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here is a bidirectional relationship between diet/nutrition and oral health in the older adult. Disorders of the oral cavity may have a significant effect on oral function and health and
consequently dietary intake and nutritional well-being. Inadequate diet and nutrition, in turn, impact oral health and can ultimately cause significant weight loss in the older adult. Along with our related research activities, this article addresses strategies for health professionals to use in managing select sequelae of oral disorders through diet.
By 2020, 54.6 million individuals will be older than 65. Diet and nutrition status may be compromised by systemic and chronic diseases including autoimmune diseases, diabetes, cardiovascular disease, HIV infection and AIDS, and by medications. Our current obesity epidemic impacts the incidence and severity of several chronic diseases. Among individuals ages 65-74, 34.6% are obese, and of those 75 and older, 23.5% are obese.
A myriad of factors, including oral health, have an impact on diet and nutritional status. My research focuses on the bidirectional and dynamic relationship between diet, nutrition and oral health. A balanced diet with adequate energy and nutrients is essential for oral health and an intact, functional oral cavity and surrounding structures are critical for nutritional and oral well-being. While older adults are retaining their natural teeth longer in the 21st century than previously, their increased lifespan in the face of rising rates of chronic diseases may impact the integrity of the oral cavity.
Tooth loss, ill fitting dentures and xerostomia can compromise diet quality and subsequently adequate nutrient intake of older adults. Local and systemic conditions such as oral infections, cardiovascular disease, diabetes mellitus, and the incidence of polypharmacy can impact the integrity and functionality of the oral cavity and nutrition status. Xerostomia in the elderly may be due to polypharmacy, dehydration, or chronic diseases including undiagnosed or uncontrolled diabetes. More than 400 medications, including antihistamines, diuretics, anticonvulsants, anti-anxiety agents and anti-depressants, cause xerostomia, which negatively affects taste perception and functional ability to swallow. Xerostomia also increases the risk of oral infectious diseases such as dental caries, periodontal disease and fungal infections.
Edentulism and ill-fitting dentures may alter food choices due to reduced masticatory function and have a significant impact on body weight and diet quality. Denture fit, retention and stability affect ability to eat and socialization around food. As dentition becomes increasingly impaired and oral function is compromised, older adults may modify their food choices, selecting soft, easily masticated foods and deleting fresh fruits, vegetables and grains, which require intact oral function. As a result, by the time these older adults get dentures, eating habits are already ingrained and positive eating behavior changes are difficult to achieve.
Our initial research started in the mid-1990s and focused on dietary habits of older adults seen at NJDS clinics for full maxillary and mandibular dentures. This study explored nutrition risk status of patients and whether diet intervention at the time of denture insertion impacted diet quality in the months following denture insertion. Prior to and post denture insertion, individuals at moderate or high nutrition risk reported significantly more difficulty biting and chewing than those at low nutrition risk. Mean nutrient intake values were inversely related to nutrition risk prior to and post denture insertion. The findings revealed that those who had diet instruction reported quicker adaptation to using the dentures for eating and were less likely to remove their dentures for eating than those who did not receive diet instruction. However, diet quality did not improve significantly in either group. These findings were consistent with similar studies from England and were more likely due to the fact that dietary habits are difficult to change, particularly in older adults who have adapted their diet to their ability to eat. As a result of this research, diet education was made a standard part of full denture delivery at NJDS.
We further explored the impact of compromised oral health on nutritional status in a pilot study of nursing home residents (65 – 100 years old). Working with graduate student Susan Musilu, we found that elderly patients with oral health problems (tooth loss, ill fitting dentures and oral infections) lost more weight over a six month period than those without oral health problems.
In both these studies patients had interactions with a variety of health professionals, and the relationship between their nutritional well-being and oral health had not been adequately addressed in their health management. Educational research approaches were developed to train both dietetics and dental students in screening patients for nutrition and oral health risk, providing counseling relative to their discipline and referring patients for appropriate intervention. Funded by an AcITAC grant, an educational CD-ROM was developed to train dietetics professionals in oral health screening. Similarly, dental students now screen all patients for nutrition risk and schedule those at risk for diet intervention.
Our latest research project, supported by an American Dietetic Association Foundation fellowship awarded to doctorate in clinical nutrition student Nancy Munoz, is exploring the impact of an educational program that includes a
CD-ROM on oral health assessment of nursing home patients in nursing and dietetics professional practices. A pilot study revealed the need for training these healthcare professionals on how to conduct an oral assessment and its interpretation relative to nutrition. By enhancing the knowledge and skills of these health practitioners, our goals are to improve practices and collaborative care provided to older adults in order to better their nutrition and oral health. The next step will be an outcomes study to explore those clinical practices pre- and post-education intervention.
While nutrition evaluation of the older individual is aimed at determining the causes of problems, and making appropriate referrals, dietary management focuses on symptoms, including oral health, weight status and systemic disease history and risk. Individuals with compromised dentition may require a diet modified in texture and consistency. The term ‘soft diet’ is often misinterpreted. Clients should be instructed to use their knife and fork as their ‘teeth,’ cut foods including fruits and vegetables into small pieces, moisten difficult-to-chew foods with gravies and sauces, and incorporate whole grain breads and cereals. Individuals with xerostomia should be instructed to consume non-sugared, low acid beverages, including fluoridated water, club soda, or milk. Although these recommendations sound logical and simple, they are often not considered by the elderly. Culturally sensitive, easy-to-read educational materials that incorporate these messages in the context of a balanced diet are needed.
Our next phase of nutrition research in aging will be to design outcomes studies to determine the impact of interventions such as those described above on nutrition and health status. Faculty of the graduate programs in clinical nutrition have the opportunity to design studies and mentor students in outcomes research on a variety of topics, including diet interventions in older adults and the impact of education on nutrition and oral health risk evaluation and management practices of health professionals with older adults.
Riva Touger-Decker is professor and director of the Graduate Programs in Clinical Nutrition and the Institute for Nutrition Interventions at SHRP and the Division of Nutrition at NJDS. Dr. Touger-Decker’s research interests include weight management programs in the workplace, nutrition and oral diseases, oral manifestations of systemic disease, and nutrition education of dietetics and dental students and practitioners. Her research experience includes educational technology, wellness in the workplace, geriatrics, nutrition education of dental students, risk factors for nutrition in oral health, and nutrition and oral diseases with an emphasis on oral manifestations of systemic diseases. She is the lead author of Nutrition and Oral Medicine (Humana Press).
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