---
title: "CAMCAM program pilot: integrated oral health and nutrition education in community children’s cafet"
id: "plos-one-22-development-and-implementation-of-an-integrated-oral-health-and-nutrition"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-22-development-and-implementation-of-an-integrated-oral-health-and-nutrition"
content_type: "clinical_feed_article"
specialty: "Pediatrics"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357410"
published_at: "2026-09-03T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# CAMCAM program pilot: integrated oral health and nutrition education in community children’s cafet
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-22-development-and-implementation-of-an-integrated-oral-health-and-nutrition
- **Specialty:** [Pediatrics](https://medichelpline.com/clinical-feed/pediatrics.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357410)
- **Published At:** 2026-09-03T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This pilot study evaluated the adapted Comprehensive Awareness Modification of Mouth, Chewing, and Meal (**CAMCAM**) program for children (CAMCAM-P for kids) delivered monthly at two community children’s cafeterias in Tokyo over six months. - The single-group pre–post design enrolled 84 participants (52 children, 32 parents/guardians) who were regular cafeteria users and had no relevant food allergies. - Sessions included a 10-minute lecture on oral health, chewing, and nutrition plus a specially designed **CAMCAM bento** intended to increase chewing via texture, portion size, cutting, and cooking adjustments; weekly informational messages and recorded lectures were provided via a mobile app. - A bespoke child-specific CAMCAM Checklist questionnaire assessed oral-health behaviors, dietary habits, chewing-related behaviors, and food intake frequency before and after the intervention. - Median ages were 8.5 years (children) and 43.0 years (parents). Outcomes included increased self-observation of the oral cavity among children and increased daily fluoride use (from 61.5% to 76.9%, p = 0.020). - The proportion of children who reported not considering nutritional balance decreased (63.5% to 38.5%, p = 0.022); parental practice of nutritionally balanced diets rose non-significantly (56.2% to 75.0%). - Reported food intake frequency increased for caregivers (meat, dairy products, tubers) and for children (rice, tubers, fruits) after the program. - The number of participants who did not consider the number of chewing cycles decreased, indicating greater attention to chewing. - As a feasibility pilot without a control group, authors note findings are preliminary and recommend larger controlled studies to confirm effectiveness. - Ethical approval, registration (UMIN000048328), data availability, funding sources, and lack of competing interests were reported in the manuscript.
## Clinical Analysis & Structured Key Points
Development and implementation of an integrated oral health and nutrition education program using community children’s cafeterias: A pilot study | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Figures Figures Abstract Background Dental and oral health activities that promote awareness of oral health are essential in children’s nutrition education. We aimed to evaluate the effects of the Comprehensive Awareness Modification of Mouth, Chewing And Meal (CAMCAM) program for kids, in which participants gather monthly to learn about oral health and nutrition while consuming a textured meal at community children’s cafeterias. Methods This single-group pre–post pilot intervention without a control group included 52 children and 32 parents/guardians who regularly attended two community children’s cafeterias in Tokyo, Japan. They participated monthly in six sessions in which they were provided a “munchy” textured meal and a 10-minute lecture on chewing, oral health, and food and nutrition. Participants completed questionnaires assessing their awareness of the subject and food intake frequency, before and after the intervention. Changes in awareness and behaviors following participation in the program were analyzed. Results The median ages of the children and parents were 8.5 (6–16) and 43.0 (36–50) years, respectively. The frequency of self-observation of the oral cavity among children increased. Daily fluoride use frequency increased from 61.5% to 76.9% (p = 0.020). The number of children who reported not considering nutritional balance decreased from 63.5% to 38.5% (p = 0.022). The number of parents/guardians who actively practiced a nutritionally balanced diet non-significantly increased from 56.2% to 75.0%. Food intake frequencies for meat, dairy products, and tubers, among caregivers, and that for rice, tubers, and fruits among children increased post-intervention. The number of participants who did not consider the number of chewing cycles decreased. Conclusion Participation in CAMCAM-P for kids was associated with favorable changes in oral health awareness and attitudes toward nutritional balance among children and parents/guardians. As a pilot study without a control group, these findings should be considered preliminary. Larger controlled studies are warranted to confirm effectiveness. Citation: Hidaka R, Kojo A, Masuda Y, Hata S, Tanaka M, Watanabe T, et al. (2026) Development and implementation of an integrated oral health and nutrition education program using community children’s cafeterias: A pilot study. PLoS One 21(9): e0357410. https://doi.org/10.1371/journal.pone.0357410 Editor: Nour Amin Elsahoryi, University of Petra (UOP), JORDAN Received: February 16, 2026; Accepted: August 18, 2026; Published: September 3, 2026 Copyright: © 2026 Hidaka et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are within the manuscript and its Supporting Information files. Funding: Mitsubishi Foundation Social Welfare Research Grant (53rd Grant, 2022), the 2024 Tokyo Metropolitan Government–University Collaborative Project, the Japan Society for the Promotion of Science (JSPS) KAKENHI Grants(23K16217). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Introduction Oral health habits, food preferences, and dietary behaviors established in early childhood are reported to have long-lasting effects throughout the life course [ 1 – 3 ]. In recent years, children’s dietary challenges have become increasingly complex. These include imbalanced nutrient intake and skipped breakfast, raising concerns about their long-term health impacts such as obesity [ 4 , 5 ]. Furthermore, there is a decrease in the frequency of breakfast consumption and intake of fruits and vegetables during the transition from elementary to junior high school [ 6 ], highlighting the importance of establishing desirable dietary habits at an early stage. In Japan, delays in the development of oral functions in children are a public health concern. To emphasize the importance of early intervention, oral hypofunction in children was added to the list of diseases covered by the national dental health insurance system in 2018 [ 7 ]. Insufficient development of oral function can result in difficulties in eating and may contribute to imbalanced nutrition. Previous research reported that the prevalence of pediatric oral hypofunction among dental outpatients aged 0–17 years was 2,431.3 per 100,000 children (2.4%), and it is suggested that the actual number of affected children may be even higher [ 8 ]. Therefore, oral hypofunction may be one of the factors underlying recent dietary issues among children. Accordingly, collaboration with dental and oral health activities that promote awareness of oral health and chewing is essential when designing nutrition education programs for children. Parental characteristics also play a significant role. Parents’ sociodemographic characteristics, such as educational level, as well as their oral health behaviors—toothbrushing practices, frequency of dental visits, and oral health education—have been shown to exert both direct and indirect effects on children’s oral health behaviors and status [ 9 – 13 ]. In addition, higher levels of parental nutrition knowledge have been associated with more desirable dietary behaviors in children [ 14 ]. These findings indicate that interventions targeting children and their caregivers are necessary to establish healthy habits from early childhood. The Comprehensive Awareness Modification of Mouth, Chewing, and Meal (CAMCAM) program (CAMCAM-P) was originally developed to prevent frailty among community-dwelling older adults [ 15 – 18 ]. The CAMCAM-P aims to promote behavioral changes related to oral health, diet, and physical health by incorporating educational components on oral health and nutrition while participants consume a specially designed CAMCAM textured meal ( CAMCAM bento®) that emphasizes chewing. A 6-month intervention has been shown to promote positive changes in awareness related to oral health, nutrition, and chewing among older adults with oral frailty, leading to improvements in oral and physical frailty. In the present study, the CAMCAM-P was adapted for children and their caregivers, to examine whether this modified program could induce changes in awareness and behaviors related to oral health, nutrition, and chewing in both groups. Materials and methods Participants This study was designed as a pre–post pilot intervention without a control group and was conducted between April 2023 and December 2024. A total of 84 participants (52 children and 32 parents/guardians) were recruited from two community children’s cafeterias in Tokyo. These cafeterias were selected based on their established collaboration with the research team and their stable user populations, which made them suitable settings for a feasibility-oriented pilot intervention. A convenience sampling approach was used, as the primary aim of this study was to assess the feasibility and preliminary changes associated with the integrated oral health and nutrition education program. Participants were eligible if they were regular attendees of the cafeterias and did not have any food allergies that would interfere with the program activities. Written and verbal informed consent was obtained from parents or legal guardians, and assent was obtained from all participating children. Participation was voluntary, and all data were anonymized prior to analysis. This study was conducted in accordance with the principles of the Declaration of Helsinki (World Medical Association, 2015) and the Ethical Guidelines for Life Science and Medical Research Involving Human Subjects (March 23, 2021). Ethical approval was obtained from the Ethics Committee of the Faculty of Dentistry, Institute of Science Tokyo (approval number: D2022-026). The study was also registered with the University Hospital Medical Information Network (UMIN) (trial ID: UMIN000048328). Intervention The Comprehensive Awareness Modification of Mouth, Chewing, and Meal (CAMCAM) program for Children (CAMCAM-P for kids) was implemented over a 6-month period. Once a month, participants attended an educational session on oral health, chewing, and nutrition, and received a specially designed bento meal ( CAMCAM Bento ) intended to promote chewing. Each educational session lasted approximately 10 min. Overall, six sessions were conducted during the intervention period. Lectures were delivered by dentists, dental hygienists, and registered dietitians using presentation slides covering topics related to oral health, chewing, and nutrition. The CAMCAM Bento consisted of rice as the staple food, a main dish, and side dishes. The bento was designed to increase chewing frequency by (1) using foods with higher chewiness, (2) cutting ingredients into larger pieces, (3) shortening cooking times, and (4) reducing moisture content. In addition, a mobile application was used to disseminate short informational messages (approximately 200 characters) once a week on topics related to oral health, nutrition, and chewing, and to allow participants to view recorded lectures. Questionnaire A child-specific CAMCAM Checklist was developed to evaluate changes in participants’ awareness and behaviors associated with participation in the program. The questionnaire was developed by the research team based on a review of previous studies and existing oral health and nutrition education materials [ 19 – 21 ], and through discussion with dentists and dental hygienists. The checklist was designed as an original instrument tailored to the objectives and context of this study. The full questionnaire is provided in Supplementary Appendix 1 to ensure transparency and reproducibility. The questionnaire consisted of items related to oral health, dietary behaviors, and chewing. Oral health items included questions on toothbrushing behaviors (frequency of toothbrushing, frequency of autonomous toothbrushing [children only], and frequency of parental-assisted brushing [parents/guardians only]), frequency of observing the oral cavity, regular dental visits, and frequency of fluoride use. Diet-related items included dietary habits (number of meals, frequency of breakfast consumption, frequency of eating breakfast together, and consideration of nutritional balance) [ 20 ]. Food intake diversity was assessed using the Dietary Variety Score [ 21 ], a previously established measure. Chewing-related items assessed the frequency of behaviors such as “paying attention to the number of chewing cycles,” “leaving hard foods uneaten,” and “consuming foods that require chewing.” Changes in awareness and behaviors related to oral health, nutritional balance, and chewing were evaluated using the Transtheoretical Model (TTM) [ 22 ]. The TTM categorizes behavior change into five stages: precontemplation (not currently performing the behavior and not interested), contemplation (not currently performing the behavior but intending to do so within 6 months), preparation (not currently performing the behavior but intending to do so within 1 month), action (performing the behavior for < 1 month), and maintenance (performing the behavior for ≥ 1 month). In the original TTM, maintenance is defined as sustaining the behavior for ≥ 6 months; however, Walton, et al. [ 23 ] recommended a shorter evaluation period of 2 months for studies involving fifth- and sixth-grade elementary school students, as 6 months exceeds the recall capacity of children in this age group. Given that the participants in the present study included children from the first grade of elementary school and above, who were of an even younger age range, the maintenance stage for children was defined as “sustaining the behavior for ≥ 1 month.” Measures Oral function assessments were conducted only in children. Oral function was evaluated using the Simplified Debris Index and Simplified Calculus Index of the Oral Hygiene Index–Simplified [ 24 ], the PMA index [ 25 ], tongue–lip motor function (oral diadochokinesis [ODK]), masticatory performance, lip pressure, and tongue motor function. Additionally, lip closure, lingual frenulum abnormalities, mouth breathing, palatine tonsil hypertrophy, and the presence of unfavorable oral habits were evaluated. Interviews were also conducted with the children and their parents or guardians. Masticatory performance was evaluated using a chewing ability test gum (XYLITOL® chewing ability test gum, Lotte Co., Ltd.). Participants were instructed to chew the gum for 1 min, and the degree of color change was assessed using a five-grade color chart [ 26 – 28 ]. ODK was assessed using an automatic speech analyzer (Kenkou-kun Handy, Takei Scientific Instruments Co., Ltd., Japan). The number of repetitions of monosyllabic sounds (/pa/, /ta/, /ka/) was recorded. Oral motor ability related to articulation was evaluated by measuring the number of syllables produced per second [ 29 ]. Lip pressure was measured using a dental lip strength measurement device (Lipple-kun, Shofu Inc., Japan) [ 30 ]. Participants were instructed to insert a button into the oral vestibule and close their lips. After pulling the button horizontally, the force required to dislodge the button from the oral vestibule was measured. Following one practice trial, measurements were taken three times, and the mean value was calculated as the lip pressure. Tongue motor function was assessed using a tongue pressure measurement device (TPM-01, JMS Co., Ltd.). Participants were instructed to press a small balloon-type disposable oral probe against the palate as forcefully as possible [ 31 , 32 ]. After one practice trial, measurements were performed three times, and the mean value was used for analysis. Based on a comprehensive evaluation of questionnaire responses, measurement results, and interview findings, the prevalence of oral hypofunction was determined [ 7 , 33 ]. Statistical analysis Comparisons before and after the intervention of the CAMCAM-P for kids were analyzed using the Wilcoxon signed-rank test. A p value of <0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 29.0 software (SPSS Inc., Chicago, IL, USA). Results The basic characteristics of the 84 participants (52 children and 32 parents/guardians) are shown in Table 1 . Download: PNG larger image TIFF original image Table 1. Participant characteristics. https://doi.org/10.1371/journal.pone.0357410.t001 The results of the CAMCAM checklist are presented in Tables 2 , 3 , 4 . Regarding items related to oral health, children showed a significant increase in the frequency of observing their oral cavity (p = 0.039). Additionally, the proportion of children who reported using fluoride “every day” increased from 32 (61.5%) to 40 (76.9%). The number of parents/guardians who reported “rarely using fluoride” decreased from 16 (50.0%) to 6 (18.8%). There were no significant changes in the frequency of parental-assisted tooth brushing, the number of daily tooth-brushing episodes, or the frequency of regular dental visits among parents/guardians. Download: PNG larger image TIFF original image Table 2. Items of the CAMCAM Checklist for children. https://doi.org/10.1371/journal.pone.0357410.t002 Download: PNG larger image TIFF original image Table 3. Items of the CAMCAM Checklist for parents/guardians. https://doi.org/10.1371/journal.pone.0357410.t003 Download: PNG larger image TIFF original image Table 4. Food intake frequency (1: Almost every day, 2: Every 2 days, 3: 1–2 times per week, 4: Rarely/Almost never). https://doi.org/10.1371/journal.pone.0357410.t004 For nutrition-related items, the number of children who reported that they had not considered dietary balance decreased from 33 (63.5%) before the intervention to 20 (38.4%) after the intervention (p = 0.015). Furthermore, among children, the intake frequency of rice, potatoes, and fruits increased significantly (p = 0.011, 0.032, and 0.036, respectively). Similarly, the intake frequency of meat, eggs, and potatoes increased significantly among parents/guardians (p = 0.021, 0.028, and 0.003, respectively). Regarding mastication-related items, the frequency of “consuming foods that require chewing” also tended to increase, albeit non-significantly, in children and parents/guardians (p = 0.085 and p = 0.112, respectively). The results of the behavioral change indicators are shown in Figs 1 – 3 . For oral health behaviors, the proportion of children in the action and maintenance stages increased from 13 (25.0%) to 17 (32.7%) (r = −0.13, p = 0.346), whereas little change was observed among parents/guardians. For nutritional balance, the proportion of participants in the action and maintenance stages increased from 9 (17.3%) to 18 (34.6%) and from 18 (56.2%) to 24 (75.0%), in children and their parents/guardians, respectively (r = −0.39, p = 0.005 and r = 0.09, p = 0.619). Regarding mastication, the proportion of children in the action and maintenance stages increased from 17 (32.7%) to 22 (42.3%). Meanwhile, the proportion of parents/guardians in the precontemplation stage decreased from 12 (37.5%) to 5 (15.6%) (r = −0.18, p = 0.197 and r = −0.13, p = 0.480, respectively). Download: PNG larger image TIFF original image Fig 1. TTM stages for oral health. Distribution of stages of change in children and parents at baseline and at the final assessment. https://doi.org/10.1371/journal.pone.0357410.g001 Download: PNG larger image TIFF original image Fig 2. TTM stages for nutritional. Distribution of stages of change in children and parents at baseline and at the final assessment. https://doi.org/10.1371/journal.pone.0357410.g002 Download: PNG larger image TIFF original image Fig 3. TTM stages for chewing. Distribution of stages of change in children and parents at baseline and at the final assessment. https://doi.org/10.1371/journal.pone.0357410.g003 The results of the oral examinations stratified by school grade are shown in Table 5 . In the lower-grade group, significant improvements were observed in ODK /pa/, ODK /ka/, masticatory performance, and tongue pressure (p = 0.014, 0.029, 0.047, and 0.023, respectively). In the higher-grade group, gingival inflammation of the interdental papillae improved significantly (p = 0.010). The prevalence of oral hypofunction was 23.3% and 40.9% in the lower- and higher-grade groups, respectively at baseline, and 36.7% and 13.6% in the lower- and higher-grade groups, respectively, at follow-up (p = 0.096). The increase in the number of children classified as “having oral hypofunction” at follow-up was attributed to an increased number of lower-grade children who reported lip incompetence in the questionnaire, which rose from 6 (20.0%) to 14 (46.7%) (p = 0.046). Download: PNG larger image TIFF original image Table 5. Oral function measurement results. https://doi.org/10.1371/journal.pone.0357410.t005 Discussion In this study, a combined oral health and food education program was implemented for children who used a community children’s cafeteria and their parents/guardians, and its effects on oral health, nutrition, mastication, and oral behaviors were evaluated. The program promoted positive changes in oral health behaviors, nutritional balance, and awareness and behaviors related to mastication in both children and parents/guardians. 1. Effects o
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