DIET COUNSELLING

DR JJ

Introduction

Diet

Types of diet

Importance of balanced diet

Diet counselling

Diet chart

Dental health diet score

Communication techniques

Guidelines for diet counselling

Contents

Diet & dental caries

Dietary studies

Non- cariogenic diet

Diet & periodontal disease

Conclusion

References

Previous year questions

Introduction

• When man broke from the natural food chain, he

developed new energy resources and applied

technologies to food processing, since then our

dietary habits have undergone major changes. Both

the qualitative nature of our diet and pattern of eating

has changed and are changing.

• The science which deals with the study of nutrient and foods

and their effects on the nature & function of organism under

different condition of age, health & disease.

-NIZEL 1989

• Nutrients are defined as the constituents of food, which

perform important functions in our body.

Nutrition

• Nizel (1989): Total oral intake of a substance that provides

nourishment & supply.

BALANCED DIET :

• One providing each nutrient in the (neither deficient nor excess)

needed to maintain optimum health.

- Stewart

Diet

TYPES OF DIETS

Vegetarian diets

• A vegetarian diet is one which excludes meat.

• Fruitarian diet: A diet which predominantly consists of raw

fruit.

• Lacto vegetarianism: A vegetarian diet that includes certain

types of dairy, but excludes eggs and foods which contain

animal rennet.

• Lacto-ovo vegetarianism: A vegetarian diet that includes eggs

and dairy.

• Vegan diet: In addition to the requirements of a vegetarian

diet, vegans do not eat food produced by animals, such as

eggs, dairy products, or honey.

Semi-vegetarian diets

• Flexitarian diet: A predominantly vegetarian diet, in which meat is

occasionally consumed.

• Kangatarian: A diet originating from Australia. In addition to

foods permissible in a vegetarian diet, kangaroo meat is also

consumed.

• Pescetarian diet: A diet which includes fish but not meat.

• Plant-based diet: A broad term to describe diets in which animal

products do not form a large proportion of the diet.

Belief-based diets

• Buddhist diet: While Buddhism does not have specific dietary

rules, some buddhists practice vegetarianism based on a strict

interpretation of the first of the Five Precepts.

• Hindu and Jain diets: Followers of Hinduism and Jainism may

follow lacto-vegetarian diets, based on the principle

of Ahimsa (non-harming).

• Islamic dietary laws: Muslims follow a diet consisting solely

of food that is halal – permissible under Islamic law. The

opposite of halal is haraam, food that is Islamically

Impermissible.

• Haraam substances include alcohol, pork, and any meat from

an animal which was not killed through the Islamic method of

ritual slaughter (Dhabiha).

Diets followed for medical reasons

• Best Bet Diet: A diet designed to help prevent multiple

sclerosis, by avoiding foods with certain types of protein.

• Colon cancer diet: Calcium, milk and garlic are thought to

help prevent colon cancer. Red meat and processed meat may

increase risk.

• Diabetic diet: An umbrella term for diets recommended to

people with diabetes. There is considerable disagreement in the

scientific community as to what sort of diet is best for people

with diabetes.

• Liquid diet: A diet in which only liquids are consumed. May be

administered by clinicians for medical reasons, such as after a

gastric bypass or to prevent death through starvation from a

hunger strike.

Importance of balanced diet

• A balanced diet is important because your organs

and tissues need proper nutrition to work effectively.

Without good nutrition, your body is more prone to

disease, infection, fatigue, and poor performance.

COUNSELLING

• Optimal growth and development are the primary objectives of

pediatric nutrition.

• Food is merely a vehicle for nutrient delivery; the nutrients

provide energy for growth, serve as structural components,

and participate in all metabolic functions of the body. Food,

however is more than just nutrients : sensory , emotional ,

social and cultural associations influence food choices.

• One of the key focuses with Dietary Counselling is making a

step by step approach, so that changes are achievable in the long

term.

• Any changes that are made might be done over a number of

weeks, so attaining your main goal is more manageable. Dietary

counselling can help putting a healthy diet in place, for an

individual and/or a family, losing weight, or simply feeling better

by eating better.

Diet chart

• A diet history concerning food intake patterns, diet

adequacy, consumption of fermentable carbohydrates

(including naturally occurring and added sugars), and

the use of fluoridated toothpaste is a strategy for

health professionals to use to determine the diet

related caries risk habits of persons.

DENTAL HEALTH DIET SCORE

• The dental health diet score gives points earned as a result of an

adequate intake of food from each of the food groups plus points for

ingesting foods especially recommended because they are the best

sources of the ten nutrients essential for achieving and maintaining

dental health.

• From this sum points are substracted for frequent ingestion of foods

that are overtly sweet – whose sweetness is derived from added refined

sugar or concentrated natural sugars.The difference is the dental health

diet score.

Instructions for Calculating a Dental Health Diet Score:

• Step 1 >• To ascertain the average daily intake, list everything you eat and

drink on an ordinary weekday including snacks.

• Record the time when the meal or snacks were eaten, the amount

ingested (in household measures), how the food was prepared, and

the number of teaspoons of sugar added.

Step 2 • Circle the foods in the diary that have been sweetened with added sugar or

are concentrated natural sweets (honey, raisins, figs, and so forth).

Classify the uncircled foods or mixed food dishes into one or more ofthe

appropriate food groups.

• For each serving of these foods listed in the food intake dairy, place a

check mark in the appropriate food group block.

• Add the number of checks and multiply by the number shown. The

maximum number of points credit for the milk and meat groups is 24 each

and for the fruit vegetable and bread-cereal groups is 24 each.

• Add the points. The sum is the Food Group Score (96 is the highest score).

Step 3• How many of the foods listed contain one or more of the ten

nutrients essential for dental-oral health? In the Nutrient

Evaluation Chart are listed the foods that are good sources of

the nutrients essential for good health in general and dental

oral health in particular.

• In each of the eight columns of foods, check the one or more

eaten on this usual weekday. If a food is checked, circle the

number 7 beside the nutrient that heads this column.

• The same food, such as broccoli, may be found in several

columns. Also, in column more than one food may be checked.

Regardless of the number of foods checked in the column, only

seven points is given per nutrient (56 is a perfect score).

Step 4• List the sweets and sugar-sweetened foods and the frequency with

which they are consumed in a typical day.

• Classify each sweet into either the liquid, solid and sticky, or

slowly dissolving category.

• Place a check mark in the frequency column for each item as long

as they are eaten at least 20 minutes apart.

• Add the number of checks. If the sweets are liquid, multiply by 5;

if solid, multiply by 10; if slowly dissolving, and multiply by 15.

• Write the products in the Points column and total them.

Step 5

• Now put it all together. Transfer the 4 Food Group Score and

the Sweet Score to the Totaling the Scores page.

• If the 4 Food Group Score is barely adequate or not adequate

and lor the Sweet Score is in the "Watch Out" zone, nutrition

counseling is indicated.

Communication Techniques :

Three rules

1. for motivating behavioural change.

2. verbal and nonverbal.

3. Personalization of the message is more likely to result

in a sustained change in behaviour.

• Interviewing

• Teaching

• Counselling

• Motivating

Interview

• (1) the problem,

• (2) the factors that contribute to it, and

• (3) the personality of the patient.

Why should a dental health professional elicit information concerning the food and dietary intake and habits of patients?

• First, the dietary interview can serve as a valuable diagnostic

aid. Food selection and eating habits may affect a person's

dental or general health or both.

• Appraisal of an individual's dietary status may provide a clue

to potential difficulties.

• Second, knowledge of a person's daily routine is important for

adapting the caries-preventive diet to an individual's lifestyle.

• This adaptation may help a patient adhere to the newly

prescribed diet, the basis for achieving the health goals and

rewards for diet counseling.

• Third, many practical research contributions could be made if

data from nutritional assessments could systematically be

gathered to correlate dental, periodontal, or oral mucosal

problems with such factors as food habits, dietary intake,

physical conditioning factors, and socioeconomic status,

among others.

Physical Setting :

THE DIET INTERVIEWER:

• Certainly nutritionists can readily qualify with some

extra course work in the nature of dental caries and

periodontal disease and in preventive dentistry.

• Ideally, as the professional authority, the dentist should be the

diet interviewer, but it is probable that he or she will not be

able to give adequate time to this phase of preventive services.

• Consequently, clinical dental nutrition services probably will

be assigned to a dental hygienist or a nutritionist. In any event,

the dentist is the responsible professional who must reinforce

the advice given by the dental hygienist or nutritionist at the

check up visits.

Teaching and Learning:

• Even with these various aids available, teaching will not be

effective if the information is not presented in small

increment.

• If the patient does not understand the explanation, it should be

repeated.

• The next level should not be attempted until the previous level

is fully understood.

• The more the patient is involved in the educational process the

greater is the extent of learning. People learn least well by

hearing; they learn better what they can also see; and they learn

best by doing, because they are totally involved.

• Any time the patient participates in evaluating his or her diet

and writes his or her own diet prescription with guidance from

the counselor, optimal learning and adherence to the new

regimen will result.

Counseling :

GUIDELINES FOR COUNSELING:

1. Gather information- Personal identifying data, likes and

dislikes, and the patient's perception as to the cause(s) of the

problem.

2. Evaluate and interpret information – relative adequacy of the

diet, eating habits, and the indirect environmental or systemic

factors that contribute to the dietary problem - to find the

reasons for the patient's dental problem.

• 3. Develop and implement a plan of action - a patient is

prescribed diet consisting primarily of gradual, qualitative

modifications of the diet using acceptable food exchanges. Be

realistic in the types and amounts of changes made initially. The

dietary frequency chart may help in determining what changes

might be made.

• 4. Seek active participation

• 5. Follow up

MOTIVATION

• Motivation stimulates or is an incentive for action. To modify

a patient's diet, the clinician can only seen and encourage the

patient's own motivation.

• However, the counselor's positive attitude and conviction as to

the necessity and effectiveness of nutrition counseling can

stimulate the patient to initiate an improved dietary pattern.

• According to Garn, the basic factors that motivate people are

self preservation, recognition, love, and money. The order of

importance varies from one individual to another, but all four

factors influence the desires of each person.

• If clinicians can help patients understand that a healthy mouth

and teeth and a nice looking smile can help them achieve one

or more of these four goals, patients will be inclined to adopt a

diet that will promote better oral health.

MOTIVATING PATIENTS TO MODIFY FOOD HABITS:

1. Awareness

2. Interest

3. Involvement

4. Action

5. Habit

1. Awareness

2. Interest

3. Involvement

4. Action

5. Habit

DIET AND DENTAL CARIES

Process of caries formation

1. Frequency of eating:

• Vipeholm study showed that frequency of consumption of sugars

and the oral clearance time for sugars are important factors

affecting cariogenicity.

• In a study of more than 1000 children in USA, indicated that the

frequency or between meal snacks of candies, cookies,

chewing gum or carbonated beverages correlated with the DMF

rates (Weiss et al 1960).

FACTORS INFLUENCING CARIOGENICITY OF SUCROSE IN DIETS

•A significant correlation was found between a high sugar

concentration in saliva with a prolonged clearance time and

caries activity (Lundquist, 1952).

• This finding implies that retentive, sticky, sweet foods with

little detergency or self cleaning properties may be potentially

more cariogenic than foods that detergent and rapidly clear the

oral cavity.

Oral clearance rate

• The availability of sucrose for support of bacterial metabolism

in plaque which is influenced by the texture, consistency of

food, the stimulation of saliva by chewing and the rapidity of

clearance of the substrate.

• With the advent of highly concentrated processed canned

sugar the level of sucrose consumption as well as

concentration of sucrose in food item increased dramatically.

Effective concentration of sucrose

Dietary studies in human population

HOW TO ASSIST THE PATIENT TO SELECT AN ADEQUATENONCARIOGENIC DIET:

Step 1

• Commend the patient. It is important to commence a

counseling procedure on a positive note. Patients do not

like to be criticized at the very outset.

• Since the food evaluation chart will probably show that

the recommended allowances were met in at least one or

two food groups, a good starting point is to commend

the patient for this and urge continuance of this good

practice.

Step 2• Allow the patient to suggest improvements and write his or her

own diet prescription. Again refer to the evaluation chart. It

can readily be seen that an intake of only two or three food

groups is insufficient.

• For improvement, positive recommendations for increasing

the amounts to the recommended levels in order to achieve an

adequate diet should be made.

Step 3• Allow the patient to delete from the diet plaque-forming, sugar-

sweetened foods.

• By reexamining the sweets intake chart, the patient will note the

grand total of the number of exposures to sweets, the type of sweets

most often consumed, and the frequency with which they were eaten.

• Since the form of sweets and the frequency of their use are the two

most pressing factors in caries production, it must be emphasized

that there can be absolutely no compromise with respect to the

deletion from the diet of sweets that tend to be retained in the mouth.

Step 4• Allow the patient to select non-plaque promoting snack substitutes.

If snacking is a habit of long standing, realize that it is futile and

unrealistic to expect total immediate abandonment of between meal

nibbling. Acceptable alternatives include raw fruits, raw

vegetables, cheddar cheese, or nuts.

• However, if the patient is consistently reminded that increasing the

total food intake at each meal will satisfy appetite and hunger, it is

possible that the number of between meal snacks will eventually be

reduced.

Step 5

• Allow the patient to select menus.

• Starting with the existing menu as a nucleus, encourage the

patient to examine each meal and make deletions,

substitutions, or additions with which he or she can

comfortably live.

• The rule is to improve the quality, not the quantity of the food

so that acceptance will be more likely.

Reinforcement by Follow-up Reevaluation:

• Schedule a follow up visit for 2 weeks later. The patient is asked

to complete a second 5 day food diary in the same manner first

just before returning.

• Evaluate the new food diary and compare the results with the

original plan to note whether recommendations have been

followed. Discuss misinterpretations, misunderstandings, and

problems that have arisen during this period.

• Menu changes are recommended if necessary.

Effect of diet on oral health

Systemic mechanism

Absorption and circulation of nutritents to

cells and tissues

These effects are mediated locally

Local mechanism

Development of teeth, quality and quantity of

salivary secretion

Influence the metabolism of oral flora

Artificial sugar substitutes

Sorbital

Xylitol

Aspartame

Saccharine

Cyclamate

REDUCING THE CARIOGENICITY OF THE DIET

Caries in rodents have been reduced significantly by adding

casein to an otherwise cariogenic diet. Since casein is a

phospho-protein, it is possible that phosphate in this protein

compound may have exerted some anti cariogenic effect.

Several animal studies show that the aminoacids such as lysine

and glycine help prevent caries.

* (Nizel et al 1970 ; McClure et al 1955; Harris et al 1967).

Protein and dental caries

There is indirect evidence that

dietary fats may help prevent caries

in humans.

For example those Eskimos whose

diets are almost solely of animal

origin and furnish about 70-80% of

their total calories as fat experience

less decay. It is only when the fat

content of the diet is reduced to 25%

or less that decay starts to appear.

Fats and dental caries

In Vitamin A deficient animals, atrophic changes in the

ameloblasts, subsequent abnormalities in tooth

morphology has been observed.

In man, severe Vitamin A deficiency during tooth

formation does not necessarily lead to defective

enamel.

The only member of the Vitamin B complex which has

been associated with caries is pyridoxine (Vitamin B6)

very high doses (10 times > than normal) have been

reported in two small scale experiments in human

subjects (pregnant and school children) to reduce

caries. * (Cole et al 1980).

Vitamins and dental caries

Trace elements and dental caries

Caries promoting elements : Selenium, magnesium, Cadmium, Platinum, Lead,

Silicon.

Elements that are mildly cariostatic : Molybdenum, Vanadium, Strontium,

Calcium, Boron, Lithium, Gold.

Elements with doubtful effect on caries : Beryllium, Cobalt, Manganese, Tin,

Zinc, Bromine, Iodine.

Caries inert elements : Barium, aluminium, nickel, iron, palladium, titanium.

Elements that are strongly cariostatic : Fluorine, phosphorous.

Kum Sun Lee, Nam-Joong Kim, Eun-Hee Lee, Ja-Won Cho. Cariogenic Potential Index of Fruits according to Their Viscosity and Sugar Content. Int J

Clin Prev Dent 2014;10(4):255-258

Fluoride : Water borne fluorides which originally were observed to cause

an unattractive discolouration and deformity to tooth enamel,

when ingested at level above 2 ppm, later were proved to be

essential of dental health because they reduced the incidence

of dental decay when ingested daily at optimum levels of 1

ppm.

Trace elements and dental caries

SUGAR-SWEETENED BEVERAGES AND DENTAL CARIES IN ADULTS: A 4-YEAR PROSPECTIVE STUDY

E DUAR DO BE R NAB É E T A L . JO UR NA L OF D EN TISTRY 2 01 6

Data from 939 dentate adults who participated in the Health 2000

Survey and the Follow-Up Study of Finnish Adults’ Oral Health

showed a positive association was found between frequency of

Sweetened Beverages consumption and 4-year net DMFT

increment. Adults drinking 1–2 and 3+ sweetened beverages

daily had, respectively, 31% and 33% greater net DMFT

increments than those not drinking any sugar sweetened

beverages.

Clinical significance: Drinking sugar-sweetened beverages on a

daily basis is related to greater caries risk in adults.

Exploring the relation between body mass index, diet, and dental caries among 6-12‑year‑old

children

Elangovan A, Mungara J, Joseph E Department of Pedodontics and Preventive Dentistry, RagasDental

College and Hospital, Chennai, Tamilnadu, India 2015Aim: The aim of the present study was to determine if there is an association between BMI‑for‑age and dental caries in

children and to find out the role of diet with respect to BMI‑for‑age and dental caries.

Materials and Methods: Demographics and anthropometric measurements were obtained for 600 children and

BMI‑for‑age was calculated. Clinical examination for dental caries was carried out following WHO criteria. A diet

recording sheet was prepared and children/parents were asked to record the dietary intake for 3 days. Data obtained were

statistically analyzed using Chi‑square, analysis of variance (ANOVA), and multiple linear regression.

Results: After excluding improperly filled diet recording sheets, 510 children were included in the study. Caries

prevalence was more in obese children than in other BMI groups. Caries scores increased as BMI‑for‑age

increased, though this was not statistically significant. Consumption of fatty foods and snacks was more with obese

children compared to other groups. A correlation was found between caries and snacks.

Conclusion: Dental caries scores showed no relationship between BMI‑for‑age in children. Both snacks and fatty food

items were consumed more by obese children, which seeks attention.

Diet and periodontal disease

• Glucose and other carbohydrates are also used to produce

extracellular polysaccharides and, therefore, diets

containing sucrose, glucose and other disaccharides can

increase the plaque mass and facilitate the retention and

colonization of the plaque biofilm which forms a substrate

for bacteria to grow leading to periodontal diseases.

-Boyd (2003)

Effect of diet on periodontal health

By interfering with the

A) integrity of gingival epithelial barrier.

B) tissue repair processes.

C) resistance mechanisms of the body.

Nutritional deficiencies contributes to periodontal disease

Research studies using an experimental

gingivitis model have shown increased

levels of bleeding on probing when

participants were fed with a diet high in

carbohydrates when compared to those on

a low sugar diet.

Carbohydrates and periodontal health

The epithelium of the gingival crevice or pocket adheres to the

tooth surface by physiochemical forces mediated by the proteins

and glycoproteins in the gingival fluid.

When a foreign body is introduced into the periodontal pocket in

a protein – deficient animal, the resorption of alveolar crest, the

down growth of the epithelial attachment, and the inflammatory

exudate are increased.

Role of protein on periodontal tissue

• Vitamin A deficiency produces hyperkeratosis and

hyperplasia of gingival tissue. There is a tendency

to periodontal pocket formation.

• A suitable antimetabolite of vitamin K might

interfere with the growth of Bacteroides

Melaninogenicus and consequently, prevent the

occurrence of periodontal disease.

• The characteristic oral sign of Vitamin C

deficiency is scurvy which results in enlargement

of the marginal gingivae that envelopes and

almost completely conceals the teeth.

Effects of vitamin deficiency on Periodontium

• Step 1 :Ascertain the dental health diet score and if necessary,

demonstrate the method for keeping a food intake diary

• Step 2 :explain the nutrition-periodontal relationship

• Step 3 : Assess nutritional status

• Step 4 : Prescribe a diet –improve adequacy of diet

• Emphasize foods that are particularly beneficial to periodontal

tissue-proteins, vit C, A, folic acid, calcium, iron and zinc.

• Encourage the elimination of plaque forming sweets and

substitution of fibrous foods.

• Allow the patient to prescribe meal.

• Step 5 :Follow up

Nutrition counselling for a patient with chronic periodontitis

The National Health and Nutrition Examination Survey (NHANES) is a

program of studies designed to assess the health and nutritional status of

adults and children in the United States.

NCHS (national centre for health statistics) is part of the Centers for Disease

Control and Prevention (CDC) and has the responsibility for producing vital

and health statistics for the Nation.

The NHANES interview includes demographic, socioeconomic, dietary, and

health-related questions.

The examination component consists of medical, dental, and physiological

measurements, as well as laboratory tests.

Epidemiological surveys

Conclusion

• Diet counselling makes the patient aware of the fact

that diet plays an important role in the treatment of

the disease.

• With today’s emphasis on prevention of disease, diet

counselling helps to reduce the risk of some illness by

appropriate counselling.

References.

Abraham E. Nizel. The science of nutrition and its application in

clinical dentistry 2nd edition, W, B Saunders Company,

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Paula J. Moynihan. The role of diet and nutrition in the etiology

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Elangovan A, Mungara J, Joseph . Exploring the relation between

body mass index, diet, and dental caries among 6-12‑year‑old

children .J Indian Soc Pedod Prev Dent. 2012 Oct-Dec;30(4):293-

300

• Eduardo Bernabé et al. Sugar-sweetened beverages and

dental caries in adults: A 4-year prospective study . Journal of

dentistry 2014.

• Kum Sun Lee, Nam-Joong Kim, Eun-Hee Lee, Ja-Won

Cho. Cariogenic Potential Index of Fruits according to Their

Viscosity and Sugar Content. Int J Clin Prev Dent

2014;10(4):255-258

• Paula J. Moynihan. The role of diet and nutrition in the

etiology and prevention of oral diseases . Bulletin of the World

Health Organization (BLT). Volume 83, Number 9, September

2005, 641-720

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