DIET AND NUTRITION

CONTENTS:
Introduction. Definitions. Classification Of Foods. Balanced Diet. Etiology Of Dietary Deficiency In Geriatric Patients. Aging Factors Affecting Diet And Nutrtional Status. Oral Factors Affecting Diet And Nutrtional Status. Recommended Dietary Allowances For Elderly. Foods recommended for the elderly.

 Dietary Counselling Of Patients Undergoing Prosthodontic Treatment. Risk Facors Of Malnutrtion. Nutrition Guidelines For Prosthodontic Paitents Diet For New Denture Wearers. Diet After Implant Placement Dietary Supplements Conclusion References

INTRODUCTION

DEFINITIONS

 DIET : (n) food and drink in general A prescribed course of eating and drinking in which the amount and kind of food as well as the times at which it is to be taken are regulated for therapeutic purposes. (Stedman) BALANCED DIET : A diet that furnishes in proper proportions all the nutrients necessary for adequate nutrition. (Stedman) NUTRITION : Is defined as the science of how the body utilizes food to meet requirement for development, growth, repair and maintainance. (DCNA) 6

 NUTRIENT :A nourishing ingredient in food. BASAL METABOLISM :The total heat produced or the energy spent by the body and the conditions to perform minimum possible work. BASAL METABOLIC RATE :The lowest level of energy production consonant with life. RECOMMENDED DAILY ALLOWANCE : Is defined as the intake of nutrient derived from diet which keeps nearly all people in good health 7

 FOOD : (n) is defined as the material usually of plant or animal origin that contains essential nutrients such as carbohydrates, fats, proteins, vitamins or minerals and is ingested and assimilated by an organism to produce energy, stimulate growth and maintain life.

(Stedman)

CLASSIFICATION OF FOODS

1. By origin

a. Plant food

: Cereals, legumes, fruits, vegetables,

sugars, oils.

b. Animal products : Meat, fish, milk, dairy products, eggs, poultry products.

2.

By chemical composition

a) Macronutrients: Proteins
Fats Carbohydrates

b) Micronutrients: Vitamins Minerals

3. By predominant function

- Body building foods (Proteins)

- Energy giving foods (Carbohydrates, fats)

- Protective foods (Minerals, vitamins)

13

Calorie is the energy needed to increase the temperature of 1 gram of water by 1 C

Calories per gram Protein 1 Gram = 4 calories Carbohydrates 1 Gram = 4 calories Fat 1 Gram = 9 calories

 Energy needs declines with age - decrease in basal metabolism & decreased physical activity . Caloric requirement decreases with advancing age . Due to reduced energy expenditure and basal metabolic rate Average energy consumption of 65 74 year old is about Men 1800 kcal Women 1300 kcal

CARBOHYDRATES
Carbohydrates are sugars and starches that the body uses for energy. PLANTS are the major source. Made up of carbon, hydrogen, and oxygen. 2 different types -simple-mono & disaccharides. -complex-polysaccharides.

SIMPLE CARBOHYDRATES
Sugars that are quickly digested and provide a BOOST of energy for the body. Cake, candy & other refined sugar products are also simple sugars but lack vitamin, minerals & fiber.

COMPLEX CARBOHYDRATES
They provide the body with long-term energy since they are digested more slowly than sugars.

Are consumed in large proportion due to Low cost Ability to be stored with out refrigeration Ease of preparation RDA : 50-60% of total calories

FIBER
Important component of complex carbohydrates.
Fiber in the form bran is used as an additive to cereals and bread.

Its main action is in the colon.

COMPOSITION : Cellulose and / hemicellulose. FUNCTIONS In colon : Promotes bowel function.

Allows reabsorption of water.

Reduces effects of toxins and carcinogens. 20

 In large intestine :
Reduces cholesterol absorption .

Even 1 gm difference in dietary fiber intake between the dentate and edentulous could lead to 2% increased risk of myocardial infarction

21

FAT
Organic compounds called lipids which are insoluble in water. Fatty acids are the building blocks of fats. Functions: -ENERGY source for the body (more than carbs and proteins) -Help in absorption of fat soluble vitamins -Help protect and cushion vital organs as well as joints -Insulate the body. -Precursors of cholesterol, steroids, hormones

In the elderly intake of food rich in saturated fats - as butter, lard, pork, and marbled meats, can contribute to atherosclerosis. Food rich in polyunsaturated fats - salad dressings and margarines from cottonseed, corn, soybean, or safflower oils, salmon, tuna, and haddock, can be recommended. Other fish and fowl that are naturally comparatively low in saturated fats can be used.

A suitable diet for the elderly should contain enough fat to provide about 25 to 30% of the calorie intake.

PROTEIN
Function: Provide the building materials your body needs to grow and repair. -The egg is the standard by which other protein foods are measured. The protein of a whole egg has a biologic value of almost 100%.
High protein foods

 When the addition of a nutrient reduces the risk of disease and its elimination increases ,it is refered resistance factor. Protein is a prime resistance agent. Age -protein requirement There is an intimate relationship between the intake quantity and the capacity for utilization of ingested calcium. 2x protein 3X calcium utilization

 Protein deficiency results in -Lower antibody production, -Reduced resistance to infection, -Anemia, -Decrease in muscle volume. Protein malnutrition is found frequently in elderly persons.

VITAMINS (VITAL AMINES)

VITAMIN A RDA : 800 1000 g . SOURCES : Vit A in food occurs in 2 forms i) Retinal or Active Vit A Liver Milk & Milk products ii) Beta carotene or Provitamin A

Deep green and yellow fruits

Vegetables (carrots, spinach, apricots

DEFICIENCY : Bitots spots. Xerophthalmia. Dryness of skin. Folicular hyper keratosis.

Decreased salivary flow.

Keratosis of oral mucosa.

28

VITAMIN B COMPLEX

THIAMINE :(VIT B1)

RDA : 0.5mg per 1000 calories or 1 mg daily SOURCES : Meat (pork and chicken) Peas Whole grains Fortified grains Cereals Yeast DEFICIENCY : Beriberi 29

VITAMIN B2
(Riboflavin) RDA : 3 g

SOURCES :
Kidney Heart Milk Egg Liver Green leafy vegetables

DEFICIENCY : Fissuring and redness of eyelid corners and mouth. Magenta colored tongue.

30

VITAMIN B6 (Pyridoxine) 50 90 % of elderly affected. It is an important cause of prevalence of carpal tunnel syndrome in the elderly . RDA : 1.2 1.4 mg DEFICIENCY : Cheilitis. Glossitis. 31

FOLIC ACID
RDA : 500 g SOURCES : DEFICIENCY : Megaloblastic anaemia Mouth ulcers Glossodynia Glossitis Stomatitis

Green leafy vegetables

Oranges Liver Legumes Yeast

32

VITAMIN C

(Ascorbic acid)
RDA : 60 g . SOURCES :

Citrus fruits
Tomatoes Potatoes

Leafy vegetable
DEFICIENCY : Spongy and bleeding gums

Petechiae
Delayed healing Painful joints 33

VITAMIN D

Elderly are deficient because of lack of sun exposure

Due to inability to synthesize in skin and convert it in kidney RDA : 5 g SOURCES : Fish liver oils DEFICIENCY :

Bowlegs
Beading of ribs VITAMIN E

Total plasma level of Vit E increase with age.

Deficiency does not seem to be a problem RDA : 8 10 mg SOURCES : Vegetable Oils 34

VITAMINS
Vitamin A Cellular differentiation, integrity,growth, antikeratinizing, vision Enamel Hypoplasia, Tooth eruption problems, cancer

Vitamin D

Calcium & Phosphorous metabolism

Cementum & dentin defects

Vitamin E

Antioxidant

rare

MINERALS
CALCIUM
Ca absorption stomach. in elderly due to hypochlorhydria in the

Calicum if not substituted can cause negative Ca balance osteoporosis. RDA : 800 mg / day SOURCES :

Milk and milk products,Dried beans and peas

Canned Salmon &Green leafy vegetables Rapid and excessive ridge resorption in CD wearers may be 37 related to negative Ca balance which contributes to development of osteoporosis

CALCIUM AND BONE HEALTH

Bone loss is a normal part of aging that affects the maxilla and mandible, as well as the spine and long bones.
Women - age 50, 40% had low bone mass. Resorption of the alveolar ridge is a widespread problem among denture wearing patients and results in unstable dentures.

 Adequate intake of vitamin D enhances calcium absorption in intestine.

Women who consume minimal amount of dairy foods ,have lactose intolerance , or allergies to dairy foods, calcium supplementation is appropriate. The most common supplements are calcium carbonate ,calcium citrate , calcium lactate, calcium gluconate, and calcium diphosphate.

The maximum calcium intake that poses no risk of adverse effects is 2.5g.

IRON :

Iron deficiency is rare in elderly

If anaemia found, suspect blood loss RDA : 10 mg SOURCES : Meat DEFICIENCY : Burning tongue Dry mouth Angular cheilosis

Fish
Poultry Whole grains

Fortified bread and cereals

Green leafy vegetables Dried beans and peas 40

ZINC
Zinc utilization declines with advancing age because intestinal absorption decreases after 65 yrs of age RDA : 15 mg SOURCES : Animal products DEFECIENCY: Taste acuity

Whole grains
Dried beans

Mental lethargy
Slow wound healing

41

MINERALS
Calcium Bone, tooth formation , Bone density, blood clotting, nerve. hypoplasia

Phosphorous

Bone & tooth formation rare

Iron

Hemoglobin

Anemia, glossitis, chelitis

WATER
Elders are susceptible to negative water balance caused by water loss through damaged kidney

Inadequate intake of fluid leads to

Dehydration Hypotension

Elevated body temperature

Dryness of mucosa Decreased urine output 44 Recommended fluid intake : 30 ml per kg body weight, per day Mental confusion

BALANCED DIET
A balanced diet is one which includes all the essential food groups and allows the body to function at an optimal level free from disease and malaise.

A balanced diet constitutes the following

Protein Carbohydrates Fats

15 % 60% 25-30%

NUTRITION IN GERIATRIC PATIENTS

ETIOLOGY OF DIETARY DEFICIENCY

Lack of proper food intake Low income and lack of knowledge on how to spend the money available for food to the best advantage. Physical handicaps, debility, lack of mobility which makes preparation of food difficult Poor facility.

Poor dentitions, or improper dentures

Depression , anxiety and loneliness.

Diseases which interfere with

Digestion Absorption Utilization of foods.

Eg: Oral cancers

Chronic ulcerative lesions Atrophic gastritis Liver dysfunction

ORAL SIGNS OF NUTRITIONAL DEFICIENCY Cheilosis Gingivitis

Glossitis.

AGING FACTORS AFFECTING DIET AND

NUTRITIONAL STATUS
Physiologic factors

Psychosocial factors
Functional factors

Pharmacological factors, medication and alcohol

52

PHYSIOLOGICAL FACTORS :
Decline in lean body mass : Caloric needs decreases and risk of falling increases

Decline in gastric acidity :

Malabsorption of food bound Vit B12 Dehydration :

Due to decrease in kidney function and total body water metabolism

Metabolic bone disease :

Due to Vit D deficiency

Neurological and behavioural impairment : Due to deficiency of several vitamins. 53

PSYCHOSOCIAL FACTORS :

Elders at risk include those

Living alone Physically handicapped

Isolated
Chronic diseases Restrictive diets

Reduced economic status

Oldest old FUNCTIONAL FACTORS :

Disabilities like
Arthritis Stroke Vision / hearing impairment 54

PHARMOCOLOGICAL FACTORS : These drugs primarily cause Anorexia Nausea Vomiting GIT disturbances Xerostomia Taste loss Interference in absorption and utilization of nutrients leads to Nutritional deficiencies Weight loss Malnutrition
55

ORAL FACTORS AFFECTING DIET AND NUTRITIONAL STATUS

Xerostomia Sense of taste and smell Oral infectious conditions Dental status Effect of dentures on taste and swallowing

Effects of dentures on chewing abilities

Effect of dentures on food choices ,diet quality and general health
56

Xerostomia (dry mouth)

Affects one in five older adults

Difficulty in chewing and swallowing Affect food selection Sense of taste and smell -Is decreased due to Health disorders Medications Oral hygiene

Use of denture
Smoking 57

Oral infectious conditions :

Periodontal disease increases with age . EFFECT OF DENTURES : On taste and swallowing : upper denture covers Hard palate ( taste buds) that affect taste. Swallowing can be poorly coordinated . Dentures can be a major contributing factor to death from choking. On chewing ability : Elderly people use more strokes -Chew longer to prepare food for swallowing

Masticatory efficiency in CD patients is 80% < in people with intact natural dentition.
58

On food choices and diet quality : Some denture wearers choose processed or cooked food rather than fresh food. Some may eliminate entire food groups from their diet . Denture wearers report that food such as raw carrots, lettuce, corn, raw apples with peels, are difficult to chew. Dentate adults tend to eat more fruits and vegetables than

full denture wearers.

59

RECOMMENDED DIETARY ALLOWANCES FOR ELDERLY

60

Recommended Dietary Allowances for the Elderly Men

Age Weight (kg) (lb) Height (cm) (in) Protein (g) Vitamin A ( g )+ Vitamin D (.g )+ Vitamin E (mg ) Vitamin C (mg) Thiamine (mg)
51+

Women
51+

70
154 178 70 56 1000 5

55
120 163 64 44 800 5

10
60 1.2 1.4 16

8
60 1.0 1.2 13

61

FOOD RECOMMENDED FOR ELDERLY

62

THE FIVE FOOD GROUPS

All the nutrients necessary for optimal health in the desirable amounts can be obtained by eating a variety of foods in adequate amounts from the five food groups.

63

Vegetable Fruit Group : Four servings of vegetables and fruits subdivided into 2 categories

Two servings of good sources of vitamin C, such as citrus

fruits, salad greens, and raw cabbage One serving of a good source of provitamin A, such as deep green and yellow vegetables or fruits

64

One serving of potatoes and other vegetables and fruits

65

2]Bread Cereal Group

Four servings of enriched bread, cereals, and flour products

66

3] Milk - Cheese group Two- four servings of milk and milk based foods, such as cheese,yogurt (but not butter)

67

4] Meat, Poultry, Fish and Beans Group

Two servings of meats, fish poultry, eggs, dried beans and peas, and nuts

68

5] Fats, Sugar and Alcohol Group

Additional miscellaneous foods, including fats and oils, sugar and alcohol; the only serving recommendation is for about 2 to 4 tablespoons of polyunsaturated fats, which supply essential fatty acids.

69

MODIFIED FOOD PYRAMID FOR 70 ABOVE ADULTS

70

71

ASSESSING NUTRITIONAL STATUS & DIETARY COUSELLING OF PATIENTS UNDERGOING PROSTHODONTIC TREATMENT

72

Providing nutrition care for the denture wearing patient entails the following steps:
o obtain a nutrition history and an accurate record of food intake over a 3 to 5 day period or complete food frequency form. Evaluate the diet; assess nutritional risk Information about the components of a diet that will support the oral mucosa,bone health, and total body health. Assist patient in establishing goals to improve the diet.

Follow-up to support patient in efforts to change food behaviors.

74

RISK FACTORS FOR MALNUTRITION IN PATIENTS WITH DENTURES

Eating less than two meals per day. Difficulty chewing and swallowing.

Undergoing chemotherapy or radiotherapy.

Loose denture or sore spots under denture.

 Oral lesions[glossitis, cheilosis, or burning tongue] Severely resorbed mandible. Alcohol or drug abuse. Unplanned weight gain or loss of more than 10 lb in the last 6 months.

NUTRITION GUIDELINES FOR PROSTHODONTIC PAITENT

77

NUTRITIONAL OBJECTIVES
1. To establish a balanced diet which is consistent with the physical, social, psychological and economic background of the patient. 2. To provide temporary dietary supportive treatment, directed

towards specific goals such as carries control, postoperative

healing, or soft tissue conditioning. 3. To interpret factors peculiar to the denture age group of patients, which may relate to or complicate nutritional therapy. 78

Nutrition Guidelines For Prosthodontic Patients Eat a variety of foods.

Build diet around complex carbohydrates fruits vegetables,

whole grains, and cereals. Eat at least 5 servings of fruits and vegetable daily.

Select fish, poultry, lean meat, or diet peas and beans every day.
Obtain adequate calcium. Limit intake of bakery products high in fat and simple sugars. Limit intake of processed foods high in sodium and fat. Consume 8 glasses of water daily. 79

DIET FOR NEW DENTURE WEARER

80

On the first post insertion day A new denture wearer can choose from the following foods, which are essentially liquids and are arranged according to the four basic food groups. Vegetable fruit group; juices. Bread cereal group; cooked in either milk or water. Milk group; fluid milk may be taken in any form. Meat group; eggs ; pureed meats, meat broths, or soups .

81

On the second the third post insertion day, the denture patient
can use soft foods that require a minimum of chewing. Vegetable fruit group; juices, tender cooked fruits and

vegetables (skinless and seedless)

Bread-cereal group: cooked cereals such as cream of wheat and softened bread; boiled rice. Milk group; fluid milk and cottage cheese Meat group: chopped beef, ground liver, tender chicken or fish in a cream sauce, scrambled eggs, thick soups etc

82

By the fourth day :

Or as soon as all the sore spots have healed, in addition to the soft diet, firmer foods can be eaten. Ideally these foods should be cut into small pieces before eating. In general it has been found that raw vegetables and

sandwiches are the foods least preferred by denture wearers. In

fact, raw vegetable requires more force during mastication to prepare them for swallowing than most other foods. Therefore if the denture patient is able to manage salads, the ultimate in denture success and patient achievement will have been realized. 83

DIET AFTER IMPLANT PLACEMENT

84

 Diet is controlled to prevent overloading during the early phases of the restorative phase.
During initial healing phase, patient is instructed to avoid chewing in the area. Patient is limited to a soft diet from the initial transitional prosthesis delivery until the initial delivery of the final prosthesis. Masticatory force for the this type of food is approx. 10 pounds / in2 of force. After initial delivery of final prosthesis, the patient may include meat in diet which requires approx. 21 pounds / in2 bite force. After final evaluation, the patient may include raw vegetables into the diet. It takes 27 pounds / in2 of force to chew a raw carrot. A normal diet permitted only after final prosthesis function, occlusion and proper cementation are evaluated. 85

DIETARY SUPPLEMENTATION

86

Except in severe deficiency states, nutritional therapy does not produce sudden, dramatic changes in oral or general health. When conditioning of abused oral tissue is undertaken, temporary dietary supplementation should be considered. This supplementation may serve several purposes : 1. Create a sense of well-being and a feeling of immediate progress in the patient 2. Stimulate appetite, thus making more acceptable any required dietary changes 3. Provide a controllable and balanced source of required nutrients during the period of dietary transition 4. Provide individual, specific nutritional elements 87

 Products intended to supplement the diet contains a vitamin,mineral,amino acid or other botanicals.

Does not represent conventional food.

Ingested in the form of capsule, powder ,soft gel etc

88

FOOD FORTIFICATION
Is defined of the addition of one or more essential nutrients to a food, whether or not it is normally contained in the food, for the purpose of preventing or correcting a demonstrated deficiency of one or more nutrients in the population or specific population groups. ( WHO 1994). Fortification is a public health measure aimed at reinforcing dietary intake of nutrients with additional supplies to prevent or control nutritional disorders in a given area. Example

Fortification of salt with iodine. Fortification of wheat with vitamins.

89

CONCLUSION The food, diet and nutrition needs of the elderly patient should be considered a part of total supportive management. It is incumbent upon the dentist to provide the patient with this nutritional information for optimal oral health, because what is good for preventing oral disease will be equally good for preventing general illness. An emphasis on good quality protein foods and a generous selection of vegetables and fruits and somewhat less stress on fats, starches, and sugars to avoid an excess of calories.

90

REFERENCES.

Zarb : Prothodontic treatment of edentulous patients Heartwel : Syllabus of complete denture. DCNA : Gerodontic nutrition and dietary counseling for prosthodontic patients. 2003, Vol. 47, DCNA : Nutrition and oral health in elderly 1989, vol. 33, No. 1. JPD : Nutrition suggestions for prosthetic patients Sept. 1966, vol. 16, No. 5. Text book of contemporary of implant dentistry by Carl Misch . Geriatric nutrition II dehydration in elderly . JPD November 1979 vol 42 issue 5. Nutrtion phase 1 of edentulous pateints- JPD August 1978 volume 40 number 2

THANK YOU

92