Examination of Witnesses (Questions 120
- 134)
TUESDAY 2 NOVEMBER 2004
PROFESSOR JOHN
MATHERS, DR
FRANS VAN
DER OUDERAA
AND PROFESSOR
ELIZABETH KAY
Q120 Baroness Finlay of Llandaff:
I would like to follow up on the research because it strikes me
that pharmaceutical industries actually do have money going into
drug development but the testing of the effect on saliva production
does not seem to be a routine question that is asked, particularly
in drugs which are aimed at the elderly, and yet there is a lot
of dry mouth in the elderly.
Professor Kay: That
is one of the huge impacts on the elderly. The usual polypharmacy—where
they are taking a number of drugs which can interact with the
drugs that a dentist might use and also the normal auto-immune
problems in ageing and then dry mouth caused by drugs—has
the most dramatic impact on the mouth and can cause a fairly healthy
dentition very rapidly to become a very painful and difficult
one in a person who is already unwell. Of course they should be
looking at it.
Q121 Baroness Finlay of Llandaff:
I just wonder where we should be recommending it and it is a question
that general reviews should be asking and looking at papers and
drugs coming through.
Professor Kay: As
I say, you can see people's teeth dissolve in their mouths in
front of your eyes, almost. It is terrible.
Q122 Lord Soulsby of Swaffham Prior:
A phrase that keeps occurring when one is discussing ageing and
aged people is quality of life. What work or research if any has
been done on the psychological or psychiatric side to study quality
of life to try to understand it more from the point of view of
the aged individual, because younger people are quite ready to
say that the quality of life of that individual is very poor,
but how does one define that? Is there some qualification or definition
which is helpful?
Professor Kay: I
would like to think that oral health research has possibly stolen
a march on some of our medical colleagues on this because we have
recognised for some time that you cannot separate the mouth from
the person or the body from the person and the only point of worrying
about dental disease and dental problems is because it belongs
to an individual person. There have been a large number of cross-sectional
studies—and they are cross-sectional studies mostly—that
have measured function in terms of whether they can actually eat
and what they can eat, but also social embarrassment, worry and
concern and their general feeling about what limitations oral
health—in our case—puts on them. I am not so familiar
with research in other areas, but those measures are available.
Professor Mathers:
There is some work going on in the area of cognitive decline and
trying to understand how you might ameliorate that with nutritional
interventions. It is a very young science and part of the problem
there is that there have not been very good instruments for measuring
cognitive function serially over relatively short time periods.
Although it is beginning—the Foods Standards Agency is funding
a little bit of work in that area—it is still a very young
science.
Dr van der Ouderaa:
I think it is a vital point you are making. Happiness is the differential
between the sort of quality of life you have and the expectation
you have of it at a single time point. There has been relatively
little research done on this and part of the happiness is to do
with the state of your health and whether the state of your health
is much worse than you expect it to be. The other one is obviously
to do with the psycho-social status. I think the only people who
have a sustained research programme in this area are the McCarter
Foundation in the United States. A number of groups in different
states in the United States have a sustained research programme
and the effect of SES and social status on health. I do not think
there is anything like it in this country.
Professor Kay: Could
I just say that I have done some work on that myself through general
dental practitioners and if you would be interested to receive
the papers I would be delighted to send them.
Chairman: Yes, that
would be useful.
Q123 Lord Turnberg:
There is a very good set of studies relating social status to
health done by Michael Marmot in his book "The Status Syndrome".
My question comes back to what you suggested in response to Lord
May, Dr van der Ouderaa, about bio markers. You quoted a number
that we have, like cholesterol, LDL-/HDL- and blood pressure,
but they are risk factors rather than bio markers. The question
that has been taxing us is whether old age is simply the accumulation
of ill health of a variety of types or is there a process of ageing?
How does the whole business of nutrition and oral health have
an impact on the ageing process as against the accumulation of
diseases?
Dr van der Ouderaa:
I think it is helpful to discriminate between age related diseases
and ageing as separate processes from a communication point of
view. I think a lot of the etiological factors are actually quite
similar, and so the etiological factors for dementia go from overweight
and metabolic dysregulation to diabetes to cardiovascular disease
to dementia. If you do not become overweight, if you do not get
diabetes, then the risk of dementia is maybe ten per cent off
the risk of you getting it. It is very important to understand
these etiological steps because that will then help you to come
up with intervention strategies. In the context of ageing we can
improve the repair of the small challenges of day to day life.
For instance if you apply sunscreen every day versus walking in
the sun without sunscreen, your facial skin will age much faster.
It is about understanding where we can make these relatively small
steps. A number of small steps in a concerted way have quite a
big effect on the ageing process as a whole.
Q124 Lord Turnberg:
I am not absolutely convinced by the argument that you are distinguishing
between prevention of an illness as against prolonging the ageing
process. In both the instances you describe they were both related
to preventing the development of an illness rather than helping
the ageing process. What I really want to know is what interventions
might actually improve the ageing process or inhibit the ageing
process per se and are there studies in relation to this?
Professor Mathers:
I tend to think of the ageing process as a process in which our
ability to cope with perturbations of the norm become more and
more difficult. The ability to maintain homeostasis, if you like,
becomes more difficult so we need to be able to defend that state
and ageing is a way in which we begin to lose that ability. If
we think of the kinds of damage that are causing that—damage
to genes and damage to other cell macro-molecules—then dietary
factors which will help to prevent that damage or help to repair
the processes—DNA repair systems—are very important.
There is now some evidence that nutrition will enhance DNA repair
process.
Q125 Lord Turnberg:
What sort of nutrition?
Professor Mathers:
Individual micro-nutrients. Most of this work has of course been
done at cellular level. We do not know very much about how well
it works at the whole person level, but at least it is pointing
us in that direction which might be helpful.
Professor Kay: In
terms of oral health there is little question that it is the accumulation
of diseases across the lifetime plus the accumulation of treatments
across the lifetime that lands you up in a certain place when
you are older. However, what I would say is because of the huge
social class differences in the same cohorts there must be some
interventions to do with lifestyle that would bring the people
at the lower levels up to the same as their peers.
Dr van der Ouderaa:
We have constructed in our programme a sort of triangle of successive
measures for healthy ageing and it starts with smoking cessation
and emotional well-being, so having a stress level that you can
cope with.
Q126 Lord Turnberg:
How do you do that, I would be very interested to know?
Dr van der Ouderaa:
The second is avoiding overweight and having enough physical activity.
The third layer is about having the right macro-nutrients so the
right balance of fat versus carbohydrates versus protein adding
predominantly poly-unsaturated fatty acids in the fatty acids
component; not having too many easily fermentable carbohydrates
and then, as Professor Mathers points out, micro-nutrients and
anti-oxidant vitamins, flavanols, isoflavols.
Q127 Lord Turnberg:
Do you have evidence for all of those?
Dr van der Ouderaa:
Indications and evidence.
Q128 Baroness Finlay of Llandaff:
Nutrition receives a great deal of attention from the public in
terms of cookery advice and issues around food safety, diet regimes
for weight control and body image and so on, and now the promotion
of herbal and complementary or alternative therapies, but I was
just wondering to what extent there is scope to include the nutritional
impact on ageing in public discussion of such issues. Rather than
a quick fix, should we be looking at a much longer term view and
a view in terms of nutrition and its affect on the ageing process
and maintaining a homeostasis which Professor Mathers referred
to?
Professor Mathers:
Perhaps I could start by saying that we will not know until we
try; we need to try to stimulate that debate. If we are going
to do it I think we need to start from some kind of evidence base
so we need to have something to say to people that will be helpful.
That brings us back to not knowing enough about nutrition and
older people. But I suspect that some of the messages will not
change; we will still want people to eat more fruit and vegetables,
we will want them perhaps to reduce their fat intake and reduce
the salt intake and so on. At that level it is fairly straightforward.
It is the more subtle things which we are trying to draw out that
we do not yet have the evidence for. You mentioned body image.
I do not think people give up on body image just because they
are getting a little bit older; I think it will be important all
the way through life and people, as they get older, want to age
well. People talk now about silver surfers, people who are at
an age when they have the luxury of the time to do things they
might not have done early in life and they want to be well enough
to do that. I understand they are very interested in websites
and television programmes and so on which address nutritional
issues, food issues, at least.
Professor Kay: In
dentistry, based on very good evidence, we have been trying to
persuade people to eat differently for the sake of their health
for many, many years. I, myself, did a review of the evidence
of how well it worked and it is lacking. It is very, very difficult
to change what people do, let alone what they eat. However, I
guess—and this relates back to something I said earlier—that
because people are interested in all the issues that you said,
that rather than try and persuade them that they want to be interested
in it because it is healthy for you or because we think it is
a good idea, we can utilise that interest to encourage people
to behave in ways that will benefit their health, but they may
not see that they are doing it necessarily for that reason.
Q129 Baroness Finlay of Llandaff:
Has there been a comprehensive epidemiological study looking at
the micro-nutrient status across a population of people who are
particularly elderly and comparing that to their functional status
and perhaps one of their perceived quality of life measures?
Professor Kay: The
others will know more than me but the American Veteran Study has
looked at that, I believe.
Professor Mathers:
In the UK the NDNS—the National Diet and Nutrition Surveys—is
the body which undertakes these kinds of surveys and they have
published reports (1998 was the most recent one) dealing with
older people. That provides information on nutritional intake
and nutritional status.
Q130 Baroness Finlay of Llandaff:
In terms of?
Professor Mathers:
Some blood markers, the sort of things that Frans was speaking
about earlier. What they do not include, as I understand it, is
the sort of functional things you were referring to.
Q131 Chairman:
Can I just extend the range of the question a little bit. We live
increasingly in this country in a multi-ethnic and multi-cultural
society and of course that intersects very closely with lifestyle
and not least nutrition. I just wonder how that is affecting—or
how it ought to affect—the structure of research projects
and research objectives.
Professor Mathers:
That is an extremely important area and it is one that has not
been addressed by the National Surveys. It is not been included
to any extent at all in them. We know relatively little at that
level, but the evidence that we do have suggests that the impact
of nutrition on quality of life in terms of expectation of disease
differs with ethnic groups so we do need to know a little bit
about individual groups.
Q132 Chairman:
Are you saying that there is not much of this information around.
Dr van der Ouderaa:
There is some very interesting information from the state of Singapore
where in one generation people have come from rural to fully urban
and if you then compare three ethnic groups—the Chinese,
the Indian and the Malays—then in an urbanised environment,
a high stress environment, not a lot of physical activity and
different nutrition, it looks like the Asian Indians become diabetic
about 15 years before the Chinese and about 10 years before the
Malays. There are quite strong ethnic influences on changes in
an environment against genes that have been developing over 20,000
years without urbanisation.
Q133 Baroness Finlay of Llandaff:
Can I just ask, as well as food type nutritional intake, have
these looked separately at fluid type intakes in terms of adequate
hydration in elderly people because elderly people are often slightly
dehydrated a lot of the time.
Professor Mathers:
I am not aware that there is any systematic collection of information
of that kind.
Q134 Lord Soulsby of Swaffham Prior:
This may sound like a flippant question but it is not meant to
be flippant. We are bombarded on the television by food programmes
and eating and cooking programmes, do you think that they do an
adequate job from the point of view of nutrition for the ageing
person or could they do better? Could they have a better message
for older people who might be living by themselves and doing their
own cooking and things like that?
Dr van der Ouderaa:
I am not convinced that they are doing a very good job. There
was a programme about a month ago by the BBC on vitamins and from
a scientific point of view I thought it was a sensational and
quite a poor programme, because they tried to imply that higher
intakes of RDAs and vitamins was a bad thing and it was argued
on a few people who took high doses of vitamin A—which is
clearly not the right thing to do—but then all the other
vitamins were tarred with the same brush. Certainly for elderly
people whose intake is not optimal and by availability through
improper chewing is not optimal. I think a lot more could be done.
The point I was going to make is that there is no single population
group. We need to look at the population and what is coming out
of our consumer studies that there are different people who are
differently engaged with investing intellectual time and money
into buying better food for the longer term.
Professor Kay: I
am afraid I do not cook and I do not watch television so I cannot
answer your question.
Chairman: Can I thank
you very much indeed. It has been a very helpful session in a
critical area that was perhaps under-emphasised. You have got
from the discussion a sense of the range of issues that we are
grappling with and if, as a result of that, you have further thoughts,
do not hesitate to let us know. At best our report can inform
Government policy and perhaps influence it. That is our intention
so this is your opportunity if you want to contribute further.
Thank you very much indeed.
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