Professor Katherine Appleton, Bournemouth University – Written evidence (INQ0035)

1. Professor Katherine Appleton is a Chartered Psychologist and Registered Nutritionist. She has researched human eating behaviour since 1998, with a special interest in the older population since 2006. Much of her research focuses on the optimisation of human health and well-bring in the normal population considering nutrition, physical activity and their impact on behaviour.

Question 4 - How complete is the understanding of behavioural determinants and social determinants of health in old age, and of demographic differences?

2. A large body of evidence is now available detailing the physical and physiological processes associated with ageing, and their potential impacts on health. In relation specifically to diet, for example, considerable evidence details increased protein requirements with age, requiring a need for greater protein intakes and greater protein utilization, to maintain health. Some evidence aiming to understand the behavioural and social determinants of healthy eating, such as high protein intakes, in older adults is available. My work demonstrates impact particularly of perceptions of liking, tastiness, familiarity, quality and healthiness; and concerns over the convenience and effort involved in food preparation, waste and spoilage, and value for money [1], [2], [3], [4], [5]. These are determinants of healthy food intakes in all adults, but are typically magnified or compounded in older adults as a result of ageing associated changes in physical abilities and circumstances. For fruit and vegetable intakes also, an aspect of diet with limited age-associated changes in requirements, similar determinants of intakes are found, and these are very similar in older adults to the determinants for those who are slightly younger [6], [7]. Evidence of demographic differences is also available[8], but there is a need to recognize that the population becomes increasingly diverse with age, thus broad generalization may not be helpful.

3. While some evidence is available on behavioural and social determinants of health, and more would be beneficial, very little evidence is currently available on what can be done based on these determinants to improve healthy ageing. A recognition that older adults need more protein has resulted in the development of protein supplements and protein fortification, but these products are generally poorly accepted and so of limited impact. By comparison, based on findings that taste, flavour and familiarity are important determinants of protein intakes, we now have a body of work that demonstrates benefit from adding flavours (in the form of sauces, seasonings and recipes) to increase intakes[9], [10], [11]. Work based on the role of liking in fruit and vegetable consumption is also showing increasing healthy intakes[12]. 

4. More work is needed particularly on understanding behaviour and developing strategies for those who need them, which they will both use and benefit from.

Question 11 - How feasible is the Government’s aim to provide five more years of health and independence in old age by 2035?

a. What strategies will be needed to achieve the Government’s aim?

b. What policies would be required, and what are their potential costs and benefits?

c. Which organisations need to be involved?

d. Who should lead the work?

5. There is a need for public health bodies to focus on prevention as opposed to treatment, by encouraging healthy habits at all ages. The similarities between older and slightly younger adults and the gradual and often undetected nature of the age-associated changes both in requirements and in abilities, suggest considerable need for an increasing focus on prevention and healthy habit formation at an earlier age, as opposed to treatment once problems occur. Work should focus on extending periods of existing good health, e.g. from ages 50-55 years to ages 50-60 years, as opposed to delaying the onset of poor health, e.g. from age 70 to age 75 years. Policies are required to support healthy habits across the adult population. Strategies should focus on immediate preventive measures, such as those supporting healthy food consumption, via high availability of affordable and good quality healthy food; and those supporting increased physical activity, via increased active transport routes; but also need to consider strategies that are of a larger scale. Individuals do not consume vegetables, for example, because they do not like the taste, or in other words, do not know how to make them tasty – they need to learn to cook, they need to develop confidence with cooking, they need time to cook on an everyday basis, they need to be willing to make the effort to cook. Changing vegetable consumption thus requires cooking lessons at school on a repeated and regular basis, opportunities to cook at home, good facilities to cook while at college, access to affordable vegetables as an adult, sufficient leisure time to allow cooking amongst competing tasks, sufficient energy to allow cooking. These require wide and progressive public health strategies. Other interested parties, e.g. the food industry, can only provide immediate or short term solutions.

6. Some specific focus is also needed for older adults, where requirements may increase with age. The behaviours and habits needed by older individuals are the same as those for younger individuals as above, but work is needed to inform individuals of changing needs with age. These communications will apply to everyone to some degree, and will be relevant not just to older individuals themselves, but also to family members, carers, etc. Again, the responsibility for these communications should lie with public health bodies. Research may be needed to understand the most effective methods for this communication. Anecdotal evidence of our own suggests that recommendations for ‘older adults’ tend to be ineffective, because most people do not identify themselves as ‘older’ or ‘frail’ or ‘in need’. Research is needed, but there is a need for the Government also to make more use of this research.

19 September 2019