Diet and Nutrition.. p

PRESENTED BY: Dr. Mohit Dhawan

M.D.S. 1ST YEAR

Introduction Problems in geriatric patients Physiologic changes that accompany ageing The impact of dental status on food intake Gastrointestinal functioning Nutritional needs and status of older patients Calcium and bone health Common nutritional disorders and diseases of

the elderly Vitamin and herbal supplementation Conclusion References

geriatrics \je˘r′ē-ăt′r′ks\ n, pl but sing in constr (1909): the branch of medicine that treats all problems peculiar to the aging patient, including the clinical problems of senescence and senility

primary aging, which involves the natural process of senescence. Examples include facial wrinkles and the need for reading glasses.

Secondary aging, which involves age-related diseases such as cancer, parkinsonism, osteoporosis, and macular degeneration of the eye.

"Elderly" was once defined as being age 65 or above, but the growing number of active and healthy older people has caused that definition to expand to "young old" (65 to 75), "old old" (75 to 85), and "oldest old" (85 and beyond). The over-85 age group is the one that is growing most rapidly.

Geriatric nutrition applies nutrition principles to delay effects of aging and disease, to aid in the management of the physical, psychological, and psychosocial changes commonly associated with growing old.

Proper nutrition is essential to the health and comfort of oral tissues and healthy tissues enhance the possibility of successful prosthodontic treatment in the elderly.

a decline in quickness of response a changed motor and visual coordination a decreased interest a lowered oxygen consumption a decreased capability of adapting to altering conditions a decrease in basal metabolism a decreased kidney function a decreased immune response a decrease in gastric juice production brain weight shrinks by 10-20% by age 80 SA node loses 90% cells by age 75.

Reduction in total number of component cells. Decrease in thickness Loss of elasticity Dryness and atrophy Tendency to hyperkeratosis

• With a decline in lean body mass in the elderly, caloric needs decrease and risk of falling increases.

• Vitamin D deficiency in turn, is a major cause of metabolic bone disease in the elderly.

• Declines in gastric acidity often occur with age and can cause malabsorption of food-bound vitamin B12.

• Many nutrient deficiencies common in the elderly, including zinc and vitamin B6, seem to result in decreased or modified immune responses.

• Dehydration, caused by decline in kidney function and total body water metabolism, is a major concern in the older population.

• Overt deficiency of several vitamins is associated with neurological and/or behavioral impairment B1 (thiamin), B2, niacin, B6 [pyridoxine], B12, foliate, pantothenic acid, vitamin C and vitamin E).

• Elders, particularly at risk, include those living alone, the physically handicapped with insufficient care, the isolated, those with chronic disease and/or restrictive diets, reduced economic status and the oldest old.

• Functional disabilities such as arthritis, stroke, vision, or hearing impairment, can affect nutritional status indirectly.

• Most elders take several prescription and over-the-counter medications daily.

• Prescription drugs are the primary cause of anorexia, nausea, vomiting, gastrointestinal disturbances, xerostomia, taste loss and interference with nutrient absorp tion and utilization. These conditions can lead to nutrient deficiencies, weight loss and ultimately malnutrition

A study by j.larson on nutritional status found that hospitalization itself resulted in detioration of nutritional status.(j.oral rehabilitation April 2004)

Xerostomia

• Xerostomia affects almost one in five older adults. Xerostomia is associated with difficulties in chewing and swallowing, all of which can adversely affect food selection and contribute to poor nutritional status.

• The use of drugs with hypo salivary side effects may have deleterious influence on denture bearing tissues.

• Age-related changes in taste and smell may alter food choice and decrease diet quality in some people. Factors contributing to this reported decreased function may include health disorders, medications, oral hygiene, denture use and smoking.

• Sense of smell decreases markedly with age, much more rapidly then the sense of taste. Diminished taste is the result of aging.

• Sensory changes may diminish the appeal of some foods (e.g., sensitivity to the bitterness of cruciferous vegetables), limiting their consumption and potential health benefits function..

• The hard palate contains taste buds, so taste sensitivity may be reduced when an upper denture covers the hard palate. As a result, swallowing can be poorly coordinated and dentures can become a major contributing factor to death from choking.

On chewing ability • As adults age, they tend to use more strokes and chew longer, to

prepare food for swallowing.

• Masticatory efficiency in complete denture wearers is approximately 80% lower than in people with intact natural dentition.(j.oral rehabilitation 2006,33;301-308)

1. Some people compensate for decline in masticatory ability by choosing processed or cooked foods rather than fresh food and by chewing longer before swallowing.

2. Others may eliminate entire food groups from their diets.

Dentate adults tend to eat more fruits and vegetables than full-denture wearers.

• Replacing ill-fitting dentures with new ones does not necessarily result in significant improvements in dietary intake.

• Similarly, exchanging optimal complete dentures for implant-supported dentures, has not resulted in significant improvement in food selection or nutrient intake.

• Energy needs decline with age due to a decrease in basal metabolism and decreased physical activity.

• Cross-sectional surveys show that the average energy consumption of 65-74 year old women is about 1300 Kcal and 1800 Kcal for men of the same age.

• Deficiency causes dull, dry, sparse easily plucked hair, parotid gland enlargement, muscle wasting, pallor, pale atrophic tongue, spoon nails and pale conjunctiva.

Calories • Caloric requirements decrease with advancing age, owing to reduced energy expenditures and a decrease in basal metabolic rate.

• The mean RDA is 1600 Kcal for women and 2400 Kcal for men.

• As the patients become older, the amount of protein required increases.

• Protein depletion of body stores in the elderly, is seen primarily as a decrease of the skeletal muscle mass. Proteins is a must for denture wearers.(American journal of clinical nutrition vol 85,no 5)

• The RDA for proteins, for persons aged 51 and over, is 0.8-g protein/kg body weight per day. (56 gms for males and 46 gms for females, or 9 and 10% respectively, of the recommended calorie intake). However, because of the general decline in energy intake, as age increases, the recommendation is that the elderly should satisfy 12% or more of their energy intake with protein-rich foods.

• The best sources of proteins for the elderly diet are dairy products, poultry, meats and fish in the boiled and not dried form. Nuts, grains, legumes and vegetables contain protein, which if eaten in the proper combination, is of the same quality as animal sources of protein.

• Deficiency of proteins causes edema.

• The elderly consume a large proportion of their calories as carbohydrates, possibly at the expense of protein, because of their low cost, ability to be stored without refrigeration and ease of preparation.

• The recommended range of intake is 50 to 60 per cent of total calories.

• Food sources include grains and cereals, vegetables, fruits and dairy products.

Fiber• An important component of complex carbohydrates is fiber, which promotes bowel function, may reduce serum cholesterol and is thought to prevent diverticular disease.

• Reduced selection of foods rich in fiber that are hard to chew, could provoke gastrointestinal disturbances in some edentulous elderly, with deficient masticatory performance.

• Elderly are particularly susceptible to negative water balance, usually caused by excessive water loss through damaged kidney.

• Inadequate intake of fluid by the elderly will lead to rapid dehydration and associated problems such as hypotension, elevated body temperature and dryness of the mucosa, decreased urine output and mental confusion.

• Under normal conditions, fluid intake should be at least 30 ml per kg body weight per day.

• The RDA for vitamin A is 800-1000 micrograms RE .

• Vitamin A in food occurs in two forms: retinal, or active Vitamin A in animal foods (liver, milk and milk products and beta-carotene or pro vitamin A, found in deep green and yellow fruits and vegetables (apricots, carrots, spinach).

• Deficiency causes Bitot's spots (eyes), conjunctival and corneal xerosis (dryness), xerosis of skin, follicular hyperkeratosis, decreased salivary flow, dryness and keratosis of oral mucosa and decreased taste acuity.

• Long standing deficiency may cause hyperplasia of the gums, as well as generalized gingivitis

Thiamine • Evidence of thiamine deficiency occurs most often in the poor, institutionalized and alcoholic segment of the elderly population.

• The RDA has been set at 0.5 per 1000 calories, or at least 1 mg daily.

• Food sources include meats (especially pork and chicken), peas, whole grains, fortified grains, cereals and yeast.

• Deficiency causes beriberi.

Vitamin B6 deficiency (pyridoxine)• Ranges from 50 to 90% of the elderly affected, which may be an important cause of the increased prevalence of the carpal tunnel syndrome (an inflamed tendon attached to the wrist bone.) in the elderly.

• The RDA is 1.2-1.4 mg .

• Deficiency causes nasolabial seborrhea, glossitis.

Vitamin B12 (riboflavin) • The RDA is 3.0 microgram.

• Is found in kidney, heart, milk, eggs, liver and green leafy vegetables.

• Deficiency causes nasolabial seborrhea, fissuring and redness of

eyelid corners and mouth magenta-colored tongue.

Vitamin C • The RDA is about 60 microgram .

• Food sources include citrus fruits, tomatoes, potatoes and leafy vegetables.

• Deficiency causes spongy, bleeding gums, petechiae, delayed healing tissues, painful joints.

Vitamin D

• The elderly are frequently deficient in Vitamin D because of lack of sun exposure and an inability to synthesize Vitamin D in skin and convert it in the kidney. Vitamin D is found in fish liver oils. .

• The RDA is 5 microgram.

• Deficiency causes bow legs, beading of ribs.

Vitamin E

• Vitamin E deficiency in the elderly does not seem to be a problem. Total plasma vitamin E levels increase with age.

• The RDA is 8-10 mg alpha-TE

MineralsA study conducted by J. Crystal Braxter illustrated deficiencies in magnesium, fluoride, folic acid, zinc and calcium, in the geriatric population.

Folic acid• Economically deprived and institutionalized elderly are at the most risk of foliate deficiency.

• RDA is 500 microgram.

• Good food sources of include leafy green vegetables, oranges, liver, legumes and yeast.

• Deficiency causes megaloblastic anemia, mouth ulcers, glossodynia, glossitis, stomatitis.

•· The recommended daily allowance of calcium is 800 mg/day.

• Because calcium absorption is decreased in the elderly (lack of hydrochloric acid in the stomach), the calcium must be acidulated before digestion.

• Lactase deficiency resulting in lactose intolerance is also common in elderly persons. This is another reason for modifying the milk for elderly persons.

• Food sources of calcium include milk and milk products, dried beans and peas, canned Salmon, leafy green vegetables and tofu.

• Elderly patients with complete dentures often experience a rapid and excessive ridge resorption, which may be related to negative balance of calcium, which contributes to development of osteoporosis.

• A recent review concluded that the prevalence of iron deficiency, is relatively rare among the healthy elderly. When anemia is found in an older person, blood loss should be suspected.

• The RDA for iron is 10 mg.

Good food sources include meat, fish, poultry, whole grains, fortified breads and cereals, leafy green vegetables, dried beans and peas.

• Deficiency causes burning tongue, dry mouth, anemia's and angular cheilosis.

Zinc • Zinc utilization declines with advancing age, because intestinal absorption decreases after the age of 65 years.

• The RDA is 15 mg.

• Good sources of zinc are animal products, whole grains and dried beans.

• Deficiency causes decreased taste acuity, mental lethargy and slow wound healing.

Enjoyment of food is regarded as an important determinant of an adult’s quality of life.

Loose teeth, edentulism, or ill-fitting dentures may prelude eating favorite foods, as well as limit the intake of

essential nutrients. Decreased chewing ability, fear of choking while eating, and irritation of the oral mucosa when food particles get under the dentures may influence food

choices of the denture wearer.

Clinical symptoms of malnutrition are often first observed in the oral cavity.

Because of rapid cell turnover (every 3 to 7 days) in the mouth, a regular, balanced intake of essential nutrients is required for the maintenance of the oral epithelium.

Inadequate long term nutrition may result in angular cheilitis,glossitis, and slow tissue healing.

The amount of alveolar bone resorption that occurs after tooth extractions may be exacerbated by low calcium and vitamin D intakes.

Undernutrition increases with advancing age. Persons older than 70 years of age are more likely

to have nutritionally poor diets. Dentate status can affect eating ability and thus the

diet quality. In elderly people, oral health problems may

contribute to involuntary weight loss and a lower body mass index.

• Poor oral health leads to impaired masticatory function. Whether MF plays a role in food selection is still matter of debate, but impaired masticatory function leads to inadequate food choice and therefore alter nutrition intake.

• The presence of natural teeth and well fitting dentures were associated with higher and more varied nutrition intakes and greater dietary quality, in the oldest old Iowans sampled.

The food choices of older adults are closely linked to dental status and masticatory efficiency.

Although an intact dentition is not a necessity for maintaining nutritional health, the loss of teeth often leads adults to select diets that are lower in nutrient density.

Denture wearers report that food such as raw carrots, lettuce, corn on the cob, raw apples with peels, steaks, and chops are difficult to chew.

Age, oral motor function, adequate saliva, and number of occluding pairs of teeth in the mouth mainly determine an individual’s masticatory

ability.When compared to those with natural dentition,

persons with removable complete dentures had greatly reduced chewing ability.

Texture and hardness rather than taste and smell determine acceptability of a food for many patients with dentures

Generally, the intake of hard food (raw vegetables or fruits, fibrous meats, hard breads, seeds and nuts) is reduced, whereas the intake of soft foods (ground beef, breads, cereals, pastries and canned fruits and vegetables) is increased.

Whether these changes in food selection negatively affect nutritional status depends on nutrient density of the food substituted, but softer foods are often lower in nutrient density and fiber.

The inability to distinguish the sensory qualities of food reduces a patient’s enjoyment of eating and may lead to reduced calorie intake.

Because a decrease in taste and smell acuity frequently accompanies aging, it is difficult to separate the effects of aging and denture wearing on sensory acuity.

Nearly all denture wearers report a transient decline in taste acuity when dentures are first inserted. This is usually attributed to denture base coverage of the hard palate.

However, the ability to taste usually improves as the patient adapts to the dentures.

major problem for seniors EDENTULOUS The comfort of wearing dentures is dependent on the

lubricating ability of saliva in the mouth. If the oral mucosa is dry, chewing is difficult, denture retention is compromised, and mucosal soreness or ulcerations develop.

DENTULOUS Because salivary flow facilitates mastication,

formation of the food bolus, swallowing, and digestion, it is a major contributor to the pleasure of eating.

Energy needs decline with age because of a decrease in basal metabolism and decreased physical activity. With aging, lean body mass is replaced by fat; this leads to a decrease in metabolic rate.

When calorie intake is low, consumption of foods of high nutrient density such as legumes, vegetable soups, meat casseroles, fruit desserts, low-fat dairy foods, and whole grain breads and cereals is important.

The best means of reducing calorie intake is to replace foods high in fat and sugar with complex carbohydrates, and these should be the mainstay for the elderly person’s diet. In contrast to pastries, whole-milk cheeses, luncheon meals, salad dressings, and frozen desserts, the choice of

nonfat dairy products, whole grain breads, cereals, pasta, fruits, vegetables, beans, and legumes will provide important amounts of vitamins, minerals, and fiber.

Fats contribute about 33% of total calories in the diet of the average adult.

Because of growing epidemiological evidence of the link between dietary intake of saturated fat, cholesterol, and occurrence of hyperlipidemias, heart disease, certain cancers, and obesity, adults are advised to maintain their dietary fat intake at 20% to 35% of total calories.

Because physiological stresses are associated with age-related degenerative diseases, protein needs of older adults are thought to be slightly higher than those of younger persons. It is recommended that 10% to 35% of total calories or 1g/Kg of body weight come from protein.

This conclusion is based on studies of serum albumin levels and nitrogen balance studies in older adults.

Vitamin B12 deficiency may lead to problems with dementia in older adults. Vitamin B12 is found only in animal products. Synthetic vitamin B12 obtained from fortified foods or vitamin supplements is better absorbed than protein bound vitamin B12.

Because of its role in collagen synthesis, ascorbic acid (Vitamin C) is essential for wound healing. There is a wide variation in vitamin C intakes of adults. Heavy smokers, alcohol abusers, or persons with high aspirin intake have a higher daily requirement for ascorbic acid. The denture-wearing patient should be encouraged to consume foods rich in vitamin C daily such as citrus fruits, peppers, melons, kiwifruit, mangos, papaya, and strawberries.

Vitamin E functions as an antioxidant in cell membranes. By acting as a scavenger of free radicals, vitamin E prevents oxidation of unsaturated cell phospholipids. Dietary sources of vitamin E include vegetable oils, nuts, margarines, and mayonnaise.

Magnesium is a component of the body skeleton, is a cofactor for more than 300 enzymes, and plays a role in neuromuscular transmission. The highest amounts of magnesium are found in vegetables and unrefined grains. Milk is a moderately good source.

Alcohol abuse appears to be a serious health problem among some older persons. Alcoholism is often undetected and untreated. The loss of spouse, loneliness, depression, retirement, loss of status, and reduced income, all contribute to excess alcohol intake in older adults.

Deficiencies of thiamine, niacin, pyridoxine, folate (all B-complex vitamins), and ascorbic acid are commonly seen in alcoholics. Osteopenia in males without a history of bone disease may be due to long-term alcohol intake. When efforts to resolve tissue intolerance to a prosthesis are unsuccessful, the misuse of alcohol should be considered.

Bone loss is a normal part of aging that affects the maxilla and mandible, as well as the spine and long bones. Skeletal sites where trabecular bone (the alveolar bone, vertebrae, wrist, and neck of the femur) is more prominent than cortical bone are affected first. Several factors are thought to contribute to age related bone loss that leads to osteoporosis: genetic background, hormonal status, bone density at maturity, a disturbance in the bone remodeling process, a low exercise level, and inadequate nutrition. Low calcium intake throughout life is a contributor to osteoporosis.

Osteopenia, loss of bone, affects women earlier than men because of loss of estrogen at menopause and a smaller skeleton. In women, bone loss begins during fourth decade of life or whenever estrogen secretion declines or ceases.

Trabecular bone in the alveolar processs is a source of calcium that can be used to meet other needs.

It has been proposed that alveolar bone loss may precede loss of mineral from the vertebrae and long bones; thus the dentist may therefore be the first health care provider to detect loss of bone mass.

Mandibular bone mass has been positively correlated with total body calcium and the bone mass and the vertebrae and wrist of healthy, dentate postmenopausal and edentulous women with osteoporosis.

Dietary calcium intake is critical to maintain the body skeleton. The most important means of preventing metabolic bone disease is acquiring a dense skeleton by the time bone maturation occurs between 30-35 years of age. A women who has a dense skeleton at 35 years of age will retain proportionately more skeletal mineral content and be less susceptible to fracture after menopause. Calcium intake of

postmenopausal women is correlated with mandibular bone mass. Patients with dentures who have excessive ridge resorption report lower calcium intakes.

A chronically low calcium intake results in a negative calcium balance. For serum calcium levels to be maintained, calcium will be mobilized from bone, and this leads to demineralization of the skeleton. Although a generous calcium intake by older adults will not result in restoration of bone mass, it will improve calcium balance and slow the rate of bone loss.

Oxalates found in spinach and phytates found in whole-grain products and legumes may form insoluble complexes with calcium, thereby reducing the amount of calcium absorbed. High intakes of sodium, animal protein, and alcohol increase calcium losses in the urine. A moderate caffeine intake (300mg or less per day) is recommended to prevent bone loss.

Major sources of calcium are milk, cheese, yogurt, and ice-cream. Dairy foods are also a source of protein, riboflavin, vitamin A, and vitamin D. Collard greens, kale, broccoli, oysters, canned salmon, sardines, calcium fortified fruit juices and cereals are non-dairy foods containing substantial amounts of calcium. To receive 1000 to 1200 mg of calcium, adults must drink three or four glasses of low-fat milk per day, eat 5 to 7 oz of hard cheeses, or consume very large quantities of nondairy foods. Lactose-intolerant adults who avoid milk may find yogurt or cheese acceptable

Poor vitamin D status is an important public health problem. Adequate intake of vitamin D enhances calcium absorption in the intestine. Low dietary intake, minimal exposure to sunlight, and a lower rate of conversion to the active metabolite in the liver and kidney are responsible for low plasma levels of vit D in the elderly population. The primary dietary source of vit D is fortified dairy products. To promote bone health, post menopausal women and andropausal men ages 51 to 70 should strive to obtain 10 μg of vit D and increase intake to 15 μg at age 71.

If an individual lacks sun exposure, is lactose intolerant, or dislikes dairy foods, a vit D supplement of 10μg is desirable.

The most common forms of supplements are calcium carbonate, calcium citrate, calcium lactate, calcium gluconate, and calcium diphosphate. Calcium carbonate contains the highest concentration of elemental calcium (40%), but in older women, body absorption of calcium citrate is better. However, less elemental calcium is obtained from each calcium citrate tablet. Calcium supplements that contain vit D to enhance absorption of calcium in the gut are useful if vit D is not obtained from other sources.

Few adverse affects of calcium supplementation have been observed. Some older women have reported nausea, bloating or constipation. Increasing calcium intake results in higher urinary levels of calcium. A small percentage of population, mainly men, are susceptible to forming kidney stones; however, a high intake of dairy foods does not appear to affect stone formation. A physician should monitor the use of calcium supplements by these persons. The maximum calcium intake that poses no risk of adverse effects is 2.5 g.

Consuming a variety of foods is considered the best means of obtaining the balance of nutrients required for good health. A varied diet also reduces the risk of chronic disease. Atleast 50% of persons older than 65 years of age report using vitamin- mineral supplements, and one-fourth of adults use herbal supplements. Persons who perceive

themselves to be in good health are more likely to use dietary supplements.

To increase energy level, to extend life, to prevent the onset of degenerative diseases, to relieve the symptoms of chronic diseases, and to make up deficits caused by unbalanced diets.A large percentage of the supplements ingested are self-

prescribed and unrelated to any specific physiological need.

Geriatrics are particularly

vulnerable to compromised

nutritional health.

The dentist who is aware of nutritional risk factors can identify patients in need of nutritional guidance.

The ability of the oral tissues to withstand the stresses of treatment is greater if the patient is well nourished.

Dietary guidance is an integral part of treatment for the prosthodontic patient.

Burkets oral medicine Boucher’s 10th edition Zarb bolender 12th edition Geriatrics july 2007, volume 62, number 7 K.A Bandodkar, Meena Aras: Nutrition For

Geriatric Denture Patients. JIPS- Jan-Mar 2005; vol:6, issue-1: 22-28.

J .ORAL REHABILITATION 2006 BY J.S FEINE VOL 33

J .DENTAL RESEARCH MARCH 2010 BY MARIE-AGNES PEYRON

J.ORAL REHABILITATION 2006 BY J.LARSON

American journal of clinical nutrition,vol 85,no 3 by dider remond.

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