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Nutrition Concepts - Part III

Nutrition Care Process


Nutritional screening, assessment, and education of patients have not been considered an important part of a dental professional’s duties in the past. As more and more studies are being conducted with results that show how important good nutrition is to oral and overall health, more dental practices are incorporating nutritional screening techniques into patient exams.1,2  

 

Nutrition Screening

Generally, screening is done (or should be done) by the dental professional as part of the initial or annual oral exam. If the results of the screening determine that further assessment is needed, the patient may be referred to a licensed nutritionist or registered dietitian who will work with the dental professional and the patient to improve the patient’s nutritional status.

The Nutritional Screening Initiative was developed in the early 1990s by several professional organizations, including The American Academy of Family Physicians, The American Dietetic Association, and the National Council on Aging. These organizations are working together to identify older people at possible risk for nutritional deficiencies. As part of the Screening Initiative, a checklist (ie, “Determine Your Nutritional Health”) was developed. The checklist is made up of ten statements; each statement is assigned a value from 1 to 4. This checklist can be administered by any level of healthcare professional. A value is circled for each question that applies to the patient. The circled numbers are, then, added up for a total. The higher the total number, the higher the individual’s nutritional risk.

Many dental practitioners hesitate to make nutritional screening a part of their practices. The reasons for this are varied. Often a lack of time or unfamiliarity with nutritional principles is cited.3 But screening does not need to take a lot of time. The “Determine Your Nutritional Health” checklist was developed with older people in mind, but it can be helpful in identifying patients at risk for nutritional deficiencies at any age. The checklist is also a good basis for a discussion about nutrition between the dental professional and the patient, and a tool to help patients realize the importance of good nutrition to their oral and overall health. The checklist is available online, as are other screening tools that could be used for nutritional screening.4

Also part of the Nutritional Screening Initiative are Level I and Level II screening forms that may be used by health professionals to further identify those individuals at high nutritional risk who may need assistance with their diets. These forms include additional information (eg, height and weight, body mass index, eating habits, living conditions, functions that the individual may need help with, and lab tests). This information could be helpful if the patient is referred to a licensed nutritionist or registered dietitian.

The American Dental Hygienists’ Association also lists suggestions for screening questions that are slightly more focused on the oral aspects of nutrition. Some of these questions ask about fluoride exposure, the frequency and types of foods consumed, and exposure to sugars in food and drink. These questions can be found at http://www.adha.org/CE_courses/course7/nutrition_screening.htm.

Dental professionals are being encouraged to make nutritional screenings part of their exams. The resources and screening instruments made available by the Nutritional Screening Initiative and the American Dental Hygienists’ Association can be used in dental settings to obtain useful information, make nutritional screening a simple and quick process, and provide an important service to patients.

 

Nutrition Assessment

Nutritional assessment is usually carried out once a screening is completed. Screening can be done by the dental professional (or any health professional) as described above. If the screening indicates that further assessment is necessary, usually the health professional who conducts the screening will refer the patient to a licensed nutritionist or registered dietitian for a more detailed assessment.

In public health, community nutritional assessments may be performed so that programs can be developed that will meet the community’s needs. Individually, as with a dental patient, an assessment would be done for that particular patient. A licensed nutritionist or registered dietitian, working with the dental professional, would most likely do a detailed nutritional assessment to create a healthier diet for that patient. 

Nutritional assessments cover more detail than that which is covered in screenings. Assessment forms can be very comprehensive and include questions not only about diet, but also about lifestyle and medications. Assessment forms can also include very detailed questions covering the patient’s medical history and current conditions.

Dietary analysis is part of a nutrition assessment. A dietary analysis can be carried out in several ways. One common technique is a food diary, in which the individual writes down everything that is eaten for several days in a row—usually for a period of one to seven days. Three-day diaries and seven-day diaries are most commonly used in dietary analysis. Usually the individual keeping the diary is asked to include one weekend day as part of the diary, so that the diary will reflect any differences between weekday and weekend diet practices. Emphasis is placed on accurately recording the amount of each food consumed along with added “extras”—especially sugars and fats in the form of sweeteners added to coffee, tea, or cereals, or butter and sauces that may be easily overlooked by the patient. Liquids that are consumed must also be recorded faithfully.

After the patient completes the food diary, the licensed nutritionist or registered dietitian calculates the total amount of calories consumed and the proportions of the macronutrients. These are then averaged to give the individual an idea of their daily consumption.

One drawback to the food diary technique is that it is time-consuming. Also, to be accurate, the patient needs to write down exactly what is eaten at the time that it is eaten. If food consumed is not recorded soon after intake, it can be difficult for the individual to remember everything later.

Another way to assess intake is with a 24-hour food recall, a technique in which the individual is asked to recall everything that was eaten during the previous 24 hours. This technique is considered to be less accurate than a diary that is kept as the food is eaten. It can be difficult to recall in detail everything that was eaten over the previous 24 hours. Also, food eaten in only one day may not represent the individual’s usual diet.

An individual nutritional assessment includes medical or lab tests and biochemical data. Anthropometric data (height, weight, waist/hip/arm measurements, skinfold thickness)) and BMI is calculated.  All of this data—the food diary, anthropometric data, biochemical data, and medical tests—are gathered and analyzed to be used in counseling the patient on diet practices and making suggestions for improvement.

(Continued from page 1 )


Diet and Nutrition Counseling

Nutrition counseling begins once all the assessment data has been collected. Some of the purposes of counseling include: helping people to avoid extremes in diet and instead develop sustainable patterns of eating; helping people make good food choices; and emphasizing eating from a variety of food groups. Often, especially if an individual is attempting to lose weight, he or she will adopt an extreme diet that is deficient in some of the food groups or is very restrictive. It is very easy to abandon the attempt in these situations because these types of diets are not sustainable or successful.

Counseling for specific oral conditions (eg, caries and periodontal disease) may be carried out in the dental office. In these cases, the counseling should include more than just advising the patient to avoid sugary foods or to “eat a well-balanced diet.” Counseling should be more comprehensive, include specific suggestions, and include the patient’s direct participation rather than simply dictating to the patient. Even counseling that is carried out in the dental office should take into consideration not only the oral condition but the patient’s overall health as well. As an adjunct to preventive guidance provided in the dental office, it may be beneficial to refer the client for additional counseling with a licensed nutritionist or registered dietitian if the caries or periodontal condition is extreme.

Often dental professionals protest that there is not enough time to do nutritional counseling during the dental visit. However, nutritional counseling in the dental office, especially with patients of record who are established in the practice and make regular visits, can be integrated into the maintenance exam. If the initial assessment and counseling have been completed previously, further nutritional counseling and guidance can be included in the periodic exam process. It can be brief and still be effective.

The method of counseling is very important, whether counseling is provided by the dental professional or by a dietary expert. Counseling styles include directive and guiding styles. With a directive style of counseling, the patient is told what he or she “must” do; the counselor uses phrases like “you should” or “you must.“ Usually, the directive style of counseling is much less effective than the guiding style because the patient tends to respond passively. People do not like to be told what they must do. The directive style is appropriate in certain specific situations, for instance, when the diet must be modified temporarily due to the requirements of an upcoming laboratory test.

Generally, a guiding style of counseling is more effective in producing changes in behavior regarding diet. The guiding style involves the patient in the process; this style is “client-centered.” It takes the patient’s or client’s concerns into consideration by asking questions of the patient rather than just telling the patient what changes must be made. With the guiding style, for instance, the patient is encouraged to think of foods that could be substituted for high-fat or high-sugar foods. The patient’s preferences are considered when making suggestions. Studies show that if the patient is fully involved in making changes, rather than just taking directions from an “expert,” the chance of successfully making and maintaining the changes will increase substantially.5

Questions asked of the patient should be open-ended (ie, questions that require more than a “yes” or “no” answer). Open-ended questions are more effective in getting a patient to discuss issues that are of concern. As the individual answers the questions, it is important that the health professional responds with affirmation to acknowledge the patient’s feelings and attitudes before beginning to educate the patient or initiate the process of changing behavior.

The Stages of Change Model is one of the most popular models for changing behavior. It is widely-used, not only for nutrition purposes but also for other areas where a behavior change is desirable (eg, quitting smoking). Studies show that the Stages of Change Model is effective because it takes into account the steps that an individual goes through as he or she is trying to change a long-established behavior. The stages are: pre-contemplation (the individual has not yet given any thought to changing); contemplation (the person is thinking about making a change soon); preparation (getting ready to take action or may have taken small steps already); action (actually making the change—has changed the behavior for a short time); and maintenance (has made the change and has continued the new behavior for six months or longer). An individual may move back and forth between the stages, “relapsing” or moving back into a previous stage at times. In this case, it is important that the health professional provide support and encouragement so that the patient does not get discouraged and give up.

Dietary counseling should emphasize consuming a variety of foods from all the food groups. The position statement of the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) emphasizes that the total overall diet be balanced with all foods in proper proportions. Relying too much on one food group can result in too much of certain nutrients and deficiencies of other nutrients. Reliance on a particular food group over others can also make the diet too restrictive and “boring” and, therefore, difficult to sustain.

Along the same line, forbidding certain foods is counter-productive. For example, with a patient who is caries-prone, completely forbidding that patient to eat a favorite fermentable carbohydrate would probably be less effective than educating the patient about ways to reduce the cariogenic effect of eating that particular food (eg, eating it with a meal instead of by itself as a snack or following it with a protein or a fat, which are not cariogenic and can reduce the effects of a cariogenic food). Encouraging the patient to brush immediately after consuming a fermentable carbohydrate is always a good suggestion. However, there may be times when this isn’t possible.   Chewing gum with xylitol is a simple preventive alternative that may be recommended to patients.

Dietary counseling in the dental setting will be less comprehensive than the counseling done by a licensed nutritionist or registered dietitian. In the dental setting, the emphasis is more on oral disease, but the overall goal is the same in both settings—to encourage patients or clients to maintain a varied, healthy diet.

 

Nutrition Referral

Patients with chronic conditions (eg, diabetes, kidney disease, or HIV/AIDS) or who need extensive counseling should be referred to a medical doctor, registered dietitian, or licensed nutritionist. It is best in these more extreme cases that the counseling done in the dental setting be supplemented in more detail by a dietary expert (ie, licensed nutritionist or registered dietician) who has the background to effectively counsel regarding specific food choices and suggestions. Ideally, the registered dietitian and the dental professional will work together with the patient. Communication between the nutrition professional, the dental professional, and the patient should always remain open for the best results.

 

References:

  1. Boyd LD, Dwyer JT. Guidelines for nutrition screening, assessment, and intervention in the dental office. J Dent Hyg. 1998 Fall;72(4):31-43.
  2. Saunders MJ. Incorporating the nutrition screening initiative into the dental practice. Spec Care Dentist. 1995 Jan-Feb;15(1):26-37.
  3. Tougher-Decker R. Nutrition education of medical and dental students: innovation through curriculum integration. Am J Clin Nutr. 2004;79:198-203.
  4. http://www.jblearning.com/samples/0763730629/Frank_Appendix10D.pdf
  5. Nappo-Dattoma, L. Dental Nutritional Counseling Techniques for the Dental Hygienist. Access. 2008
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