The relationship between nutrition and systemic and oral well-being in older people
Paula J. Moynihan, PhD, BSc
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ABSTRACT
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Background. Diet plays a key role in disease prevention in older age. The aims of this report were to review the causes and consequences of a poor diet in later life and its interrelationship with oral health.
Conclusions. Energy requirements decrease with age; however, many factors, including poor oral health, loss of appetite and illness, may compromise energy intake. Absorptive capacity may reduce with age; therefore, to prevent deficiencies of micronutrients, a nutrient-dense diet is essential.
Clinical Implications. The first signs of micronutrient deficiencies often are manifest in the oral tissues. Consequently, the dentist has an important role in the early diagnosis of malnutrition. Furthermore, optimizing oral health is important in maximizing older patients’ functional capacity to consume a healthful and varied diet.
Key Words: Older people; undernutrition; malnutrition; micronutrients; edentulous; oral healthAbbreviations: DRI: Dietary reference intake • PEM: Protein energy malnutrition
The number of adults aged 75 years and older is increasing steadily,1 and disease prevention in this sector of the population is an important objective in which diet plays a key role. Malnutrition (that is, deficiency of calories, protein and/or micronutrients) is not an inevitable consequence of aging, nor is it exclusive to elderly people (> 75 years of age). However, in industrialized countries, it is most common in elderly people. In this article, I provide an overview of the etiology and consequences of malnutrition in the advanced years and describe the interrelationship of malnutrition with oral health.
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IMPORTANCE OF NUTRITION AND CHANGES IN NUTRIENT NEEDS OF ELDERLY PEOPLE
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Protein energy malnutrition (PEM) in elderly people is associated with loss of muscle tissue, reduced bone mass, impaired cognitive function, poor wound healing and increased morbidity and mortality.2 A healthful diet will reduce the risk of malnutrition, as well as chronic diseases such as cardiovascular disease and cancer.3
The decline in body weight that occurs with age often is due disproportionately to a loss of muscle,2 which, in turn, leads to reduced mobility and an increase in falls.4 Although less than 10 percent of community-dwelling elderly people are underweight, this percentage is much higher in institutionalized elderly people.5–7 The decline in lean body mass, which occurs more rapidly after the eighth decade, results in decreased energy requirements.7 An average decline in basal metabolic rate of 1 to 2 percent occurs every decade in men who maintain constant weight8; despite this, energy intakes often fail to meet nutritional requirements.2,9 An adequate intake of dietary protein is important to maintain lean body tissue; the U.S. dietary reference intake (DRI) for protein for elderly people is 0.8 grams/kilogram per day,8,9 but some authors6 have suggested higher requirements (1.25 g/kg per day).
Reduced food intake and a decrease in absorption capacity in older people may lead to micronutrient deficiencies.
Reduced food intake and a decrease in absorption capacity in older people may lead to micronutrient deficiencies, the oral consequences of which are summarized in Table 1
.10,11 Calcium and vitamin D are important to minimize bone loss12,13 and subsequent osteoporosis. Osteoporosis increases the risk of experiencing bone fracture, which has serious consequences with regard to mobility and quality of life. The DRI for calcium for elderly people is 1,200 milligrams per day. People who take calcium supplements should make sure that they also take vitamin D, which plays an important role in calcium absorption. Elderly people are susceptible to vitamin D deficiency owing to age-related renal impairment (resulting in reduced hydroxylation of vitamin D), reduced exposure to sunlight (if home-bound) and reduced efficiency of vitamin D synthesis through the skin12; vitamin D supplementation may be necessary to achieve the DRI (15 micrograms per day).
Elderly people often experience reduced efficiency of iron absorption. Health care professionals should encourage elderly people to consume foods containing iron and vitamin C together, because vitamin C promotes iron absorption. An adequate vitamin B status—in particular, folate and B12—is important in preventing dementia.14 Dementia affects one in five adults older than 80 years and one in 20 adults older than 65 years.4 Vitamin B12 absorption may be compromised owing to age-related achlorhydria and other gastrointestinal conditions.14 Some medications alter folate status15; therefore, an adequate dietary intake is important. However, elderly people should take supplemental B12 and/or folate only under the guidance of a physician or registered dietitian and in conjunction with a hematologic assessment of B12 and folate levels.
A patient’s immune response may deteriorate with age. PEM and deficiencies of zinc, selenium, folate and vitamins A, C and E all influence the body’s immune response. Despite the link between nutrition and immune status, dietary interventions to improve the immune status in elderly people have resulted in inconsistent findings4; however, adequate intakes of vitamin C and zinc, apart from their roles in immune function, are important for wound healing.
Diagnosing nutritional deficiencies in elderly people is difficult and often not done until clinical signs of advanced nutritional deficiency are present.4 Early signs of micronutrient deficiencies often are first noted in the oral tissues (Table 1
); therefore, the dentist plays an important role in the early diagnosis of such deficiencies.16
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CAUSES OF UNDERNUTRITION AND NUTRIENT DEFICIENCIES IN ELDERLY PEOPLE
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As Table 2 (page 496) shows, socioeconomic factors and disease have a greater impact on nutritional status than does the aging process or age itself.4 Anorexia (that is, loss of appetite) is common in elderly people because of age-related early satiety,2 changes in taste and sensory perceptions,12 and use of medications that suppress the appetite and decrease taste sensation.17 Elderly people often consume smaller meals and eat more slowly, as well as consume few snacks between meals.18 Tooth loss, dentures and decreased salivation affect the ability to eat and compromise the nutrient intake of older adults.
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IMPACT OF ORAL HEALTH ON NUTRITIONAL WELL-BEING
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The prevalence of edentulism increases with age. In the United States, 26 percent of people aged 65 through 69 years have no natural teeth,19 which affects eating ability and diet,20–23 as well as eating-related quality of life. Dentures also may affect the sensory perception of texture and taste of food.16,17 The aging process in a healthy dentate adult is associated with moderate changes in oral physiology. However, major changes in chewing behavior and masticatory efficiency are seen when aging is associated with a compromised dentition.17 Although many studies have shown that edentulous people have poorer diets than do dentate people,20,21,24,25 a causative effect has not been demonstrated. Studies generally have shown that prosthetic rehabilitation in the absence of dietary counseling does not lead to dietary improvement.21,23–26 Nutritional counseling along with the provision of dentures in older adults can, however, result in dietary improvements.22
Reduced salivary flow is common in elderly people and is compounded by PEM and some medications.17 It alters the perception of taste and texture, makes eating more difficult, reduces denture comfort and increases the risk of developing dental caries, periodontal disease and oral infections such as candidiasis.27 This further compromises food intake and may result in a soft diet that provides little stimulus to salivary flow.16
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CONCLUSIONS
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Reduced dietary intake in elderly people may be caused by many factors, increasing the risk of losing muscle tissue and experiencing malnutrition. Strategies to maintain an adequate dietary intake are important. Despite a modest reduction in energy requirements, the need for micronutrients is not reduced in this population. Elderly people need a nutrient-dense diet, and health care professionals should discourage the consumption of foods with empty calories.
Compromised oral health is one of many barriers to achieving an adequate food intake in older age; therefore, optimizing a patient’s dental status is important. Dentists should be aware of the early signs of nutritional deficiencies, which often manifest first in the oral tissues. They should be observant with regard to other indicators of poor nutrition, such as weight loss, and refer at-risk patients to a registered dietitian for further assessment and intervention.
Health care professionals can develop successful prevention and treatment strategies only through an increased awareness and understanding of the causes of poor nutritional status in older age. Good professional relationships between registered dietitians and dental professionals are essential to this process.
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FOOTNOTES
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Dr. Moynihan is a reader in nutrition and oral health, School of Dental Sciences, Newcastle University, and director, World Health Organization Collaborating Centre for Nutrition and Oral Health. Address reprint requests to Dr. Moynihan, School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4BW, England, e-mail "p.j.moynihan{at}ncl.ac.uk".
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ABSTRACT
IMPORTANCE OF NUTRITION AND...
