habits questionnaire (FHA) for males and females at
Males (mean age) 16e19 years: 16.97, SD: 0.94 different levels. N [ 60 M/60 F.
20e25 years: 22.25, SD: 1.88 Levels BMI BMI RBS RBS FHA FHA
Females (mean age) 16e19 years: 17.07, SD: 0.96 Female Male Female Male Female Male
20e25 years: 23.1 SD: 1.64
Gender distribution Males: 60; females: 60 T0 Mean 18.58 19.92 14.83 15.53 20.33 20.33
Work status 68: undergraduate/school students std. 2.67 3.22 1.76 2.08 2.4 2.45
40: postgraduate students deviation
12: employed T1 Mean 18.06 19.42 15.1 16.03 17.56 17.83
Socio-economic status Middle and lower middle class std. 2.76 3.24 1.84 1.77 2.31 1.83
Malocclusion Dental class I, class II, class III deviation
T2 Mean 17.57 19.23 15.1 16.06 17.6 17.26
std. 2.78 3.12 1.84 1.65 2.08 2.19
deviation
T3 Mean 17.82 19.39 15.63 16.56 17.7 15.33
Table 2: Interpretation of BMI for different age groups. std. 2.87 3.35 1.62 1.61 2.13 1.47
Interpretation of BMI for Interpretation of BMI for deviation
ages 20 and above ages 2e19 T4 Mean 18.09 19.55 18.7 17.23 17.06 13.73
std. 2.73 3.24 2.4 1.47 2.27 1.56
<18.5: underweight <5th percentile: underweight deviation
18.5e24.9: normal or 5th percentile to 85th T5 Mean 18.48 20.13 20.23 17.6 16.5 13.7
healthy weight percentile: healthy weight std. 2.69 3.08 2.47 1.58 2.09 1.51
25.0e29.9: overweight 85th to <95th percentile: deviation
overweight
>30.0: obese 95th percentile: obese T0, T1, T2, T3, T4, and T5 indicate the start, and the end of the
first, second, third, sixth, and twelfth months, respectively. BMI
Based on growth charts from the Centers for Disease Control and gradually decreased in females from T0 to T4 and increased from
Prevention ([Link]). T4 to T5. BMI in males did not differ drastically from T0 and
returned to the initial values at the end of study period. The
average self-esteem score was normal in males and moved to a
Thereafter, the mean BMI began to increase slowly (T3, T4, higher level, whereas females had lower self-esteem initially but
and T5). The decrease in BMI was statistically significant showed a marked improvement at the end of the study period.
during T1, T2, T3, and T4 with respect to baseline T0 in FHA scores showed a gradual improvement for females and a
females, and during T1, T2, and T3 with respect to significant improvement for males from T3.
baseline T0 in males. In both genders, the values at the end
of T5 (18.48 for females and 20.13 for males) did not
statistically differ from those at T0 (18.58 for females and for males (p ¼ 0.96) and females (p ¼ 0.77) between T0
19.92 for males) (Table 5). The height ranged from a and T5 were not significant.
minimum of 1.44 m to a maximum of 1.64 m. The change
in height averaged of 2e4 cm. The changes in BMI scores Self-steem

The mean Rosenberg scores (RBSs) during T4 and T5

Table 3: Distribution of BMI categories according to age (in (18.7 and 20.2) in females showed significant differences
years). with respect to T0, T1, T2, and T3 (14.8, 15.1, 15.1, and
15.6) (Table 4). The scores rapidly increased from T3 (15.6)
Age group BMI category Males Females
to T4 (18.7). However, in males, the mean steadily
(N ¼ 44) (N ¼ 50)
increased from T0 to T5 (15.5, 16.0, 16.0, 16.5, 17.2, and
T0 T5 T0 T5 17.6). In both genders, the mean RBS began to increase
16e19 years Underweight 19 18 28 27 immediately after T0 and continued to T5. A significant
Normal 22 23 21 22 difference in RBS values was observed among different
Overweight 3 3 1 1 treatment intervals in males as well as in females
Obese 0 0 0 0 (p < 0.0001) (Table 5).
Age group BMI category Males Females
(N ¼ 16) (N ¼ 10) FHA
T0 T5 T0 T5
The mean FHA values were 20.33 at T0 and 16.5 at T5 in
20e25 years Underweight 4 2 2 1 females, and were 20.33 at T0 and 13.7 at T5 in males
Normal 11 13 6 8
(Table 4). In females, the changes in the mean FHA values
Overweight 1 1 2 1
Obese 0 0 0 0
were significant from T0 to T5 but were not significant at
other levels (T1, T2, T3, and T4) with respect to T0. Males
N ¼ number of patients. Distribution of patients under different showed no significant changes from T0 to T1, T2, and T3,
categories of BMI according to different age groups. T0: begin-
but showed significant changes from T0 to T4 and T5
ning of treatment; T5: end of the study.
(Table 5).
822 BMI in orthodontic patients

Discussion
Table 5: Comparison of statistical significance of BMI, RBS,
and FHA at various treatment levels.
BMI
Levels Levels BMI BMI RBS RBS FHA FHA
Female Male Female Male Female Male
Placement of separators, placement of initial arch wires,
T0 T1 P* P** NS NS P*** P***
adjustments, and activation of orthodontic appliances can
T2 P*** P*** NS NS NS P*
T3 P*** P*** NS NS NS NS
cause discomfort and pain for 2e3 days, which decreases by
T4 P* NS P*** P*** NS NS the fifth or sixth day.15 This pain affects patients’ eating
T5 NS NS P*** P*** NS NS patterns. Patients may avoid hard foods and restrict food
T1 intake because of the conditioned and nociceptive reflexes
T2 P* NS NS NS NS NS elicited by arch wire activation.16 Michelotti et al., in an
T3 NS NS NS NS NS NS electromyography study with separators, have found a
T4 NS NS P*** P* NS P** decrease in motor output and pressure pain threshold in
T5 NS NS P*** P** P*** P*** the mastication muscles.17 This finding may be considered
T2 a protective mechanism against further damage to the
masticatory system. Similarly, Krishnan has concluded that
T3 NS NS NS NS NS NS
T4 NS NS P*** P* NS P***
the placement and activation of arch wires cause pain and
T5 NS NS P*** P** P*** P*** may affect dietary habits and daily life activities.2
T3 Interference with arch wires may result in reduced intake
of food and a loss of pleasure in eating. In general, the
changes in dietary patterns might result in an increase or
T4 NS NS P** NS NS P*** decrease in weight.
T5 NS NS P*** NS P*** P*** Body mass index is often used as a screening instrument
T4 for weight-related disorders such as obesity. Several factors
influence BMI values, including age, gender, ethnicity, socio-
economic status, physical activity, and diet. The rising trend
T5 NS NS NS NS NS P*
in BMI may indicate unfavorable societal and environmental
conditions that promote inactivity, excessive energy intake,
P*: significant; P**: highly significant; P***: extremely signifi- and malnutrition.18 Lilja et al. have demonstrated greater
cant; NS: not significant. BMI scores showed no significant
BMI gain in young adulthood,19 and Whitlock et al. have
changes between T0 and T5 in both genders. The Rosenberg scale
showed significant changes between T0 and T5 in females and
noted a linear relationship of BMI with age.20 Being
males. FHA scores showed significant changes from T0 to T1, underweight is also associated with health problems,
and T1 to T5 in males and females. BMI and FHA scores showed similarly to being overweight or obese. In children and
no significant changes between T0 (at the beginning of the adolescents, being underweight increases the risk of several
treatment) and T5 (at the end of 12 months). infections, particularly in developing countries.21

Figure 2: BMI trend in females and males.

 V. Gnanasambandam and S.M. Gnaneswar 823

Figure 3: Rosenberg’s self-esteem scale.

In the present study, we recorded and analyzed the BMI following months. Patients require time for adaptation
of participants from T0 to T5 over 12 months during or- after being introduced to the new challenge of combating
thodontic treatment. Jan et al. have studied the changes in discomfort and pain. As observed in our study, this
BMI for 2 months and concluded that orthodontic treatment adaptation occurs only from the third month onward. The
causes weight loss, and the treatment can be used to prevent patients showed a positive trend in weight gain, reverting
obesity and improve personality.9 Ajwa et al. have arrived at to their pre-treatment BMI scores. The overall mean
a similar conclusion regarding a change in BMI between the revealed that males had a higher BMI (19.9) than females
first and second treatment visits.10 Additionally, they have (18.58) (Table 4). BMI changes in males were minimal, and
claimed that their results can be used as guidance for no significant changes were observed from T0 to T4 and
structured diet planning. Drawing such emphatic T5, similarly to the findings in Sandeep et al.11 Several
conclusions seems premature without observing sequential patients even showed increases in BMI scores (Table 5).
changes in BMI. Our observations were similar to those in Because BMI does not distinguish between fat and muscle,
a study by Sandeep et al.,11 whose period of observation the higher BMI scores and minimal changes in males were
was 3 months. Our study involved a longer observation attributable to the development of greater muscle mass
period of 12 months to gain a better understanding of BMI than that in females during the developmental ages or
changes over the course of the treatment. Our results could also have been due to males reverting to old food
during the first 2 months were similar to those in the above habits more quickly than females, as observed in this
studies, but the change In the trend was evident in the study. In contrast, the changes in BMI were relatively

Figure 4: Food Habit Questionnaire scores.

824 BMI in orthodontic patients

greater in females, similarly to findings from a study by Yi government hospital and to the socio-economic conditions
et al.22 Females showed a sharp dip in the graph, whereas (lower middle class) of the outpatients visiting the hospital.
males showed gradual changes. However, both values The inclusion of patients from all BMI categories would have
returned closer to their initial values at the end of the study strengthened the study.
period (Figure 2). We observed that patients might show Duration of the study period: The duration of ortho-
increases in their BMI values but still fall under the same dontic treatment differs among patients. In our study, we
BMI category (underweight or normal). The current study could not continue with a longer follow-up because of the
revealed that the BMI changes are temporary, as affirmed differences in treatment duration, dropout, and missed
by the patients. Because orthodontic treatment generally follow-ups, thus leading to a decreased sample size at the end
occurs over long periods, conclusions based on of the year.
observations over a short period might be deceptive. Prospects of the study:
Dietary changes based on a short observation period might
not be advisable. Hence, considering fixed orthodontic 1. Studies involving BMI analysis for the entire treatment
appliances for weight reduction regimens is questionable period would limit conflicting opinions on this subject.
and should be advised with caution, particularly in males. 2. Studies with similar types of treatment plans would pro-
vide better insight into the difficulty level for eating and
Self-esteem oral hygiene maintenance.

Malocclusion is known to affect self-respect and self- Conclusion

esteem, and thus overall quality of life. Similarly to the ob-
servations of Jung et al., our findings indicated a marked  BMI decreased in the first 3 months and gradually recov-
improvement in the patients’ self-esteem.23 The changes were ered by the end of the first year of treatment. Hence,
greater in females than in males. The average self-esteem changes in BMI during orthodontic treatment can be
score in males was 15.3 at T0 and gradually increased to considered temporary and to have no significant overall
20.2 at T5, whereas females initially had lower self-esteem impact at the end of 1 year.
but showed marked improvements in self-esteem at the end  The self-esteem of the patients significantly improved
of the study period (14.8e20.23) (Figure 3). Interestingly, during the course of orthodontic treatment.
females considered their facial esthetics more important to  Changes in diet patterns were observable only during the
their self-esteem than males of the same age. This finding first few months of orthodontic treatment, after which the
may be related to a higher number of female patients opting patients resumed their regular eating habits. Hence,
for orthodontic treatments than males, similarly to the re- considering fixed orthodontic appliances for a weight loss
sults of a study by Lagorsse et al.24 regimen is questionable and should be advised with
caution, particularly in males.
FHA questionnaire
Source of funding

Our food habit questionnaire revealed that patients

This research did not receive any specific grant from
experienced difficulty only in the initial months, and by the
funding agencies in the public, commercial, or not-for-profit
end of the third month, they were able to return to their
sectors. This was a self-funded study.
regular eating habits. Similarly to studies Jawad et al. and
Soni et al., our study indicated that patients’ eating habits
Conflict of interest
improved significantly with time, as they learned how to
manage their fixed appliances, and developed the skills to
bite and chew firmer and harder food items with their Both authors (VG and SG) certify that they have no af-
appliance.14,25 They reverted to their old eating habits, filiations with, or involvement in, any organization or entity
similarly to findings in studies by Azaripour et al. and with any financial interest or non-financial interest in the
Negrutiu et al.26,27 Consequently, the patients regained lost subject matter or materials discussed herein. All authors
weight from the third month of treatment. Feldmann et al. declare no conflicts of interest.
have concluded that masticatory ability decreases during
the first 24 h after the insertion of a fixed appliance and Ethical approval
returns to baseline after 4e6 weeks.28 We concur with
those results and ascribe the improvement in our patients’ Institutional Ethical Committee, Government. Dental
eating habits to this effect (Figure 4). Many of our patients College and Hospital, TN Dr. MGR Medical University,
reported eating fewer snacks and eating healthier foods, Tamilnadu, India approved this study (ref. No. 0425/DE/
similarly to the findings of a study by Sandeep et al.11 2010) on 24 April 2013.
Improvements in self-esteem were also attributable to pa-
tients eating healthier food. Authors contributions

Limitations of the study VG conceived and designed the study; supervised the data
collection; analyzed and interpreted data; wrote the initial
Non-availability of obese patients: We attribute the lack and final drafts of the article; and gave final approval of the
of obese patients partly to the geographic location of the draft. SG designed and conducted research; provided
 V. Gnanasambandam and S.M. Gnaneswar 825

research materials; collected, organized, analyzed, and 15. Bondemark L, Fredrikkson K, Ilros S. Separation effect and
interpreted data; wrote the initial and final drafts of the perception of pain and discomfort from two types of ortho-
article; and gave final approval of the draft. All authors agree dontic separators. World J Orthod 2004 Summer; 5(2): 172e
to be accountable for all aspects of the work in ensuring that 176. PMID: 15615136.
16. Erdinc AME, Dincer B. Any arch wire: perception of pain during
questions associated with the accuracy or integrity of any
orthodontic treatment with fixed appliances. Eur J Orthod 2004
part of the work are appropriately investigated and resolved. Feb; 26(1): 79e85. [Link]
All authors have critically reviewed and approved the final 17. Michelotti A, Farella M, Martina R. Sensory and motor
draft and are responsible for the content and similarity index changes of the human jaw muscles during induced orthodontic
of the manuscript. pain. Eur J Orthod 1999 Aug; 21(4): 397e404.
18. Reas DL, Nygård JF, Svensson E, Sørensen T, Sandanger l.
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