Title of the Topic: Nutritional Considerations in Geriatrics

Running Title: Geriatric Nutrition

List of Cotributors:

1. Dr.Veena B. Benakatti, Post Graduate student, Department of Prosthodontics, KLEVK Institute of Dental Sciences, KLE University Belagavi
2. Dr.Raghunath Patil, Professor and Head, Department of Prosthodontics, KLEVK Institute of Dental Sciences, KLE University Belagavi
3. Dr Ulhas N Amasi , Professor, Department of Prosthodontics, KLEVK Institute of Dental Sciences, KLE University Belagavi

Dr Veena Benakatti¹, Dr Raghunanth Patil², Dr Ulhas N Amasi³

Department of Prosthodontics, KLEVK Institute of Dental Sciences, KLE University Belgavi.

Abstract: Human beings need a wide range of nutrients to lead a healthy and active life. The nutrients required for different physiological age groups can be derived only from a well balanced diet. One of the major challenges for the success of health sciences in present scenario is increasing elderly population in the society. Nutritional deficiency, particularly of proteins is very common in elderly people. Over 60% of elderly people are malnourished, and there are many causes for this malnutrition and it is not always easy to differentiate the age related from the pathological. We always need to remind the phrase that ‘it is of great importance to add life to years and not years to life’. Here is an article reviewing the basics of nutrition in elderly people and role of prosthodontist in the same.

Key words: Diet Counseling, Geriatrics, Healthy, Nutrition, Prosthodontist, Recommended Dietary Allowance.

1. Introduction

Nutrition is the basic human need and a prerequisite for healthy life. A well proportionate diet is essential from the very early stages of life for proper growth, development and maintatinance of normal body functioning, physical activity and, health.¹

The three basic prerequisites to sustain life are air, water, and food. Human being is supposed to consume air, water and food in pure and naturally occurring condition. However, assuming air and water is being consumed in pure form, food is the basic requisite for healthy life which is in control of human being but still the one most neglected. The overall improvement in economy at the macro level and subsequent improvements in purchasing power (though unevenly distributed) among households have not resulted in the expected levels of improvement in the nutritional status of Indians mainly because of ignorance. The major food issues of concern are insufficient and imbalanced intake of nutrients.¹

One of the major challenges in field of health sciences is the increasing number of geriatric population in the society. Also, it is expected that by 2050, 20% of the total geriatric population of the world would be in India.² Nutritional deficiencies particularly concerning protein is very common in elderly. Over 60% of elderly people are malnourished, and many causes may be traced for this malnutrition and it is not always easy to differentiate the age related factors from the pathological.³ We need to always remember the phrase that ‘it is of great importance to add life to years and not years to life’.²

2. Nutritional needs of the elderly

Nutrition in geriatrics needs a special attention considering factors that affect nutritional status of an aging individual. Physiological changes that occur with age, like Body composition (Annual decline in lean body mass of 1-2% and decline in extracellular water) reduced and impaired organ function, therapeutic drugs affect nutritional status of elderly people. Apart from these, Emotional problems, Insufficient funds, inability to shop and food preparation problems, adherence to specific diet, alcohol, above all the individuals’ taste play a more important role for the selection of food than does the availability of nurients.⁴

The main sources of energy in Indian diets, which are mainly plant food based, are Carbohydrates, Fat, Protein considered to be macronutrients. Other nutrients are Vitamins and minerals, which are considered as micronutrients. The required nutrients for different physiological groups can only be derived from a well balanced diet.¹

1. Water

Water accounts for 70% of total human body weight. It is a constituent of blood and other vital body fluids. A normal healthy person will require 8 glasses (2 liters) of water per day. During very hot weather and when undertaking vigorous physical activity, the requirement of water increases as a considerable amount of water is lost through sweat. Water should be free from disease-causing agents like bacteria, viruses, parasites etc., and harmful chemical substances like pesticides, industrial wastes, and heavy metals, nitrates, arsenic and excess of fluoride. Boiling for 10-15 minutes is a satisfactory method of purifying the water. Tablets containing 0.5 g of chlorine can disinfect 20 liters of water.¹

2. Energy

Body needs energy, to maintain body temperature, metabolic activity and for supporting physical work and growth. The main source of energy in the Indian diet is carbohydrates which derived largely from cereals. These cereals constitute 80% of our diet and provide 50-80% of daily energy intake. Elderly Men need 46kcal/kg/day (average 2730kcal/kg/day). Elderly Women need 41kcal/kg/day (average 2230kcal/kg/day).¹

3. Carbohydrates

Carbohydrates provide energy of 4 Kcal/g (Table 1). The simple carbohydrates, glucose and fructose, are found in fruits, vegetables and honey, sucrose in sugar and lactose in milk, while the complex polysaccharides are starches in cereals, millets, pulses and root vegetables and glycogen in animal foods. The elderly consume a large proportion of their calories as carbohydrates, possibly at the expense of other nutrients like protein, because of their low cost, ability to be stored without refrigeration and ease of preparation. Denture patients preferring soft foods high in simple sugars & fat should be advised importance of complex carbohydrates. Fiber component of complex carbohydrates promotes bowel function, lowers glycemic response, reduce serum cholesterol & prevents diverticular disease. Most of the fruits and vegetables (except potatoes, watermelon, sweet corn) whole grains, beans, lentils are low glycemic index foods.¹

4. Proteins

Dietary proteins should provide eight essential amino acids in a proper proportion and in adequate quantities to synthesize tissue proteins in the body. Particularly Egg protein is used as a reference protein against which the quality of other proteins can be considered. Vegetable proteins, like cereals, legumes and vegetables are of poorer quality than animal proteins. Cereal proteins are generally deficient in lysine and pulses or legume proteins deficient in methionine. However, when both cereal and pulses (legumes) are consumed in the diet in proper proportions, the proteins from these two sources will supplement each other and overcome each other‘s deficiencies in lysine or methionine to a significant extent. Daily requirement of protein is .8g/kg body wt (60g for males & 55g for females per day).¹

5. Fat

The maximum amount of fat that can be consumed in the diet should not exceed 30 %E (about 60g visible fat / day). Fat intake if exceeds 35% E may increase the risk of diet related non communicable diseases and should be avoided. However, daily fat intake in the diet can be between 20-30%E (20- 40 g/day). Low fat milk and dairy foods should be consumed. Processed, premixed, ready to eat and fast foods should be avoided. Beef and mutton should be consumed moderately. Use of butter/Ghee should be limited. Intake of saturated fat (butter, ghee and hydrogenated fats) and cholesterol (red meat, eggs, organ meat) should be restricted. Excess of these substances could lead to obesity, diabetes, cardiovascular disease and cancer. Use palm oil, sesame, rice bran, or cotton seed oils as they have higher thermal stability. For bakery items use coconut oil, palm oil, palm kernel oil or their blends/solid fractions.¹

6. Dietary fiber

Dietary fiber is the remnants of the edible part of plants and is similar to carbohydrates which are resistant to digestion and absorption in the human small intestine with complete or partial fermentation in the human large intestine. Dietary fiber includes polysaccharides, oligosaccharides, lignin and associated plant products. Dietary fiber exhibits one or more of either laxation (fecal bulking and softening; increased frequency; regularity), blood cholesterol attenuation, blood glucose attenuation. Animal foods do not contain fiber. Cereals, seeds, beans, many fruits and vegetables, bran and whole grain are sources of fiber. In Indian scenario fiber deficiency is rare as it is consumed adequately in daily Indian foods. However, a minimum intake of 20-35 g of fiber is recommended for long-term good health.¹

7. Minerals

Minerals are calorie free and essential nutrients which regulate many biological functions. Minerals such as iron, zinc and copper aids in collagen formation, Wound healing, and regulate inflammation.⁵

Calcium and Phosphorous

Average need of calcium over 60yrs is 1500mg daily, and of phosphorous 1gm/day. Elemental Ca:P ratio of 1:1 has to be maintained. Sources include Milk and milk products, Egg, Meat, Fish, millet ragi, Green Leafy Vegetables. Milk is Rich source of bioavailable calcium. Milk fat serves as a vehicle for fat-soluble vitamins A, D and E. Since milk fat is of the saturated type, those who need to be on a low fat diet can consume skimmed/toned milk. For strict vegetarians, milk is the only source of vitamin B12. Milk is also rich in riboflavin. Only pasteurized or boiled milk should be consumed to ensure protection from disease-causing agents. Osteoporosis is the most common disease affecting aging person and postmenopausal women resulting from calcium deficiency.¹

Iron, Zinc, Sodium, Magnesium and Potassium – (Table No 2)

8. Vitamins

These are essential organic and calorie free molecules necessary for human body. They are further classified as fat soluble and water soluble vitamins.⁵ (Table No 3)

As a person grows older, he tends to become physiologically less active and therefore need lesser calories to maintain their weights. The daily intake of oil should not exceed 20 g. Use of ghee, butter, and coconut oil should be avoided. They need foods rich in protein such as pulses, toned milk, egg-white etc. Therefore, the elderly need nutrient-rich foods rich in calcium, micro-nutrients and fiber. Apart from cereals and pulses, they need daily at least 200-300 ml of milk and milk products and 400 g of vegetables and fruits to provide fiber, micro-nutrients and antioxidants. Inclusion of these items in the diet improves the quality of the diet and bowel function. Flesh foods and eggs add to the quality of diet. The diet needs to be well cooked, soft and less salty and spicy. Small quantities of food should be consumed at more frequent intervals and adequate water should be consumed to avoid dehydration hyponatraemia. ⁶

3. Food preparation

Fermentation and germination (sprouting) are common Indian food practices which definitely improve digestibility and increase nutrients such as B-complex vitamins and vitamin C. Repeated washing of food grains like rice and pulses will lead to loss of minerals and vitamins. Cutting vegetables into smaller pieces will expose a greater surface area of the foodstuff to the atmosphere, resulting in loss of nutrients like vitamins due to oxidation. Cut vegetables should not be soaked in water for longer time, as water-soluble minerals and vitamins will get dissolved. Boiling being the most common method of cooking, will lead to loss of heat-labile and water-soluble vitamins like vitamins B-complex and C. excess water should not be used while cooking rice. Shallow frying uses much smaller amounts of oils than deep frying. Repeated heating of oils particularly PUFA-rich oils results in formation of peroxides and free radicals and, thus, should be avoided. Oils which have been repeatedly heated should not to be mixed with fresh oil. Microwave do not cook uniformly and leave some cold spots in the food by which harmful bacteria can enter into body, avoid large amounts and big pieces in the microwave oven otherwise mix the food in between for uniform heating or cooking.⁶

Natural fruit juices provide energy, vitamins (beta carotenes, vitamin C) and minerals (potassium, calcium). Fruit juices are potassium rich and are ideal for hypertension. Compared to natural fruit juices, synthetic drinks do not contain nutrients. Tea and coffee although relieve mental and muscular fatigue should be avoided at least one hour before and after meals due to presence of tannin that interfere with absorption of iron. Coffee known to increase Blood Pressure and abnormalities in heart beat, excess tea & coffee is harmful to health as they contain caffeine. Decaffeinated coffee and tea can be consumed which are being marketed to obviate the adverse effects of caffeine.⁶

4. Role of Prosthodontist

Teeth are not a prerequisite in healthy individuals for proper digestion. However edentulous subjects with poor masticatory function consume more medications than those with better masticatory function for their digestive problems. Impaired masticatory function may lead to adhesion to specific diet and an unbalanced diet in elderly individuals. Apart from masticatory efficiency several other oral conditions like painful mucosal disorders, oral dryness may also lead to nutritional problems.³

Adequate nutrition plays a vital role in maintaining health of aging oral tissues which in turn is going to influence the prognosis of prosthesis⁶. An adequate dentition either natural or artificial is not always essential for sufficient food intake for maintaining balanced nutrition in normal health, but is necessary to support extra demands of illness & aging. Prosthodontist is in a strategic position to evaluate & correct nutritional deficiencies that promote premature aging of oral tissues by providing a functional prosthesis. A prosthodontist need to understand aging patient & his requirements provide prosthetic treatment to meet his demands & helping him towards optimal health & a happier life.

Quality of denture wearing patient can definitely be improved by diet counseling. Creating nutrition awareness & referral to physician or dietitian when required is of utmost importance. A careful screening, diet evaluation and regular follow ups will help to identify nutritional risk & deal with it. Objective of diet counseling is to correct imbalance in nutrition that interfere with body as well as oral health.⁷

Older people with dry mouth are likely to prefer foods that are high in fats, oils and sugars due to ease of chewing and swallowing. Older people with altered taste and smell may consume more sugars as a way of making food palatable. Some people may not consume some foods that are good sources of dietary fiber due to problems with their teeth or dentures. For those with dry mouth, encourage frequent sipping of non-sugared, low acidic drinks such as water. The intake of sugar-containing medications should be limited. Ask the doctor for alternatives for the person in your care. Prepare chopped up vegetables or mashed vegetables for them. Avoid giving them stringy foods. Provide small bite-sized portions of fruit.

Conclusion

The geriatric population being a very important asset for our society, their experience and guidance in real life is indispensible. As a Prosthodontist, if we think what we can give back to the society? One of the answers could be obtaining detailed knowledge of diet and nutrition and guiding our patients during our long and repeated appointments. This way, Prosthodontist can bang a correct balance between profession and their responsibility towards society at a large and attain professional happiness.²The concluding principle is that proper nutrition is an important aid in preventive medicine in geriatric people in which the practicing Prosthodontist can play a vital role.

References

1. Recommended Dietary Allowances For Indians, Report Of Expert Group Of Indian Council Of Medical Research, National Institute Of Nutrition, Hyderabad.
2. Palaskar J. Diet & nutrition in geriatric patients- A matter of concern. J Dent Allied Sci 2012; 1(2):44.
3. Philippie Mojon, Ejvind Budtz-Jorgensen, Charles-Henri Rrapin. Relationship between oral health and nutrition in very old people. Age and ageing 1999; 28:463-68
4. Nancy G sebring, Albert D Gluckes, Shou Hua, Mccarthy. Nutritional adequacy of reported intake of edentulous subjects treated with new conventional or implant-supported mandibular dentures.

J Prosthet Dent oct 1995; 74(4):358-63

5. Snehal Sonarkar, Rucheet Purba, Shishir Singh, Rajesh Podar. “Components of diet and it relation to dental caries: A review”. Int J Contemp Dent Med Rev 2014
6. Dietary guidelines for Indians, National Institute Of Nutrition 2010
7. Zarb, Hobkirk, Eckert, Jacob. Prosthodontic Treatment for Edentulous Patients, 13^th Ed. New Delhi, Mosby, Elsevier, 2013;28-33
8. Sheldon Winkler. Essentials of Complete Denture Prosthodontics, 2nd Ed. New Delhi, AITBS publishers, 2012,15-20

List of Tables:

Table 1

Amount of energy derived from various macronutrients.¹

Table 2

Recommended Daily Allowance and sources of micronutrients.¹

Table 3

Recommended Daily Allowance and sources of vitamins.¹

Table 1: Amount of energy derived from various macronutrients.¹

Table 2: Recommended Daily Allowance and sources of micronutrients.¹

Table 3: Recommended Daily Allowance and sources of vitamins.¹