Food for thoughtGuidelines for putting oral health into thecontext of healthy eating for older people

Edited by Janice Fiske' and Debbie Lewis''Dcparlincnl Dental Public Hcallh. King's College, London, UK; ^Community Dental Service,Dorset Healthcare NHS Trust, UK.

These guidelines are the result of a joint studyday between the BDA Community Dental ServicesGroup and the Gerodontic Study Group. The drawon advice from expert bodies such as COMA,the experience of nutritionists, and the ideas of100 dental workers with an interest in geriatricdentistry.

The dental health care worker's role in increasingawareness and knowledge of good nutrition is animportant one.

Diet contributes to the maintenance of health,oral health and well being and special considerationsshould be made for older people. The committeeon Medical Aspects of Food Policy (COMA)have produced a report on the Nutrition of ElderlyPeople (HMSO, 1992. No. 43) and made recommen-dations.

It is important that dietary advice for oral healthdoes not jeopardise the health and well being of olderpeople. Consequently, these guidelines are aimed atpromoting greater understanding of how dietaryadvice for oral health can be made congruent withdietary advice for general health.

The following are general guidelines which mightneed to be adapted for particular client groupseg. free-living individuals, people in institutionalsettings. For clarity, the provision of food and mealsfor older people has been placed in the followingcategories:1. General advice2. Dental advice3. Evaluation4. Skills training5. Practical advice

1. General advice

Recommendations ofthe COMA report should formthe basis for all dietary advice:• Maintain optimum energy intakes• Eat higher fibre breakfast cereals and wholemeal

bread

Reduce the intake of non-milk extrinsic sugarsAdopt a diet which moderates plasma cholesterole.g. grill as opposed to frying foodsMaintain calcium intake from milk, cheese andyoghurt (RNI 700 mg)Ensure vitamin D levels are maintained (RNI 10

• Consume more fruit, vegetables and fruit juice toensure adequate daily intake of vitamin C (RNI40 mg)

• Eat oily fish e.g. herring, trout or mackerel toavoid thrombosis

Guidelines should consider the needs and viewsofthe consumer, family, carer and staff working witholder people. These groups should be involved indrawing up loeal guidelines.

The needs of the consumer which will have to betaken into consideration include: age; mobility;dependence; culture and religion.

Identify whether a nutritional policy exists, whatit consists of and whether it is used.

Identification of the source and preparationof meals, the timing of meals and snacks andfinancial constraints upon food preparation areimportant prerequisites in setting nutritional guide-lines.

2, Dental advice

• Limit the intake of non-milk extrinsic sugars• Restrict the intake of non-milk extrinsic sugars

to mealtimes whenever possible• Discourage sugar containing snacks as these

reduce appetite and may affect nutrition adversely• Suggest alternatives for sugar containing snacks,

e.g. fresh fruit, tooth friendly confectionary(BATS)

• Suggest alternatives for sugar added to drinks, e.g.artificial sweeteners

• Suggest alternatives for added sugar in recipes,e.g. fruit juices, dried fruits

© The Gerodontology Association 1995Volume 12, No. 1

• Discourage sugar containing and li/./y soil drinks,suggest sugar tree allcmativcs

• Review medications and if necessary liaisewith medical praclilioncrs over sugar freealternatives and medications without xerostomieside elTects

• Hncourage regular dental check-ups.

Remember, a smile speaks volumes and a healthysmile is ageless.

3. Evaluation

One way of evaluating existing practice is to:• Decide on what you are aiming to achieve• Look at existing practice• Compare existing practices with what you aim to

achieve• Decide if change is required to reach your aim• Implement the change in easy stages• Re\ iew practice to ensure the aim is being met

Methods of doing this could include:• Diet questionnaire• Satisfaction questionnaire• Dietary sheets {to cover what relatives bring)• Monitor food wasted and compare when altema-

tives are offered• Costing exercise

Information from your evaluation would thenbe considered by consumers and staff. In the lightof your findings you may need to make furthermodifications and re-evaluate.

4. Skills training

The skills training required will vary according to thegroup being considered:

Individuals may require some new skills in prepar-ing different vegetables and fruits and cookingmethods e.g. use of microwave.

Care staff mz.y require training:• To improve knowledge of diet and nutrition in

relation to oral and general health and well-being

• In the use of feeding aids• In the best methods to assist with frail people

Caterers may need to be provided with informationrelating to diet and nutrition for oral and generalhealth specifically for older people. They should beencouraged to produce nutritionally attractive andpalatable meals.

Menu planners should consider:• A three tu lour week cycle rather than seven days• Seasonal menus every six months• Providing a choice at each meal• Any special dietary needs in a way that avoids

labelling people• Adopting a Hcxible approach• Using food and drink to celebrate special occasions

5. Practical advice

I. For communal dining in residential care daycentres/luneheon clubs

Create a pleasant dining environment:• Use tablecloths and tlowers• Encourage eating together• Remove distractions, e.g. tum the TV off• Stimulate conversation

Other considerations for managers:• Keep a weight book to record and monitor indi-

viduals* weight on a regular basis• Ensure availability of appropriate food and

choices for interest and rehabilitation• Provide supplementary snacks and vitamins• Use vouchers for calorie counting, i.e. to ensure

clients take sufficient calories rather than as an aidto weight reduction

• Make sure that nutritional advice is available tovisitors

• Ensure adequate fluid intake, in practical terms,this means 6-8 cups a day

Other considerations for meal providers:• Consult with consumers for likes and dislikes• Consider cultural and religious preferences in

meal planning• Timing of meals is important, e.g. make breakfast

the most flexible meal of the day• Identify access to regular dietetic advice on shop-

ping and supplements• Introduce a salad bar in institutions• Encourage healthy choices by offering healthy

alternatives at each meal• Use healthier cooking methods:

- cut down on boiling time for vegetables to pre-serve vitamins and minerals

- grill instead of fry to reduce fat content andhelp control cholesterol

- reduce salt in cooking but offer condiments atthe table for those who require them

• Do not reduce fat intake• Offer clients a glass of fruit juice daily as a source

of vitamin C

Gerodontology

Offer ;in occasional glass of sherry before mealsas an appetite stimulantConsider fitting a drinks machine with healthyoptions into institutions or have drinking waterreadily available

ii. For (hose living at home

• Enjoy your food• Give yourself a treat every day• Try something new every week• Be self-sufficient - grow a few of your own

vegetables. If you do not have a garden, use awindov^ box or large flower pot

• Check out food stores that deliver• Make meals a social occasion, e.g. invite a friend

around or eat with the family

• Keep a well stocked store cupboard of foods foran emergency.

Conclusion

The intimate relationship between good oral healthand good nutrition is an important one. It can affectgeneral health, dietary selection and enjoyment, self-esteem and social interaction. In short, it can have aprofound influence on the quality of life.

The dental team has a responsibility to take anholistic view of patients' health and to make sugges-tions which can improve food selection andenjoyment. Any advice given must be in accordancewith general dietary guidelines. Thus, they have aresponsibility to liaise with other health workers,such as dieticians, and carers to enhance and stream-line the quality of care provided.

Volume 12, No. 1