Examination of Witnesses (Questions 100
- 119)
TUESDAY 2 NOVEMBER 2004
PROFESSOR JOHN
MATHERS, DR
FRANS VAN
DER OUDERAA
AND PROFESSOR
ELIZABETH KAY
Q100 Chairman:
So they will have special problems if all the dentists in the
area are basically private practices.
Professor Kay: Yes.
Q101 Baroness Finlay of Llandaff:
That leads us on to a question I have which relates to the current
trends in oral health and how they affect nutrition. Looking at
it from eating being very complex it does not just mean that you
have to have an intact mouth but it is the whole digestive system
as well that needs to be in good condition.
Professor Kay: That
goes without question, but I think the mouth and teeth have a
specific role in terms of eating not just being a function; it
is also a very large part of the psycho-social well being, and
it is known that people who have embarrassment with their teeth
then their nutrition suffers from that. They do not like eating
in front of people.
Q102 Baroness Finlay of Llandaff:
I have to declare an interest here. I have a specific interest
in Canada in the terminally ill. I was wondering if there was
any research going on outside of that area into some of the communication
problems that arise for people with bad oral care as well, socialising,
part of being socially integrated and being able then to eat socially
and how that affects nutrition.
Professor Kay: There
has been a great deal of research—specially in Canada actually—that
has looked at the impact of oral health on quality of life, specifically
in the elderly. There is no question that the number of teeth
that you have impacts on your psycho-social well-being. There
are a lot of studies that show that throughout the world.
Dr van der Ouderaa:
There is also data from the United States that the level of dental
plaque and sub-gingival plaque are proportionate to the risks
of cardiomyopathy and cardiovascular complications. If people
have sufficient dexterity to clean well they will have less risk
of these sorts of infections of the heart valve.
Q103 Baroness Finlay of Llandaff:
Is there a direct link between the plaque and the disease or is
it because those who do not clean well tend to be more depressed
and have all the other lifestyle factors that put them at risk?
Dr van der Ouderaa:
If you have a lot of sub-gingival plaque then there is probably
also a permeability of the epidemia that leads to direct bacterial
infection.
Professor Kay: I
am aware of that data but there is also another study that has
looked at edentulous people—as in they do not have plaque—that
has shown that their cardiac risk is the same as people with plaque.
Chairman: So you
cannot solve a cardiovascular problem by having no teeth.
Q104 Baroness Murphy:
In the area of oral health and whether or not you have dentures
depends, rather like nutrition, on your life time habits and your
individual behaviour and clearly that is going to have a big impact
on how ageing affects you. You have been very good at telling
us about that. However, I do not see any evidence that there is
much public awareness of the impact of oral health in later life.
Although we have many messages about nutrition we do not get much
aimed at middle-aged people or younger people about looking after
their teeth or how to hang on to their own teeth into later life.
Is that something you could talk to us about?
Professor Kay: Yes.
I think that is partly because the research is relatively recent,
so the recognition of the enormity of the impact has only fairly
recently come to light. I think the other problem is that although
the face is such a huge part of your psycho-social well-being
people do not recognise it until they lose it and therefore oral
health has not been recognised as a huge quality of life issue.
You have this history of people replacing their teeth with plastic
teeth and assuming that would be all right and we are only just
understanding that that has quite a profound impact particularly
towards the end of life.
Q105 Baroness Murphy:
What do you think could be done or should be done to engage the
public in this debate? It is remarkable how much has been done
for children and parents in convincing parents that they should
pay to have their children's teeth straightened—whether
wise or not, but probably wise—but what should we be looking
to do?
Professor Kay: That
is an issue I have been battling with most of my professional
life, how do we persuade people about it? I think the answer is
that we, as a profession and professions in general, have to stop
telling people what is good for them because we believe it to
be good for them and try harder to understand why it is important
to them and, if I can use the term, sell the messages on the basis
of: this is of profound interest to you, your family and your
own personal life.
Q106 Baroness Murphy:
I have a question now for all of you about nutrition, how much
in later life—and particularly later old age—does
the age-related loss of taste and smell impact upon nutrition?
That is an issue we have not covered but seems to be clinically
quite important for some people.
Professor Mathers:
It is a very important area. The best evidence of links between
nutrition and taste perception is through the effect of zinc.
There are some nice examples of where people are zinc deficient
and they cannot taste things, they do not taste normally, and
so on. I am not aware of good nutrition data from very old people
on what factors affect taste perception in that particular group;
most of this work has been done on younger people. In general
I think it is a potential problem. It is exacerbated of course
by the fact that many older people are taking drugs of one kind
or another which also affect taste.
Dr van der Ouderaa:
I have done a study on this subject specifically a few months
ago and there is very, very little data. Also people seem to lose
their sensory faculties relatively late in life so it may only
be a problem aged 75-plus and that is a sort of forgotten population
almost in research terms. We are planning to do a big review of
this in December. This is an area where a lot of research needs
to be done.
Q107 Lord Drayson:
Do we take from that in a sense that there is ageism in terms
of a lack of interest in that population? Given that the over-85's
is the fastest growing segment within the population, why is there
not more research being done?
Dr van der Ouderaa:
I have asked that question of a lot of eminent researchers in
the academic field and they say there is no real funding for it.
A lot of funding in the context of ageing research is given for
age related diseases and not for how to live healthily for longer.
The research interests are into cancer, cardiovascular disease,
dementia but not in quality of life issues like sensory perception
and sensory faculties. It is just a question of priorities and
if you are a researcher interested in senses you probably do not
get through the competition at the research level which is extremely
high and get it funded. It is just a question of priorities. Because
it is so difficult to get funding people are not going to put
proposals in because they put proposals in in the areas where
they can get funding.
Q108 Baroness Finlay of Llandaff:
How much evidence is there behind dental hygienist intervention
and how much nutritional advice is there? Quite often they are
telling people to cut down on fruit because of the acid content
of fruit and so on, but that flies in the face of some of the
nutritional advice which one is given typically.
Professor Kay: The
traditional role of the hygienist was concentrating more on gum
disease, periodontal disease, than on decay. Therefore the concentration
is almost solely on oral hygiene and things that will not damage
the gums. That is changing with the evolution of a more team approach
in dentistry and there are a greater number of dental therapists
where a much more holistic preventative pattern is emerging. The
evidence that giving dietary advice to patients in the dental
chair has an effect is not strong. There is a little pilot evidence
from a colleague of Professor Mathers showing that when you are
fitting a denture if you explain very carefully and give nutritional
advice to the elderly person who is receiving the dentures about
how it may affect them—fruit and vegetable and vitamin C
intake—you can make quite dramatic changes in their food
intake. That is just pilot evidence; it is certainly something
that needs to be explored.
Professor Mathers:
Can I add to that that I think there is a resource issue here
that very few dental schools have nutrition experts on the staff.
It has not been traditional to have that and I think it might
help to build this team work that my colleague referred to.
Q109 Baroness Hilton of Eggardon:
You mentioned the role of diet in relation to tooth decay but
not in relation to gum disease. I was wondering whether anything
was known about what aspects of nutrition produced gum disease
rather than the effects of having it and losing teeth and not
being able to eat properly.
Professor Kay: It
is the plaque in the mouth that causes the gum disease and it
is the plaque that plays a role in dental decay as well. There
is some evidence that the higher your sugar intake as well as
causing decay it affects the micro-biology of the plaque basically,
making it stickier, so it is harder to get rid of and it builds
up more quickly. There is a link but it is not quite as direct
as with sugar and decay.
Q110 Baroness Hilton of Eggardon:
Is there anything people could do in a preventive way in terms
of nutrition?
Professor Kay: Reduce
sugar intake is the evidence based message. We used to say that
an apple a day or a carrot a day, but there is no evidence that
detersive types of food help clean the mouth in any effective
way.
Q111 Baroness Hilton of Eggardon:
I have a more general question now, if I may go onto that, about
what you see as being your highest priorities in terms of improving
nutrition and what are your particular scientific challenges which
you see in the way of improving the nation's nutritional health.
Professor Mathers:
This is a huge topic and I think there are a number of different
aspects to it. There is one fundamental area and that is understanding
nutritional needs of people as they get older. In the UK we have
what are known as Dietary Reference Values which describe the
nutritional needs of different population groups. The last publication
in that area was in 1991 and it has not been revised since then.
The evidence base for nutritional needs of older people was very
thin then and I suspect it is still rather patchy. That is an
area which I think needs some attention. It would fall into the
remit of the Scientific Advisory Committee on Nutrition and I
understand they are going to revise the DRVs at some point but
I am not sure when. The other area is around understanding the
biology of ageing and understanding how the normal homeostatic
mechanisms are disrupted as we get older and the extent to which
nutrition can help us buffer those changes. That introduces a
very large area of biology which has been largely unexplored and
I think that is a fundamental area I would like to see work done
in.
Professor Kay: Could
I have four priorities? In terms of nutrition in oral health there
are two things: one is, decrease sugar intake and have the optimum
level of fluoride intake. I think the other two priorities are
to determine how this very vulnerable elderly population (with
very poor oral health which does affect their nutrition) can access
and be persuaded to access affordable oral care. I think there
is one other issue that we have not touched upon. Because of this
cohort effect in people's oral health, we need to take very great
care that we are continuing to train an oral care profession who
are adequately and suitably trained to deal with these issues
because they are going to be different for each generation of
dentists.
Dr van der Ouderaa:
I think I have seven priorities. I think we need to build a holistic
picture of how nutrition and lifestyle together improve ageing
outcomes. This is to do with metabolic circulation. If ageing
is to do with regulation of the metabolism, how can we prevent
metabolic dysregulation due to overweight, due to the wrong nutrition,
due to the lack of physical activity and so on? Then I think there
is a lot of mileage in understanding the genetics of longevity
and using the genetics of centenarians, for instance, to come
up with new solutions on how to prevent age related conditions
in people who do not have these genes. There is some evidence,
for instance, that the metabolism of fatty acids of centenarians
is more effective. For instance, after a meal the concentrations
of LDL cholesterol are brought down quicker. If we can by nutritional
measures mimic what the genes do in centenarians then that would
be a step forward. I think we also need to have bio-markers for
healthy ageing to allow people to self-assess. Then I think we
need to learn more about studies for behavioural change because
if people want to live longer healthier they will have to change
behaviours. We need to understand how to communicate that to people.
Q112 Lord Turnberg:
We have spoken about nutrition but not about appetite and the
two must go together. What about research into appetite as we
age? Is there much going on in that field?
Professor Mathers:
I suspect rather little. Much of the work on appetite has been
concerned with appetite in relation to energy balance because
of the problems of obesity. There is a great deal of work in that
area of appetite but I am not aware of anything being done on
appetite and ageing.
Dr van der Ouderaa:
I searched for this for two days and I found two papers, so there
is very little done. There is a huge amount of appetite research
done to understand defective appetite and weight gain in the general
population but that is not geared to the older population. There
is also evidence that people of 75 and older lose weight rather
than gain weight.
Q113 Lord May of Oxford:
This might be a more futurist question and I preface it by a parenthetic
remark that the person who coined that word was an obese character
called Herman Khan 40 years ago who published a book which listed
the 50 major research priorities for the future. A pill to control
appetite was ranked number four and safe, effective contraception
was in the twenties which has permanently imperilled my respect
for anything futuristic. Against that background, can I ask you,
looking more broadly and basically at your nutrition and teeth,
within your period looking five or 10 years ahead, what would
you see as possible areas of scientific research on ageing that
ought to be pursued? And even looking beyond that, setting aside
the question of whether the Research Council would smile on them
or not, what are the things you think are specific research agendas
in the medium term and the longer time we might be thinking about?
Professor Kay: From
the BDA's point of view what I think is the most crucial thing
is some joined up thinking. There are relatively few people with
expertise in this tiny area so what I think we need are longitudinal
studies whereby we are sure that not only general health variables
data are collected but oral health data and nutritional data.
I am not sure that we have actually got all the causal links necessarily
in the right direction. We do not understand enough as yet and
we need to collaborate, possibly internationally, so that we have
the relevant expertise to join up all the areas that hinge on
nutrition and the elderly together.
Dr van der Ouderaa:
For me a very important parameter is to have accurate bio-markers
that look at people's ageing trajectories. We all have a lifetime
of professional work and ageing studies generally last so long
because the end bio-marker is mortality and you cannot race these
things. We need some very good measures that relate as to whether
certain interventions actual improve or do not improve your trajectory.
We have some of these markers—blood pressure, cholesterol,
HDL-/LDL- levels—but we need much better metabolic markers
from modern techniques that help us to find new interventions
on a much shorter timescale than a 50 year timescale.
Professor Mathers:
On a cellular level what we describe as ageing is a result of
damage to cell macro-molecules. I think we need to try to understand
that process of damage accumulation and defence against damage
and how nutrition can modulate it. I think that will require an
inter-disciplinary approach which we have not had in the past
and it requires some large scale biology.
Q114 Lord May of Oxford:
I am ignorant of this, but my impression is that the big, half-million
cohort genetic study that the MRC and Wellcome are planning, does
that have a very deliberate component of following nutrition or
is it just looking at the medical history in relation to genotypes?
If not, it is quite a specific thing that one might wish to recommend.
There is a similar study about to get underway in China too, governed
by a much more rational set of rules and informed consent than
we have in this country.
Dr van der Ouderaa:
I think that is very important, but there are limitations from
a financial point of view which constrain the degree of information
being obtained in the study. I do not think that the nutritional
information is going to be guaranteed to be sufficiently detailed
to be of the highest value. Interestingly Professor Cole in Cambridge
has probably developed the best nutritional measures for big population
studies so the ways of doing it are actually known.
Professor Mathers:
The parallels with EPIC that Dr van de Ouderaa has already referred
to are quite striking. They are cross-European studies and have
excellent measures of dietary exposure.
Q115 Lord Mitchell:
Could we now turn to Government and Government relations with
what you do? First of all, to what extent are your priorities
recognised by Government departments? Secondly, do you think there
is a good link between science and policy in Government in the
field of nutritional or oral health and its impacts on ageing?
In what respects could more be done to develop such links and
what benefits do you think might result? Could I also ask you
just to look at the issue that always comes up, that is relationships
between Government departments and them not speaking to each other?
Professor Mathers:
I think DH has the primary responsibility in the area of nutritional
health but I had a look at their website at the weekend and if
you put "nutrition" into the website it does not come
up as a heading which I think is rather striking; nor does "ageing"
interestingly. So the two things we are discussing here this afternoon
do not appear as major headings in the Department of Health. We
are eagerly awaiting the Public Health White Paper and I hope
that that will address some of these issues but the omens are
not particularly strong. More broadly, of course the Government
does put an enormous amount of money into ageing research and
I think the Research Councils would argue that it is tens of millions
of pounds per year but it is not clear that very much of that
is spent on the interface between nutrition and ageing. I think
that is an area which has been poorly funded up to now.
Professor Kay: There
is a national service framework for older people. Unfortunately
it pays very little attention to the impact of oral health on
the quality of life of the elderly.
Chairman: Can I just
halt for a moment because a division has been called and there
may be some who have to go or want to go or have good reason to
go, in which case perhaps we can just pause for a few minutes.
The Committee suspended from 4.25 pm to 4.36 pm
for a division in the house
Q116 Chairman:
I think we should resume now. The two still to come back will
catch up with us. Professor Kay, you were answering Lord Mitchell's
question.
Professor Kay: I
was talking about the national service framework where oral health
does not really feature. Of course, primary care trusts refer
to that framework to drive what they do, to decide what to pay
for, and while oral health is not there you are certainly not
going to get implementation of it on the ground for the elderly
population. There are a lot of health issues which may not be
within the national framework.
Q117 Baroness Emerton:
Following on the departments' issue, do you think that the Research
Councils and the Department of Health and other research funding
organisations really give appropriate recognition to the importance
of ageing in general and to nutritional and oral health aspects
of ageing in particular? I think you have answered some of those
already. If not, what actions might remedy the situation?
Professor Kay: The
short answer is, no, I do not think they do.
Q118 Baroness Emerton:
What are the actions which you think might remedy this situation?
Professor Kay: I
will let my colleagues speak, I think.
Professor Mathers:
Let me start with something about the research community because
I think that is part of the problem. The research community who
are interested in this area are rather small and fragmented and,
by and large, poorly funded. I think this is an area where something
should be done to stimulate that community. The very basic work
on the ageing process is funded, if you like, at the cellular
level. When you get to the whole person that is where it begins
to fall down; I think that is where we need considerably more
effort. The BBSRC has the Healthy Organism as part of its portfolio
of work and they have just instituted a strategy panel to look
at diet within that Healthy Organism umbrella and will be looking
at ageing as part of that process.
Dr van der Ouderaa:
I am a board member of the Medical Research Council so I know
the situation there from the inside. Ageing is one of the 10 priorities
of the Medical Research Council but the translation of councils'
intention to what is happening on the ground does not seem very
strong so the boards look at proposals on the basis of scientific
merit and not on the basis of social merit. I think maybe something
should be done to fine tune a little bit because this is a very
important area for society. There are very few young researchers
who are interested in doing this because there is no funding.
There should be new instruments that encourage people to come
with proposals and I concur with Professor Mathers that it is
particularly important to work on new models where you can look
at model ageing units and not go too much to animal experiments
where there is also a difficulty. In the United States there is
the National Institute of Aging. Maybe to have a single focus
in this country from the research councils for ageing research
would be extremely valuable.
Q119 Baroness Emerton:
Do I take it from what you are saying that you would recommend
that this Committee makes some recommendation on the basis of
taking forward research?
Dr van der Ouderaa:
Absolutely.
Professor Mathers:
It might be creating a national centre which would be a focus
for this kind of research and would help to raise the profile.
Baroness Emerton:
Perhaps, Lord Chairman, we could ask them to put forward a recommendation.
Chairman: Please
do.
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