The New Canada Food Guide: Considerations For Periodontal Health

The Updated Canada Food Guide
This year marked the first update to the Canada Food Guide (CFG) since 2007. The highly recognizable rainbow showing different food groups was replaced with a plate of food – known as the ‘Eat Well Plate’–representing proportions of different foods that Canadians should be putting on their plates to conform to healthy eating patterns.¹ The updated food guide may be easier for Canadians to use because of the removal of serving sizes and the recommended number of servings and instead switching to the different proportions of types of foods. Similar to the previous CFG, the updated CFG was also created in a way that continues to promote the integration of ethnic cuisine, helping to make the guide applicable to all Canadians².

What’s New in the Canada Food Guide?
Some of the key changes that Canadians will have noticed with the updated CFG are the removal of the four food groups ‒ instead, there is emphasis on eating vegetables and fruits, whole grains, and protein-rich foods. Also, as mentioned previously, the recommended number of servings has been replaced by advising Canadians to consume the proportions outlined in the Eat Well Plate: one half of the plate with vegetables and fruits, one quarter of the plate with whole grains, and one quarter of the plate with protein rich foods. While the “Eat Well Plate” visual shows a variety of foods that can be included in each section, it is also worth mentioning that the foods depicted are by no means exhaustive. Also, the CFG highlights that healthy eating habits is not merely the food we eat, but also includes social factors such as eating meals with others, planning and cooking meals, and being mindful of dietary patterns. The CFG was released along with resources to make it more accessible including tips on meal planning, how to make eating healthy more affordable, and recipes.²

What Are the Implications for Periodontal Health?
Epidemiological studies have consistently demonstrated the relationship between diet and periodontal health. Higher intakes of vitamin C, calcium, vitamin D and fibre are just some of the nutrients and food components that have been shown to be associated with periodontal health. Though, it is important to consider that consuming levels above current dietary recommended levels does not necessarily result in better periodontal health. Each country has specific guidelines for nutrient intakes; in Canada and the United States, we have the dietary reference intakes, often referred to as the recommended dietary allowance (RDA) for each nutrient.³ Based on the current evidence in the scientific literature, does the updated CFG have potential implications for periodontal health? And if so, what aspects are relevant for supporting periodontal health?

Vitamin C: Fruits and vegetables are the primary source of vitamin C in the diet. Vitamin C has important antioxidant functions and plays an integral role in collagen synthesis⁴. Higher levels of dietary vitamin C have been associated with improved healing following sanative therapy in patients with periodontal disease.⁵ The RDA is 90 mg/day for adult males and 75 mg/day for adult females.⁴ It is recommended that smokers consume an additional 35 mg/day because of the additional oxidative stress⁴. The Canadian Health Measures Survey (2012-2013 cycle) found that fewer than 3% of adults 20-79 years of age were vitamin C deficient and that smoking and having a higher Body Mass Index (BMI) were risk factors for having lower plasma vitamin C concentrations.⁶ Because vitamin C is water-soluble, excess amounts are not stored, but excreted in the urine. This is why it is important to ensure that vitamin C is being consumed every day. Individuals who are following the CFG recommendations and filling half their plate with fruits and vegetables every day will meet the RDA for vitamin C.

Calcium and Vitamin D: The removal of the milk and alternatives food group has left some wondering if they should continue consuming dairy. Most people are aware that dairy is an excellent source of calcium, but might not be aware that it is also one of the few dietary sources of vitamin D. Epidemiological studies have shown that individuals who report consuming more calcium-rich foods are less likely to have periodontal disease.⁷ It has also been shown that calcium from dairy foods such as milk and fermented dairy products is associated with a reduced risk of periodontal disease.⁸ It is important to educate patients that the “milk and alternatives” food group, which previously served as a bold reminder to be aware of calcium intake, is still present in the updated CFG, but has been incorporated into protein-rich foods portion of the “Eat Well Plate”. Individuals should continue to be mindful of their calcium intake. The RDA for calcium is 1000 mg for males 19-70 years old and females 19-50 years old; it increases to 1200 mg for males >70 years old and females >50 years old. Therefore, one serving of dairy (approximately 300 mg of calcium) is about ¼ of the daily recommended amount of calcium for a female >50 years old or a male >70 years old⁴. For individuals who cannot or choose not to consume dairy, fortified soy beverages are an alternative as they are typically fortified to equal the amount of calcium and vitamin D in milk. Table 1 presents the calcium levels found in representative foods from each of the three sections of the “Eat Well Plate” (fruits and vegetables; protein-rich foods; whole grain foods).

Few foods contain significant quantities of vitamin D (Table 1); this means that most people are unlikely to reach the RDA through diet alone. Vitamin D can be synthesized through the skin following exposure to ultraviolet B rays; however, risks of skin cancer due to sun exposure and the fact that synthesis in the skin cannot occur for six months of the year in Canada (due to distance from the sun) necessitate dietary and/or supplemental sources of vitamin D to meet the recommended requirement. Vitamin D is essential for maintenance of bone and teeth, as well as aiding the absorption of calcium from the small intestine.⁹ Some studies have shown that lower levels of vitamin D have been associated with an increased risk of gingivitis and chronic periodontitis and loss of jaw bone.¹⁰ Additionally, the production of anti-microbial peptides, cathelicidin and defensins, are stimulated by vitamin D and these compounds can reduce the number of harmful bacteria in the mouth.¹⁰

Vitamin D supplements are warranted to achieve appropriate levels at all times of the year. The International Osteoporosis Foundation advises individuals who are 60 years of age and older to take a vitamin D supplement of 800 to 1000 IU/day. There are similar recommendations from Osteoporosis Canada which advises that healthy adults between 19-50 years of age, including pregnant or breastfeeding women, need between 400 and 1,000 IU daily; adults over age 50 years and individuals at higher risk of fracture (those with osteoporosis, fractures, or conditions affecting vitamin D absorption) should receive 800 to 2,000 IU daily. The two types of vitamin D supplements are vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). When it comes to choosing the right supplement, evidence has suggested that vitamin D3 is more efficacious and faster in increasing the level of total vitamin D than vitamin D2 and therefore, the preferred supplement choice for patients.¹¹

Fibre: Fibre is an emerging nutrient of interest for periodontal health. Individuals eating a plant-based diet are likely meeting the recommended levels of fibre (Table 1): 25 or 21 g/day for females aged 19-50 years old or >50 years old, respectively; and 38 or 30 g/day for males aged 19-50 years old or > 50 years old, respectively.³ Fibre consumption is associated with reduced risk of cardiovascular disease, type II diabetes, and obesity.¹² Plant-based sources of protein also tend to be rich in dietary fibre as shown in Table 1. With whole grains also being rich in fibre, there is the opportunity to consume fibre in every portion of the “Eat Well Plate”, but based on the Canadian Community Health Survey, individuals are not meeting the recommended level of dietary fibre.¹³ According to Health Canada, most Canadians are only getting about half of the recommended amount.¹⁴ There is evidence that a diet high in fibre may be protective against periodontal disease.¹⁵ Using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012, the periodontal health and dietary fibre intake of 6052 adults was analyzed.¹⁵ Individuals in the lowest quartile of dietary fibre intake, determined to be ≤ 11.9 g/day, were more likely to have moderate-severe periodontitis than those in the highest quartile of dietary fibre intake (>23.25 g/day). To put this in context, a 40-year-old female in the lowest quartile would be eating less than half the recommended amount of fibre, but if she were in the highest quartile, she would be consuming the recommended amount. When the source of dietary fibre was analyzed, those who had lower intakes of fibre specifically from whole grains were more at risk for having periodontal disease. Those in the lowest quartile of fibre from fruit and vegetable sources did not have increased risk of periodontal disease. This indicates that not only the total amount, but also the source of fibre might be important for periodontal health. Therefore, it is important to ensure patients are consuming fibre from a variety of sources including whole grains. Thus, the emphasis of the updated CFG to include more plant-based protein such as legumes and nuts, whole grains, and fruits and vegetables should help Canadians achieve the recommended intake for fibre. Starting the day with a bowl of bran cereal, choosing fruit or nuts for snacks, and adding a legume at dinner will help individuals meet their fibre needs (Table 1).

Guidance for Patients:
Following the CFG will help individuals be mindful of consuming foods that not only benefit overall health but also periodontal health.

• Encourage patients to eat a variety of fruits and vegetables because they all differ in levels of vitamins and minerals. Half their plate should consist of fruits and vegetables, one quarter should include whole grains and one quarter should include protein-rich foods.
• For guidance regarding meal planning, how to make eating healthy more affordable, and recipes, visit this website: https://food-guide.canada.ca/en/tips-for-healthy-eating/
• Dairy has not been removed from the CFG. It continues to be an excellent source of calcium, vitamin D, and protein. Calcium supplements should only be taken if the calcium requirement cannot be met by food intake alone. An estimated 300 mg of calcium comes from eating a healthy, varied diet as many different foods contain small amounts of calcium. Dairy or alternatives with similar level of calcium should be considered to meet the recommended level.
• Meeting the recommended intake for vitamin D is difficult through food alone, therefore, vitamin D3 supplementation should be considered.
• Individuals can get fibre in their diet from food sources belonging to all three sections of the “Eat Well Plate”. Fruits and vegetables, whole grains, and protein – particularly plant-based legumes and nuts – can be sources of fibre.
• All diets, but particularly plant-based diets, should vary in protein sources to ensure adequate intake of the essential amino acids.

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References

1. Health Canada. (2019). Canada’s Food Guide. Available at: https://food-guide.canada.ca/en/.
2. Health Canada. (2019). Tips for healthy eating. Available at: https://food-guide.canada.ca/en/tips-for-healthy-eating/.
3. Health Canada. (2006). Dietary reference intakes tables. Available at: https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/dietary-reference-intakes.html.
4. Brock, G. R., and Chapple, I.L.C. (2016). The potential impact of essential nutrients vitamin C and Dupon periodontal disease pathogenesis and therapeutic outcomes. Current Oral Health Reports, 3(4): 337-346.
5. Dodington, D.W., et al., Higher intakes of fruits and vegetables, beta-carotene, vitamin C, alpha-tocopherol, EPA, and DHA are positively associated with periodontal healing after nonsurgical periodontal therapy in nonsmokers but not in smokers. Journal of Nutrition, 2015. 145(11): 2512-9.
6. Langlois, K., M. Cooper, and C.K. Colapinto. Vitamin C status of Canadian adults: Findings from the 2012/2013 Canadian Health Measures Survey. Health Report, 2016. 27(5): 3-10.
7. Nishida, M., et al., Calcium and the risk for periodontal disease. J Periodontol, 2000. 71(7): 1057-66.
8. Adegboye, A.R., et al., Intake of dairy products in relation to periodontitis in older Danish adults. Nutrients, 2012. 4(9): 1219-29.
9. Jagelavi iene, E., et al., The relationship between vitamin D and periodontal pathology. Medicina (Kaunas), 2018. 54(3): 45.
10. McMahon L., et al. Vitamin D-mediated induction of innate immunity in gingival epithelial cells. Infection and Immunity, 2011. 79: 2250–2256.
11. Tripkovic, L., et al. Comparison of vitamin D2 and vitamin D3 supplementation in raising serum 25-hydroxyvitamin D status: a systematic review and meta-analysis. American Journal of Clinical Nutrition, 2012. 95(6): 1357–1364.
12. Cho, S.S., et al., Consumption of cereal fiber, mixtures of whole grains and bran, and whole grains and risk reduction in type 2 diabetes, obesity, and cardiovascular disease. American Journal of Clinical Nutrition, 2013. 98(2): 594-619.
13. Health Canada. (2012). Do Canadians meet their nutrient requirements through food intake alone? Available at: https://www.canada.ca/en/health-canada/services/food-nutrition/food-nutrition-surveillance/health-nutrition-surveys/canadian-community-health-survey-cchs/canadian-adults-meet-their-nutrient-requirements-through-food-intake-alone-health-canada-2012.html#a323.
14. Health Canada. (2019). Fibre. Available at: https://www.canada.ca/en/health-canada/services/nutrients/fibre.html.
15. Nielsen, S.J., et al., Dietary fiber intake is inversely associated with periodontal disease among US adults. Journal of Nutrition, 2016. 146(12): 2530-2536.

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About The Author

Jennifer Beaudette is a PhD candidate in Applied Health Sciences at Brock University. Jennifer’s research focuses on the effect of diet on oral and bone health.

 

 

Carly Zanatta is a MSc candidate in Applied Health Sciences at Brock University. Carly’s research focuses on the effect of diet on healing after sanative therapy.

 

 

Wendy Ward is a Professor and Canada Research Chair in the Department of Kinesiology in the Faculty of Applied Health Sciences at Brock University. Her research team investigates how diet supports a healthy skeleton as well as healing after periodontal procedures within preclinical and clinical studies.

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