Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 100 - 119)



  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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