Relationship between mastication and malnutrition in community-dwelling older adults: a meta-analysis

Medeiros, Alba Maria Melo; Araújo, Ramon Cipriano Pacheco de; Borges, Allya Francisca Marques; Sousa, Sara Estéfani Soares de; Araujo, Cristiano Miranda de; Magalhães Junior, Hipólito Virgilio; Cavalcanti, Renata Veiga Andersen; Taveira, Karinna Veríssimo Meira

doi:10.1590/2317-1782/20242023209en

Alba Maria Melo Medeiros

were responsible for the conceptualization and design of the work

data analysis

interpretation of the results

and drafting the scientific manuscript

Grupo de Pesquisa Estudos em Motricidade Orofacial e Disfagia Orofaríngea, Universidade Federal do Rio Grande do Norte – UFRN - Natal (RN), Brasil.

https://orcid.org/0000-0003-0264-2982

Ramon Cipriano Pacheco de Araújo

were responsible for the conceptualization and design of the work

data analysis

interpretation of the results

and drafting the scientific manuscript

Programa de Pós-graduação em Fonoaudiologia, Universidade Federal do Rio Grande do Norte – UFRN - Natal (RN), Brasil.

https://orcid.org/0000-0003-1316-8091

Allya Francisca Marques Borges

conceptualization and design of the work

data analysis

interpretation of the results

drafting the scientific manuscript

Programa de Pós-graduação em Fonoaudiologia, Universidade Federal do Rio Grande do Norte – UFRN - Natal (RN), Brasil.

https://orcid.org/0000-0003-0967-4899

Sara Estéfani Soares de Sousa

conceptualization and design of the work

data analysis

interpretation of the results

drafting the scientific manuscript

Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte – UFRN - Natal (RN), Brasil.

https://orcid.org/0000-0001-8231-1643

Cristiano Miranda de Araujo

conceptualization and design of the work

data analysis

interpretation of the results

drafting the scientific manuscript

Programa de Pós-graduação em Distúrbios da Comunicação, Núcleo de estudos Avançados em Revisão Sistemática e Meta-análise – NARSM, Universidade Tuiuti do Paraná – UTP - Curitiba, PR, Brasil.

https://orcid.org/0000-0003-1325-4248

Hipólito Virgilio Magalhães Junior

conceptualization and design of the work

data analysis

interpretation of the results

drafting the scientific manuscript

Departamento de Fonoaudiologia, Universidade Federal do Rio Grande do Norte – UFRN - Natal (RN), Brasil.

https://orcid.org/0000-0002-8469-9570

Renata Veiga Andersen Cavalcanti

conceptualization and design of the work

data analysis

interpretation of the results

drafting the scientific manuscript

Departamento de Fonoaudiologia, Universidade Federal do Rio Grande do Norte – UFRN - Natal (RN), Brasil.

https://orcid.org/0000-0002-3953-4881

Karinna Veríssimo Meira Taveira

conceptualization and design of the work

data analysis

interpretation of the results

drafting the scientific manuscript

overseeing the research

critical review of all phases of the research

overseeing the article

drafting the scientific manuscript

Programa Associado de Pós-graduação em Fonoaudiologia, Núcleo de Estudos Avançados em Revisão Sistemática e Meta-análise – NARSM, Departamento de Morfologia, Centro de Biociências, Universidade Federal do Rio Grande do Norte – UFRN - Natal (RN), Brasil.

https://orcid.org/0000-0001-6978-4083

Conflict of interests: nothing to declare.

Correspondence address: Karinna Veríssimo Meira Taveira Departamento de Morfologia, Universidade Federal do Rio Grande do Norte – UFRN Av. Salgado Filho, 3000, Lagoa Nova, Campus Universitário, Natal (RN), Brasil, CEP: 59072-970. E-mail: karinna.taveira@ufrn.br

Figures (2)
Tables (5)

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Figure 1
Flow diagram of the literature search and selection criteria⁹9 Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372:n160. http://doi.org/10.1136/bmj.n160. PMid:33781993.
http://doi.org/10.1136/bmj.n160...

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Figure 2
Forest plot of the meta‐analysis of the relationship between mastication and malnutrition in community-dwelling older adults, and displaying risk-of-bias judgements for each study included

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Chart 1
Database search strategy

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Table 1
Summary of the characteristics of the studies included (n=3)

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Chart 2
Risk of bias assessed by the Joanna Briggs Institute critical appraisal tool for cross-sectional studies

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Table 2
Analysis of information quality through GRADE

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Author Reason for exclusion * Alia et al.(1) 3 Aquilanti et al.(2) 2 Baumgartner et al.(3) 4 Braud et al.(4) 4 Borges et al.(5) 4 Brodeur et al.(6) 2 Chatindiara et al.(7) 1 Cousson et al.(8) 1 Harel et al.(9) 3 Hutton et al.(10) 5 Iwasaki et al.(11) 5 Khandelwal et al.(12) 6 Khandelwal et al.(13) 1 Kiesswette et al.(14) 6 Kim et al.(15) 1 Kim et al.(16) 1 Kiss et al.(17) 1 Kolb et al.(18) 6 Krishna et al.(19) 1 Kwon et al.(20) 2 Majumder et al.(21) 1 Mann et al.(22) 2 Manzon et al.(23) 1 Matsuo et al.(24) 7 Mbodj et al.(25) 4 Morais et al.(26) 1 Musacchio et al.(27) 5 Oliveira et al.(28) 7 Oliveira et al.(29) 1 Osta et al.(30) 3 Osta et al.(31) 2 Özsürekci et al.(32) 7 Özsürekci et al.(33) 3 Palmer et al.(34) 1 Putri et al.(35) 3 Riesen et al.(36) 6 Saksono et al.(37) 1 Saletti et al.(38) 1 Samnieng et al.(39) 5 Samnieng et al.(40) 5 Semba et al.(41) 5 Soini et al.(42) 1 Stajkovic et al.(43) 6 Tani et al.(44) 5 Treesattayakul et al.(45) 4 Volkert et al.(46) 7 Volkert et al.(47) 7 Woo et al.(48) 1 Yuniendra et al.(49) 3 Wallace et al.(50) 4 Ziylan et al.(51) 1 *

Database	Search (January 19^th 2022, and update August 3^th 2023)
Embase	'aged'/exp OR 'aged' OR 'elderly'/exp OR 'elderly' OR 'elderlies' OR 'elderly people'/exp OR 'elderly people' OR 'elderly population' OR 'aging'/exp OR 'aging' OR 'ageing'/exp OR 'ageing' OR 'older adults'/exp OR 'older adults' OR 'senior' OR 'seniors' OR 'geriatric'/exp OR 'geriatric' OR 'geriatrics'/exp OR 'geriatrics' AND 'malnutrition' OR 'nutritional deficiency' OR 'nutritional deficiencies' OR 'undernutrition' OR 'malnourishment' OR 'weight loss' OR 'management of malnutrition' AND 'mastication' OR 'chewing' OR 'chewing ability' OR 'chewing performance' OR 'masticatory ability' OR 'masticatory function' OR 'masticatory disability' OR 'masticatory dysfunction' OR 'chewing function' OR 'chewing discomfort' OR 'chewing disorder' OR 'chewing problems'
LILACS	“Idosos” OR “Pessoa de Idade” OR “Pessoa Idosa” OR “Pessoas de Idade” OR “Pessoas Idosas” OR “População Idosa” “Anciano” OR “Adulto Mayor” OR “Ancianos” OR “Persona de Edad” OR “Persona Mayor” OR “Personas de Edad” OR “Personas Mayores” OR “Aged” OR “elderly” OR “elderlies” OR “elderly's” OR “elderly people” OR “elderly population” OR “Aging” OR “ageing” OR “older adults” OR “senior” OR “seniors” OR “geriatric” OR “geriatrics” AND “Desnutrição” OR “Desnutrición” OR “Malnutrition” OR “nutritional deficiency” OR “nutritional deficiencies” OR “undernutrition” OR “malnourishment” OR “weight loss” OR “management of malnutrition” OR “Subalimentação” OR “Subnutrição” AND “Mastigação” OR “Masticación” OR “Mastication” OR “chewing” OR “chewing ability” OR “chewing performance” OR “masticatory ability” OR “masticatory function”
PubMed/ Medline	“Aged” OR “elderly” OR “elderlies” OR “elderly's” OR “elderly people” OR “elderly population” OR “Aging” OR “ageing” OR “older adults” OR “senior” OR “seniors” OR “geriatric” OR “geriatrics” AND “Malnutrition”[MeSH Terms] OR “Malnutrition” OR “nutritional deficiency” OR “nutritional deficiencies” OR “undernutrition” OR “malnourishment” OR “weight loss” OR “management of malnutrition” AND “Mastication”[MeSH Terms] OR “Mastication” OR “chewing” OR “chewing ability” OR “chewing performance” OR “masticatory ability” OR “masticatory function” OR “masticatory disability” OR “masticatory dysfunction” OR “chewing function” OR “chewing discomfort” OR “chewing disorder” OR “chewing problems”
Scopus	(TITLE-ABS-KEY (“Aged” OR “elderly” OR “elderlies” OR “elderly's” OR “elderly people” OR “elderly population” OR “Aging” OR “ageing” OR “older adults” OR “senior” OR “seniors” OR “geriatric” OR “geriatrics”) AND TITLE-ABS-KEY (“Malnutrition” OR “nutritional deficiency” OR “nutritional deficiencies” OR “undernutrition” OR “malnourishment” OR “weight loss” OR “management of malnutrition”) AND TITLE-ABS-KEY (“Mastication” OR “chewing” OR “chewing ability” OR “chewing performance” OR “masticatory ability” OR “masticatory function” OR “masticatory disability” OR “masticatory dysfunction” OR “chewing function” OR “chewing discomfort” OR “chewing disorder” OR “chewing problems”))
Web of Science	“Aged” OR “elderly” OR “elderlies” OR “elderly's” OR “elderly people” OR “elderly population” OR “Aging” OR “ageing” OR “older adults” OR “senior” OR “seniors” OR “geriatric” OR “geriatrics” (Tópico) and “Malnutrition” OR “nutritional deficiency” OR “nutritional deficiencies” OR “undernutrition” OR “malnourishment” OR “weight loss” OR “management of malnutrition” (Tópico) and “Mastication” OR “chewing” OR “chewing ability” OR “chewing performance” OR “masticatory ability” OR “masticatory function” OR “masticatory disability” OR “masticatory dysfunction” OR “chewing function” OR “chewing discomfort” OR “chewing disorder” OR “chewing problems” (Tópico)
Google Scholar	“older adults” AND “Malnutrition” AND “chewing problems” OR “masticatory disability” filetype:PDF
Biblioteca digital brasileira de teses e dissertação (BDTD)	“Idosos” OR “Pessoa de Idade” OR “Pessoa Idosa” OR “Pessoas de Idade” OR “Pessoas Idosas” OR “Aged” OR “elderly” OR “elderlies” OR “elderly's” OR “elderly people” OR “elderly population” OR “Aging” OR “ageing” OR “older adults” OR “senior” OR “seniors” OR “geriatric” OR “geriatrics” AND “Desnutrição” OR “Malnutrition” OR “nutritional deficiency” OR “nutritional deficiencies” OR “undernutrition” OR “malnourishment” OR “weight loss” OR “management of malnutrition” OR “Subalimentação” OR “Subnutrição” AND “Mastigação” OR “Mastication” OR “chewing” OR “chewing ability” OR “chewing performance” OR “masticatory ability” OR “masticatory function”
Open Gray	“older adults” AND “Malnutrition”
ProQuest	noft((“aged” OR “elderly” OR “elderly people” OR “elderly population” OR “elderlies” OR “elderly's” OR “elderlys” OR “aging” OR “ageing” OR “senescence” OR “older adults” OR “older adult” OR “older people” OR “senior” OR “seniors” OR “geriatric” OR “geriatrics”)) AND noft((“myofunctional therapy” OR “myofunctional therapies” OR “orofacial myotherapy” OR “oral myotherapy” OR “orofacial myology” OR “oral exercise” OR “promotion program” OR “long-term care prevention programs” OR “resistance training” OR “strength training” OR “exercise program” OR “exercise therapy” OR “remedial exercise”)) AND noft((“Stomatognathic System” OR “Masticatory System” OR “mastication” OR “Chewing” OR “Deglutition” OR “Deglutitions” OR “Swallowing” OR “Swallowings” OR “Speech” OR “Respiration” OR “Breathing”))

Author, year, and country	Sample size and sex	Mean ages	Nutritional assessment	Mastication assessment	Result of the relationship between mastication and nutrition	Lacking/not lacking teeth
Gupta et al.(¹¹11 Gupta A, Khandelwal R, Kapil U. Interrelationship between dental health status and nutritional status among elderly subjects in India. J Family Med Prim Care. 2019;8(2):477-81. http://doi.org/10.4103/jfmpc.jfmpc_353_18. PMid:30984658. http://doi.org/10.4103/jfmpc.jfmpc_353_1... ), 2019, India	n=1,003*; 363 men; 640 women;	69.5 years (men); 67.8 years (women)	Mini Nutritional Assessment, 24-hour dietary recall (n = 248), and body mass index (BMI)	Oral examination	Malnourished with mastication problems: 26.4% (88)	Malnourished, completely toothless = 13 (24.5). Malnourished, with teeth = 127 (13.7)
					No mastication problem: 8% (52)
						At risk of malnutrition, completely toothless = 34 (64.2)
						At risk of malnutrition, with teeth = 587 (63.3)
					Malnutrition prevalence (MNA < 17) was 14.3%	At risk of malnutrition, with teeth = 587 (63.3)
Motokawa et al.(¹²12 Motokawa K, Mikami Y, Shirobe M, Edahiro A, Ohara Y, Iwasaki M, et al. Relationship between chewing ability and nutritional status in japanese older adults: a cross-sectional study. Int J Environ Res Public Health. 2021;18(3):1216. http://doi.org/10.3390/ijerph18031216. PMid:33572969. http://doi.org/10.3390/ijerph18031216... ), 2021, Japan	n= 509 older adults; 294 women	301 participants had poor mastication (73.9 years); 208 had good mastication (72.1 years)	Blood sample; Anthropometric measures; semi-quantitative food frequency questionnaire (Takahashi et al., 2001)	Chewing gum test (Xylitol; Lotte, Saitama, Japan)	301 participants (59.1%) had poor mastication, and 208 had good mastication (40.9%)	Older adults with mastication problems and mean number of teeth: 26.3 (±4.1) p= <0.001
						Older adults without mastication problems and mean number of teeth: 27.6 (±1.8) p= <0.001
					60 participants (11.8%) were malnourished, while 449 (88.2%) had a good nutritional status
					Masticatory ability and nutritional status (Model 1): 95%CI: 1.205- 1.994 p= <0.001
					Masticatory ability and nutritional status (Model 2): 95%CI: 1.004–2.022 p= 0.027
Okamoto et al.(¹³13 Okamoto N, Amano N, Nakamura T, Yanagi M. Relationship between tooth loss, low masticatory ability, and nutritional indices in the elderly: a cross-sectional study. BMC Oral Health. 2019;19(1):110. http://doi.org/10.1186/s12903-019-0778-5. PMid:31196057. http://doi.org/10.1186/s12903-019-0778-5... ), 2019, Japan	n = 1,591 men; 1,543 women	71 years	Blood sample and BMI	Self-report questionnaire and maximum occlusal force measure (Dental Prescale System)	Able to masticate all food groups; with serum albumin <4.4: 260 (20.5%) p=0.041	All five groups of chewable foods significantly decreased with the number of teeth (p= <0.001)
	n = 1,591 men; 1,543 women	71 years	Blood sample and BMI		Unable to masticate all food groups; with serum albumin <4.4: 83 (25.8%) p= 0.041

Question	Answer^* * Y = Yes; N = No; U = Unclear
Question	Gupta et al.(¹¹11 Gupta A, Khandelwal R, Kapil U. Interrelationship between dental health status and nutritional status among elderly subjects in India. J Family Med Prim Care. 2019;8(2):477-81. http://doi.org/10.4103/jfmpc.jfmpc_353_18. PMid:30984658. http://doi.org/10.4103/jfmpc.jfmpc_353_1... )	Motokawa et al.(¹²12 Motokawa K, Mikami Y, Shirobe M, Edahiro A, Ohara Y, Iwasaki M, et al. Relationship between chewing ability and nutritional status in japanese older adults: a cross-sectional study. Int J Environ Res Public Health. 2021;18(3):1216. http://doi.org/10.3390/ijerph18031216. PMid:33572969. http://doi.org/10.3390/ijerph18031216... )	Okamoto et al.(¹³13 Okamoto N, Amano N, Nakamura T, Yanagi M. Relationship between tooth loss, low masticatory ability, and nutritional indices in the elderly: a cross-sectional study. BMC Oral Health. 2019;19(1):110. http://doi.org/10.1186/s12903-019-0778-5. PMid:31196057. http://doi.org/10.1186/s12903-019-0778-5... )
1. Were the inclusion criteria in the sample clearly defined?	Y	Y	N
2. Were the study subjects and the scenario described in detail?	Y	Y	U
3. Was the exposure measured in a valid and reliable way?	U	Y	Y
4. Were objective and standard criteria used to measure the condition?	N	N	N
5. Were confounding factors identified?	N	Y	Y
6. Were strategies for deal with confounding factors stated?	N	U	N
7. Were the outcomes measured in a valid and reliable way?	Y	Y	U
8.Was appropriate statistical analysis used?	Y	Y	Y
% yes/risk	50%	75%	37.5%
% yes/risk	Mod	Low	Hight

Research question: To determine the relationship between mastication and malnutrition in community-dwelling older adults?
Certainty assessment							Certainty
Nº of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Prevalencia
3	observational studies	Serious^a a Exclusion factors were not undefined, and confounding factors;	serious^b b Presence of a source of heterogeneity even after the feasibility analysis;	not serious	Serious^c c Wide confidence interval	none	⨁◯◯◯
3	observational studies			not serious	Serious^c c Wide confidence interval	none	VERY LOW

[1] Conflict of interests: nothing to declare.

Brasil

Brasil

Relationship between mastication and malnutrition in community-dwelling older adults: a meta-analysis

ABSTRACT

Purpose

Research strategies

Selection criteria

Data analysis

Results

Conclusion