Food Avoidance and Food Modification Practices of Older Rural Adults: Association With Oral Health Status and Implications for Service Provision

In this article, we describe how older adults avoid or modify foods in order to accommodate oral health deficits that they experience. We argue that behaviors that contribute to dietary intake are important because of diet’s association with health maintenance and disease prevention. There is little research that considers the changes in eating that accompany oral health declines. We suggest that older adults make these changes in eating—food avoidance and food modification—as part of their nutritional self-management strategies. Consuming a varied diet that includes fresh fruits and vegetables, nuts, and meats is associated with protection against a variety of chronic diseases and chronic disease risk factors. Vegetable consumption has been associated with reduced risk of some cancers (Edefonti et al., 2009; Kim & Park, 2008; Nomura et al., 2008; Wright et al., 2008). Diets that include vegetables, fruits, and nuts are also associated with lower incidence of diabetes, reduced risk of mortality from diabetes and cardiovascular disease, and lower rates of risk factors such as hypertension and obesity (Dauchet et al., 2007; Heidemann et al., 2008; Masala et al., 2008; Nash & Nash, 2008; Nettleton et al., 2008). Loss of teeth and other oral health deficits that may accompany aging are associated with real and perceived declines in chewing ability. Having 20 natural teeth has been suggested as a threshold below which both laboratory-measured and self-reported chewing efficiency declines (Gotfredsen & Walls, 2007). Compared to persons with more teeth, those with fewer teeth report avoiding hard foods such as apples and raw vegetables more often (Hung, Colditz, & Joshipura, 2005). Nevertheless, studies sometimes fail to find declines in nutrient intake that might be expected from oral health deficits (Walls & Steele, 2004), raising the possibility that, in addition to food avoidance, some persons adopt adaptive food-related behaviors such as food modification. These behaviors may be responsible for the maintenance of adequate dietary intakes. Older adults with oral health deficits are likely to avoid or modify foods that are problematic to eat due to difficulties in chewing and swallowing, due to pain, or due to fear of causing further harm to a fragile dentition. Avoiding foods can have a variety of dietary effects, depending on whether the avoidance prevents consumption of an adequate diet. These changes in diet, in turn, can affect nutritional status and health. Existing studies have demonstrated the impact of oral health deficits on nutritional status of older adults (Hung et al., 2003, 2005; Lee et al., 2004; Marcenes, Steele, Sheiham, & Walls, 2003; Nowjack-Raymer & Sheiham, 2007) and on chronic disease status (Garcia, Henshaw, & Krall, 2000). Modifying foods in ways that still permit their consumption may have fewer dietary consequences than food avoidance, thus permitting older adults to maintain their customary food consumption patterns. Food plays a role in maintaining identity and feelings of connectedness to family and place (Quandt, 2006). Therefore, older adults may sometimes resist eliminating food from their diet (food avoidance) and practice food modification behaviors to facilitate consuming familiar foods to maintain their sense of well-being. Such foods help to reinforce ethnic group membership, regional affiliation, or attachment to families (Mintz & Du Bois, 2002). The literature on the avoidance of foods due to oral health deficits is limited. A study of tooth loss in a large (>83,000) prospective sample of U.S. women found that women who lost teeth tended to begin avoiding hard foods such as raw fruits and vegetables (Hung et al., 2005). A study of 753 community-dwelling older adults in Great Britain found that those with fewer teeth and poorer oral condition avoided specific foods like apples, well-done meats, nuts, and raw carrots (Sheiham & Steele, 2001). In most cases, the oral health associations with food avoidance have been limited to tooth loss, functional posterior occlusal contacts (Hildebrandt, Dominguez, Schork, & Loesche, 1997; Marcenes et al., 2003; Sheiham et al., 2001), having dentures (Ellis, Thomason, Jepson, Smith, & Allen, 2008; Nowjack-Raymer & Sheiham, 2003), and dry mouth (Makhija et al., 2007; Rhodus & Brown, 1990). Although these have been examined individually in separate populations, no study has looked at multiple oral health deficits in the same sample. Existing studies have used a variety of ways to determine foods avoided. These include assuming avoidance by comparisons of foods on dietary recall measures of those with and without oral health deficits (e.g., Nowjack-Raymer & Sheiham) or using a list of foods exemplifying eating challenges (e.g., sticky, crunchy, stringy; Hildebrandt et al., 1997). Studies of food modification—that is, making changes in the texture, size, or consistency of foods to facilitate their consumption—as a result of oral health deficits are rare. Occasional suggestions of food modification are found in a few studies (e.g., Anastassiadou & Heath, 2002), but no deliberate study of these practices has been conducted. Despite the dearth of previous research documenting food avoidance and food modification for oral health deficits, the field of self-care and self-management research (Clark, 2003; Ory, 2008) suggests that older adults likely undertake such measures to adapt to changing health conditions and, to the extent possible, to maintain their diet. Health self-management is defined as behaviors undertaken to enhance health, prevent disease, limit illness, or restore health (World Health Organization, 1983). Self-management includes behaviors based on one’s own resources (self-care), on informal support from family and friends, on formal services, and on medical care. The self-management literature argues that older adults’ primary means of dealing with health deficits is self-care: performing behaviors and leveraging resources to meet their health-related needs (Clark, 2003; Clark et al., 2008). Nutritional self-management has been described as a specific type of health self-management. Quandt, Arcury, and Bell (1998) have proposed that older adults bring these four types of resources (self-care, informal support, formal services, and medical care) to bear on a set of three food-related tasks (food acquisition, food consumption, and maintaining food security) necessary to maintain adequate nutritional status (Quandt et al.). Behaviors that contribute to these food-related tasks can include gardening (for food acquisition), cooking food (for food consumption), and preserving food (for food security). We propose that food avoidance and food modification are specific types of behaviors that contribute to older adults achieving “food consumption” in the context of a variety of problems, including oral health deficits. Food avoidance and food modification can be accomplished by self-care (choosing or modifying foods oneself), informal support (having others, most likely a family member, choose and prepare foods to accommodate dental problems), or formal services (having an aide prepare foods). This article focuses on a multiethnic sample of older adults in the rural South. The purposes of this article were to investigate a set of nutritional self-management practices related to oral health deficits by (a) quantifying the food avoidance and food modification practices of older adults in a rural, multiethnic population and (b) testing the hypothesis that food avoidance and food modification practices are significantly associated with oral health deficits.