- Email: [email protected]
Commonsense dietary recommendations for geriatric dental patients
Commonsense dietary recommendations for geriatric dental patients Ken Wical, D.D.S., M.S.D.* Loma Linda University, School of Dentistry, Loma Linda, Calif.
N
umerous surveys have documented the fact that elderly people frequently suffer from malnutrition.‘” Some of the reasons for the elderly’s poor diet patterns and food utilization include (1) impaired chewing ability, (2) decreased appetite, (3) lack of knowledge, (4) established habits, (5) financial limitations, (6) social isolation, (7) logistic problems with food, (8) medical restrictions, (9) impaired digestion, (10) decreased absorption, (11) impaired glucose tolerance, and (12) effects of drugs. It is clear that not all people who have passed the arbitrary milestone of 65 years have health or nutrition problems, but a high percent of prosthodontic patients disadvantaged” might be classified as “nutritionally geriatric patients, A dental examination frequently reveals signs suggestive of nutritional deficiencies such as atrophic mucous membrane, excessive resorption of alveolar bone, or slow healing responses following injury. It must be emphasized that patients who have systemic diseases or oral conditions for which inadequate nutrition is a contributing factor cannot be restored to health until their nutritional problems are corrected. The dentist should be responsible for seeking out and treating nutritional inadequacies just as he or she is responsible for treating any other factors in dental disease, such as infections, irritations, malocclusions, or neoplasms. Patients with less-thandesirable eating habits should be offered the benefits of guidance in establishing better long-term dietary practices.
RATIONAL
BASIS FOR COUNSELING
Practical recommendations for dietary changes should be based on the particular problems of an individual patient rather than on generalizations Presented at the Pacific Coast Society of Prosthodontists, Newport Beach, Calif., and at the American College of Prosthodontists, Monterey, Calif. *Professor and Chairman, Department of Removable Prosthodontics.
162
FEBRUARY
1983
VOLUME
49
NUMBER
2
gleaned from surveys. A personal history, medical history, and dental history will often disclose the existence of some of the described specific factors. In addition to this information, a reliable evaluation of the patient’s diet pattern is also essential for realistic personal counseling. The method of dietary evaluation taught by Dr. Abraham Nizel has proved most useful in office practice. It is explained thoroughly in his recent book Nutrition in Preventive Dentistry: Science and Practice.6 Significant variances from a balanced diet that are revealed in a patient’s diet history indicate the need for instruction. In some circumstances it is possible to, refer the patient to a registered dietitian. It is important, however, that the dietitian recognize the handicaps faced by a patient with impaired masticating ability when preparing diets and menus for these patients. For dentists who wish to provide this service in their own office, Dr. Nizel’s book is recommended.6
THE ELUSIVE GOAL: A “BALANCED
DIET”
Ideally, we like to see every patient eat four or more daily servings of vegetables and fruits, four servings of whole grain cereal foods, three servings of milk or cheese, three or more servings of meat or other protein foods, 1 teaspoon of vegetable oil, and six glasses of water. Such a diet would provide most of the caloric needs and most of the requirements for the other essential nutrients. We would also like to minimize the use of sugars, highly refined carbohydrates, solid fats, and salt. Unfortunately, few of our geriatric patients are able to adopt an ideal program simply because it is suggested, particularly if it presents too much of a change from their established dietary patterns. Common sense dictates that we start with what patients will accept, reinforce their desirable practices, wean them away from poor habits as much as possible, and lead them toward the described goal insofar as they are willing to follow. It is not the purpose of this article to review all the
00%3913/83/020162
+ [email protected]/0@ 1983 The C. V. Mosby Co.
DIET
AND
THE GERIATRIC
DENTAL
PATIENT
accepted basic principles of nutrition and dietary counseling. However, a few “commonsense” dietary modifications that have proved helpful in treating patients with restricted diet preferences and capabilities are in order. The reader who is interested in basic nutritional information is referred to reliable, readily available sources.6,7
PRACTICAL DIETARY SUGGESTIONS The suggestion of vegetable soups with meat and bone added, as advocated by Massler,8 has shown good patient acceptability. Thick soups contain vitamins, minerals, protein, fiber, and water at the same time. Whole grain breads softened with fruit, soups, and stews make up other valuable combinations of nutritious foods that can be enjoyed by patients with limited chewing ability. Many patients cannot or will not drink milk. Individuals do not need milk per se, but they do require calcium and vitamin D, which in the typical North American dietary pattern are obtained almost solely from milk and milk products. The use of yogurt and cheesesis acceptable to many milk-avoiders. Powdered dry milk added to cooked or prepared dishes is another way to introduce milk into the diet. For other patients calcium supplements may be the most practical and acceptable way of providing for their critical calcium needs9 Reviews of recent studies of the protein requirements for elderly persons indicate that past recommendations for the level of protein intake may not consistently maintain nitrogen balance in these persons.‘,” My experience with prosthodontic patients has reinforced my conviction that denture tolerance is improved with a higher intake of protein. I encourage patients to eat, at a minimum, three servings of protein foods each day. The use of high-quality animal protein is stressed. For vegetarian patients the use of milk, eggs, and whole grain foods is particularly important. Occasionally protein supplements may be indicated. Confusion regarding the importance of whole grain breads and cereal foods, which are largely neglected by most patients, often exists. Only whole grain breads and cereals provide the protein, vitamins, and minerals that are the important contributions of this group of foods. Refined carbohydrate foods, which make up the bulk of the diets of most geriatric patients, supply little more than calories, with relatively insignificant amounts of the other essential nutrients. Whole grain wheat and oat cooked cereals seem to be readily accepted by most patients once their importance is pointed out.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
An importam principle in dietary evaluation and counseling for geriatric patients is that while energy needs decrease with aging due to slowing of body metabolism and reduced physical activity, the requirements for protein, vitamins, minerals, carbohydrates, water, and essential fatty acids remain the same. If less food is eaten bec,auseof decreased needs and diminished appetites, the choice of foods that are able to supply the required essential nutrients becomes even more critical.
INDICATIONS
FOR SUPPLEMENTS
While it is recognized that a careful selection of foods can supply all the necessary nutritional factors, the profession must realistically face the fact that only a few of our geriatric patients will achieve the goal of a complete and balailced intake of highly nutritious foods. For patients who cannot or will not follow an ideal recommended dietary plan, selected food supplements may be very beneficial. Vitamin and mineral suppiements may favorably improve the poor nutrient-to-calorie ratios of the frequently encountered soft carbohydrate diet. Both economic and nutritional abuses can result from the indiscriminate use of supplements, but this can be avoided by careful matching of the patients’ needs with proper supplements and can be done as a result of the diet analysis discussed earlier. Brin and Bauernfeind’ extensively reviewed studies of geriatric nutrition and observed that it costs less to supplement diets with multivitamins than to buy the necessary foods to correct vitamin deficiencies. They also conclude that the potential benefits for elderly patients “outweigh considerably any remote possible complications” of the use of supplements.
CONCLUSION Providing dietary guidance for geriatric patients can be a very rewarding aspect of dental practice. Some knowledge of foods, nutrition, and eating patterns is required, but books and courses that prepare the dentist to provide this service are available. With increasing emphasis placed on the relationship between nutrition and health, dentists will be increasingly expected to fulfill their responsibility for providing nutritional guidance as a part of oral health care. REFERENCES 1. U.S. Department of Health, Education, and Welfare: TenState Nutrition Survey, 1968-1970, V-Dirtaw. DHEW Publication No. (HSM) 7241333, 1972. 2. Baxter, J. C:.: The nutritional intake of ~wnpletc denture
163
WICAL
patients: A computerized study. J Indiana Dent Assoc 59~14, 1980. 3. Schafer, S.: Malnutrition in the aged. Dent Hyg 54~233, 1980. 4. Berger, R.: Nutritional needs of the aged. J Calif Dent Assoc 7:45, 1979. 5. Brin, M., and Bauernfeind, J. C.: Vitamin needs of the elderly. Postgrad Med 63~155, 1978. 6. Nizel, A. E.: Nutrition in Preventive Dentistry: Science and Practice, ed 2. Philadelphia, 1981, W. B. Saunders Co. 7. Recommended Dietary Allowances, ed 9. Washington, D. C., National Research Council, National Academy of Sciences.
8.
Massler, M.: Geriatric nutrition II: Dehydration in the elderly. J PROSTHETDENT 42~489, 1979. 9. Wical, K. E., and Brussee, P.: Effects of a calcium and vitamin D supplement on alveolar ridge resorption in immediate denture patients. J PROSTHETDENT 41:4, 1979. 10. Munro, H. N., and Young, V. R.: Protein metabolism in the elderly. Postgrad Med 63:143, 1978. Reprtnt requests to: DR. KEN WEAL LOMA LINDA UNIVERSITY SCHOOLOF DENTISTRY LOMA LINDA, CA 92350
ARTICLES TO APPEAR IN FUTURE ISSUES Two-piece orbital prosthesis J. B. Barron, D.M.D., M.Ed.Admin.
J. E. Rubenstein, D.M.D.,
Protective effect of polystyrene
MS., D. Archibald, D.M.D.,
and R. E. Manor,
liners for composite resin restorations
Martin Brannstrom, D.D.S., Ph.D., Karl Johan Nordenvall, D.D.S., Ph.D., Bodil Torstenson, D.D.S., Karl G. Hedstrom; D.V.M., Ph.D., and Hans Wahlstam, Ph.D.
Posterior palata! seal location and preparation denture cast
on the maxillary
complete
A. A. Calomeni, D.D.S., MS., E. E. Feldman, D.D.S., M.S., and W. A. Kuebker, D.D.S., MS.
Compatibility of irreversible dental stones
hydrocolloid
impression materials with
L. W. Carlyle III, D.D.S.
Staining of composite and microfilled Robert L. Cooley, D.M.D.,
resin with stannous fluoride
MS., and Wayne W. Barkmeier, D.D.S., M.S.
Removable partial denture survey: Clinical practice today J. M. Cotmore, D.M.D., D.D.S., M.S.
E. B. Mingledorf,
D.D.S.,. J. M. Pomerantz, D.D.S., and J. E. Grasso,
Resorption of the edentulous mandible after a vestibuloplasty grafting
with skin
W. Howard Davis, D.D.S., Howard M. Landesman, D.D.S., M.Ed., James Martinoff, M.A., Ph.D., and Ronald Kaminishi, D.D.S.
164
FEBRUARY
1983
M.Ed.,
VOLUME
49
NUMBER
2
N
umerous surveys have documented the fact that elderly people frequently suffer from malnutrition.‘” Some of the reasons for the elderly’s poor diet patterns and food utilization include (1) impaired chewing ability, (2) decreased appetite, (3) lack of knowledge, (4) established habits, (5) financial limitations, (6) social isolation, (7) logistic problems with food, (8) medical restrictions, (9) impaired digestion, (10) decreased absorption, (11) impaired glucose tolerance, and (12) effects of drugs. It is clear that not all people who have passed the arbitrary milestone of 65 years have health or nutrition problems, but a high percent of prosthodontic patients disadvantaged” might be classified as “nutritionally geriatric patients, A dental examination frequently reveals signs suggestive of nutritional deficiencies such as atrophic mucous membrane, excessive resorption of alveolar bone, or slow healing responses following injury. It must be emphasized that patients who have systemic diseases or oral conditions for which inadequate nutrition is a contributing factor cannot be restored to health until their nutritional problems are corrected. The dentist should be responsible for seeking out and treating nutritional inadequacies just as he or she is responsible for treating any other factors in dental disease, such as infections, irritations, malocclusions, or neoplasms. Patients with less-thandesirable eating habits should be offered the benefits of guidance in establishing better long-term dietary practices.
RATIONAL
BASIS FOR COUNSELING
Practical recommendations for dietary changes should be based on the particular problems of an individual patient rather than on generalizations Presented at the Pacific Coast Society of Prosthodontists, Newport Beach, Calif., and at the American College of Prosthodontists, Monterey, Calif. *Professor and Chairman, Department of Removable Prosthodontics.
162
FEBRUARY
1983
VOLUME
49
NUMBER
2
gleaned from surveys. A personal history, medical history, and dental history will often disclose the existence of some of the described specific factors. In addition to this information, a reliable evaluation of the patient’s diet pattern is also essential for realistic personal counseling. The method of dietary evaluation taught by Dr. Abraham Nizel has proved most useful in office practice. It is explained thoroughly in his recent book Nutrition in Preventive Dentistry: Science and Practice.6 Significant variances from a balanced diet that are revealed in a patient’s diet history indicate the need for instruction. In some circumstances it is possible to, refer the patient to a registered dietitian. It is important, however, that the dietitian recognize the handicaps faced by a patient with impaired masticating ability when preparing diets and menus for these patients. For dentists who wish to provide this service in their own office, Dr. Nizel’s book is recommended.6
THE ELUSIVE GOAL: A “BALANCED
DIET”
Ideally, we like to see every patient eat four or more daily servings of vegetables and fruits, four servings of whole grain cereal foods, three servings of milk or cheese, three or more servings of meat or other protein foods, 1 teaspoon of vegetable oil, and six glasses of water. Such a diet would provide most of the caloric needs and most of the requirements for the other essential nutrients. We would also like to minimize the use of sugars, highly refined carbohydrates, solid fats, and salt. Unfortunately, few of our geriatric patients are able to adopt an ideal program simply because it is suggested, particularly if it presents too much of a change from their established dietary patterns. Common sense dictates that we start with what patients will accept, reinforce their desirable practices, wean them away from poor habits as much as possible, and lead them toward the described goal insofar as they are willing to follow. It is not the purpose of this article to review all the
00%3913/83/020162
+ [email protected]/0@ 1983 The C. V. Mosby Co.
DIET
AND
THE GERIATRIC
DENTAL
PATIENT
accepted basic principles of nutrition and dietary counseling. However, a few “commonsense” dietary modifications that have proved helpful in treating patients with restricted diet preferences and capabilities are in order. The reader who is interested in basic nutritional information is referred to reliable, readily available sources.6,7
PRACTICAL DIETARY SUGGESTIONS The suggestion of vegetable soups with meat and bone added, as advocated by Massler,8 has shown good patient acceptability. Thick soups contain vitamins, minerals, protein, fiber, and water at the same time. Whole grain breads softened with fruit, soups, and stews make up other valuable combinations of nutritious foods that can be enjoyed by patients with limited chewing ability. Many patients cannot or will not drink milk. Individuals do not need milk per se, but they do require calcium and vitamin D, which in the typical North American dietary pattern are obtained almost solely from milk and milk products. The use of yogurt and cheesesis acceptable to many milk-avoiders. Powdered dry milk added to cooked or prepared dishes is another way to introduce milk into the diet. For other patients calcium supplements may be the most practical and acceptable way of providing for their critical calcium needs9 Reviews of recent studies of the protein requirements for elderly persons indicate that past recommendations for the level of protein intake may not consistently maintain nitrogen balance in these persons.‘,” My experience with prosthodontic patients has reinforced my conviction that denture tolerance is improved with a higher intake of protein. I encourage patients to eat, at a minimum, three servings of protein foods each day. The use of high-quality animal protein is stressed. For vegetarian patients the use of milk, eggs, and whole grain foods is particularly important. Occasionally protein supplements may be indicated. Confusion regarding the importance of whole grain breads and cereal foods, which are largely neglected by most patients, often exists. Only whole grain breads and cereals provide the protein, vitamins, and minerals that are the important contributions of this group of foods. Refined carbohydrate foods, which make up the bulk of the diets of most geriatric patients, supply little more than calories, with relatively insignificant amounts of the other essential nutrients. Whole grain wheat and oat cooked cereals seem to be readily accepted by most patients once their importance is pointed out.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
An importam principle in dietary evaluation and counseling for geriatric patients is that while energy needs decrease with aging due to slowing of body metabolism and reduced physical activity, the requirements for protein, vitamins, minerals, carbohydrates, water, and essential fatty acids remain the same. If less food is eaten bec,auseof decreased needs and diminished appetites, the choice of foods that are able to supply the required essential nutrients becomes even more critical.
INDICATIONS
FOR SUPPLEMENTS
While it is recognized that a careful selection of foods can supply all the necessary nutritional factors, the profession must realistically face the fact that only a few of our geriatric patients will achieve the goal of a complete and balailced intake of highly nutritious foods. For patients who cannot or will not follow an ideal recommended dietary plan, selected food supplements may be very beneficial. Vitamin and mineral suppiements may favorably improve the poor nutrient-to-calorie ratios of the frequently encountered soft carbohydrate diet. Both economic and nutritional abuses can result from the indiscriminate use of supplements, but this can be avoided by careful matching of the patients’ needs with proper supplements and can be done as a result of the diet analysis discussed earlier. Brin and Bauernfeind’ extensively reviewed studies of geriatric nutrition and observed that it costs less to supplement diets with multivitamins than to buy the necessary foods to correct vitamin deficiencies. They also conclude that the potential benefits for elderly patients “outweigh considerably any remote possible complications” of the use of supplements.
CONCLUSION Providing dietary guidance for geriatric patients can be a very rewarding aspect of dental practice. Some knowledge of foods, nutrition, and eating patterns is required, but books and courses that prepare the dentist to provide this service are available. With increasing emphasis placed on the relationship between nutrition and health, dentists will be increasingly expected to fulfill their responsibility for providing nutritional guidance as a part of oral health care. REFERENCES 1. U.S. Department of Health, Education, and Welfare: TenState Nutrition Survey, 1968-1970, V-Dirtaw. DHEW Publication No. (HSM) 7241333, 1972. 2. Baxter, J. C:.: The nutritional intake of ~wnpletc denture
163
WICAL
patients: A computerized study. J Indiana Dent Assoc 59~14, 1980. 3. Schafer, S.: Malnutrition in the aged. Dent Hyg 54~233, 1980. 4. Berger, R.: Nutritional needs of the aged. J Calif Dent Assoc 7:45, 1979. 5. Brin, M., and Bauernfeind, J. C.: Vitamin needs of the elderly. Postgrad Med 63~155, 1978. 6. Nizel, A. E.: Nutrition in Preventive Dentistry: Science and Practice, ed 2. Philadelphia, 1981, W. B. Saunders Co. 7. Recommended Dietary Allowances, ed 9. Washington, D. C., National Research Council, National Academy of Sciences.
8.
Massler, M.: Geriatric nutrition II: Dehydration in the elderly. J PROSTHETDENT 42~489, 1979. 9. Wical, K. E., and Brussee, P.: Effects of a calcium and vitamin D supplement on alveolar ridge resorption in immediate denture patients. J PROSTHETDENT 41:4, 1979. 10. Munro, H. N., and Young, V. R.: Protein metabolism in the elderly. Postgrad Med 63:143, 1978. Reprtnt requests to: DR. KEN WEAL LOMA LINDA UNIVERSITY SCHOOLOF DENTISTRY LOMA LINDA, CA 92350
ARTICLES TO APPEAR IN FUTURE ISSUES Two-piece orbital prosthesis J. B. Barron, D.M.D., M.Ed.Admin.
J. E. Rubenstein, D.M.D.,
Protective effect of polystyrene
MS., D. Archibald, D.M.D.,
and R. E. Manor,
liners for composite resin restorations
Martin Brannstrom, D.D.S., Ph.D., Karl Johan Nordenvall, D.D.S., Ph.D., Bodil Torstenson, D.D.S., Karl G. Hedstrom; D.V.M., Ph.D., and Hans Wahlstam, Ph.D.
Posterior palata! seal location and preparation denture cast
on the maxillary
complete
A. A. Calomeni, D.D.S., MS., E. E. Feldman, D.D.S., M.S., and W. A. Kuebker, D.D.S., MS.
Compatibility of irreversible dental stones
hydrocolloid
impression materials with
L. W. Carlyle III, D.D.S.
Staining of composite and microfilled Robert L. Cooley, D.M.D.,
resin with stannous fluoride
MS., and Wayne W. Barkmeier, D.D.S., M.S.
Removable partial denture survey: Clinical practice today J. M. Cotmore, D.M.D., D.D.S., M.S.
E. B. Mingledorf,
D.D.S.,. J. M. Pomerantz, D.D.S., and J. E. Grasso,
Resorption of the edentulous mandible after a vestibuloplasty grafting
with skin
W. Howard Davis, D.D.S., Howard M. Landesman, D.D.S., M.Ed., James Martinoff, M.A., Ph.D., and Ronald Kaminishi, D.D.S.
164
FEBRUARY
1983
M.Ed.,
VOLUME
49
NUMBER
2