Insomnia, sun exposure | Low-carb diets | Sodium in food | Hepatitis in kids | Social prescribing

Norman Swan: Hello and welcome to this week's Health Report with me, Norman Swan, on Gadigal land.

Tegan Taylor: And me, Tegan Taylor, on Jagera and Turrbal land.

Norman Swan: Now, Tegan, you might notice in front of you a little surprise, a little different way of starting the program. There are two little pots in front of you with white granules in them.

Tegan Taylor: Oh my gosh, you're gonna try to drug me.

Norman Swan: Don't snort them.

Tegan Taylor: What am I not snorting here?

Norman Swan: Well, we're going to do a little taste test on you. So you're going to taste each one and tell me if it tastes any different.

Tegan Taylor: Okay, let's have a little tasty. Oh, it's salt.

Norman Swan: What's the other one?

Tegan Taylor: Oh, it's also salt. I'm really missing some tequila here, Norman, what's going on?

Norman Swan: So they're exactly the same?

Tegan Taylor: Yeah, I guess so.

Norman Swan: So the one on your right is potassium salt.

Tegan Taylor: Oh, potassium salt. I mean, I've heard of it, but I know that technically NaCl, sodium chloride, is what we would usually have.

Norman Swan: Yep. So sodium is the stuff that's bad for you. And the idea here is, and we've had stories on this before, that if you change it for potassium salt, it's really good for you. Anyway, we're gonna have a story later on; can we reduce our salt intake? Because Australians have doubled the recommended intake, on average.

Tegan Taylor: And one of the solutions might be this potassium.

Norman Swan: Potassium, yeah, not just at the table, but in your processed food.

Tegan Taylor: Also coming up on today's show, I have been talking to someone whose life has been changed by a gardening club that she was able to access via a referral from her GP, kind of indirectly.

Norman Swan: Social prescribing. We've done it before, I think, on the show.

Tegan Taylor: Yes, a fair bit over the years. There's been lots of studies, there's been lots of pilot programs, but now the push is on to have a consistent national approach to it. And I'm also going to be shedding a bit more light on a Covid-era mystery that you and I have talked about on Coronacast back in the day, Norman, the question of what was behind a brief but really serious spate of liver disease in really young kids.

Norman Swan: Yeah, a big mystery there, and we'll have hopefully have some of it uncovered for us.

And low carb diets.

Tegan Taylor: But first, let's dig into a little bit of health news from this week. And this is one of…I know it's one of your favourite topics, Norman; insomnia. And I know that you must suffer from it at least a little bit because I get journal articles, like New England Journal of Medicine article texts from you at 3am. This is all about what's the best way to cure it. I hope you've been reading it very closely.

Norman Swan: I have, I've been scrutinising it really closely and didn't fall asleep as I read it. So this was looking at psychotherapy for insomnia, and what bits of psychotherapy work when you try to treat people who are bothered by…a lot of the element of insomnia is does it bother you and are you distressed by it, as much as the insomnia itself. Anyway, it's quite interesting. So what we found was there's not much point in teaching people about sleep hygiene, you know, keeping your room dark and all that sort of thing. Either people know it or it just doesn't make any difference to your sleep. Relaxation, teaching you about relaxation could make it worse. Isn't that interesting.

Tegan Taylor: That really feels counterintuitive. What's behind that?

Norman Swan: Well, it probably doesn't get you off to sleep, and just keeps you in bed longer. Because one of the things that does work is stimulus control, which is really about teaching you what your bed is for, and the bed is for two things—sleeping and sex—not working, not sending New England Journal of Medicine articles, which is what I do, and relaxation will actually just keep you in bed when you're awake and not actually help you very much. No doubt we'll get swamped with people telling us how marvellous it is.

What we call third wave components, which is more really just mindfulness meditation, that does work quite well, and sleep restriction, which we've talked about before, which is really going to bed as late as possible so that you get an uninterrupted high-quality night's sleep, and then only extending that time in bed when you're getting a reasonable night's sleep and not waking up a lot. So it's a good study bringing together all the evidence from studies around the world (I should have said that at the beginning) which shows you what works, and don't lie in bed fretting and trying to relax yourself back to sleep.

Tegan Taylor: Well, that's some good advice there. And there's also been new advice on sun exposure that better reflects Australia's diverse population. Previous guidelines have been very much geared towards limiting exposure, which is good if you're white, but it's not universally useful.

Norman Swan: Yeah, I think that the previous recommendations have been for a white Anglo Irish population where you burn and you get all sorts of skin cancers ACCs, BCCs and melanoma, and we have the highest rate of skin cancer in the world. And of course, a high percentage of the population now (and it's increasing) have dark skin or black skin, and what they've said there is you've got such a low incidence and risk of melanoma, that people with dark skin really don't need to routinely put on sunscreen when they go out, although if they're out for extended periods of time, they should cover up. And that's partly because if you've got really dark skin, you convert sunlight to vitamin D very inefficiently, and you want to keep that topped up.

Tegan Taylor: And I heard you promising something before about low carb diets.

Norman Swan: Yes. Now, this is really interesting. A lot of people are on low carb diets, but they mean different things to different people. Some people have a low carb diet where there is a lot of fats, a lot of animal protein or fat. Some people have more of a plant based low carb diet. And so the question is, which are better for you, particularly when you look at weight loss? And this study took data from massive studies, you know, thousands of people, they were health professionals and nurses who'd been followed for different health conditions for many, many years. And they were looking at weight change. Now, Tegan, this is not weight loss, because sadly, as you know, as we get older…well, you don't know, you're slim and lithe...is that we all put on weight as we get older. The question is, are we putting on weight faster or slower, and it really looked at the trajectory of our weight gain over time, relative to the kind of low carb diet we were on. And one of the people on this study was Qi Sun who's Associate Professor of Nutrition and Epidemiology at Harvard School of Public Health.

Qi Sun: I found really contrasting effects on body weight, depending on which type of low carb diet our participants consumed. For example, when we look at the low carb diet that is dense in animal protein and animal fats, we found consuming this kind of low carb diet is actually associated with faster weight gain. In contrast, if we look at the low carb diet that emphasised plant protein, vegetables oils and so forth, those actually are associated with slower weight gain.

And we also examined two other types of low carb, one we called healthy low carb, which means this low carb diet emphasises carbohydrates from whole grains and also plant proteins and also vegetable oils. So this is the best version of the low carb diet and associated with less weight gain in comparison with other low carb diets. But the last one is the worst, called unhealthy low carb diet. So this diet emphasises carbohydrates from white bread, from sugar sweetened beverages, emphasises protein from animal products, and also emphasises animal fats. This diet is actually associated with faster weight gain.

Norman Swan: So even if it's low carb, the quality of carbs was low, and you were getting more animal proteins, animal fats.

Qi Sun: That's absolutely correct. But I think there's an interesting point I want to make that following a healthy, low carb diet, a very healthy vegetarian or vegan diet could fall into this category, however it can still contain a small proportion of animal products. But a diet that emphasises really…if you eat carbs from whole grains, from fresh fruits, vegetables, nuts, and so on as a source and also cooking oil as a source of protein and fat, within that there could be still a small proportion of animal product but it's not emphasised.

Norman Swan: So, let's go back to basics here. When you compare low carb diets with just calorie control or portion control or a Mediterranean diet, do you need to be on a low carb diet to moderate your weight gain as you get older?

Qi Sun: Based on our data, and also the data from others studies, the answer is no, you don't have to focus on a low carb diet. What you should focus on is to improve the diet quality, whether it's a low carb diet, a healthy low carb diet, whether it's a DASH diet, whether it's a Mediterranean diet, those kinds of high quality diets are all associated with slower weight gain. So I think absolutely it's not necessary that you have to eat a low carb diet to achieve weight maintenance or weight loss, you should focus on the quality of your diet. That's the key.

Norman Swan: So the bottom line here really is, yet again, you're showing that if you only focus on one element of your diet, in this case carbohydrates, you could be misled into thinking that you've got the solution to your future weight and health, when you should really be thinking about your diet as a whole.

Qi Sun: Yes, I agree with you, 100%.

Norman Swan: Thank you very much for joining us.

Qi Sun: Thank you for having me.

Norman Swan: Qi Sun is Associate Professor in the Department of Nutrition and Epidemiology at the Harvard School of Public Health.

Tegan Taylor: So, my beloved potatoes are safe, by the sounds of it.

Norman Swan: They are safe, as long as you don't fry them in animal fat…the best bit! Well, now to what goes with your animal fat fried chips, which is salt. As I said at the beginning, Tegan, we consume about 10 grams of salt a day in Australia, where the recommendation from World Health Organisation is five grams. We should just qualify this because people get confused about salt and sodium, and when you look at the back of the pack, you get confused about salt and sodium. So sodium is roughly half, a little bit less than half of salt, because it's sodium chloride. So for the recommended daily intake of salt, it's around about two grams a day, and if you take it as salt, it's five grams. So it's just confusion there when you look at the back of the pack.

But anyway, the associations of high salt diets are quite long lists, like stomach cancer, maybe actually autoimmune diseases, high blood pressure, kidney damage, which may be a consequence of the blood pressure or the salt itself. And if you look at the avoidable burden of disease in the community, so burden of disease that's preventable, about 3% could be put down to salt, so if you actually did that you could reduce avoidable burden of disease. But that's actually misleading because if you've already got coronary heart disease, high blood pressure or diabetes, then in fact the benefits of salt reduction will be even greater. And that's often focused on suburbs where people are poorer, live in poorer housing and have poorer access to food. So salt reduction could have a disproportionate effect around the community.

Tegan Taylor: And the relevance of processed foods here is that they're in foods that are actively salty, but they're also used as a preservative to extend the shelf life of a lot of processed foods, so it's hidden in a lot of foods that don't necessarily taste salty but still have a lot of salt in them.

Norman Swan: That's right, and that's where we get most of our salt from, rather than salt that's added at the table or in our own cooking. Anyway, a team from the University of Melbourne and the Grattan Institute and George Institutes have modelled what reducing salt (sodium) could look like in the community and the benefits. And earlier today I spoke to Professor Tony Blakely, who was one of the team.

Tony Blakely: In the modelling we've just done, for example, you see 60% to 100%, 1.6 to 2 times greater health gain for people in the most deprived quintile of Australia versus the least deprived.

Norman Swan: So in other words, if you're basically unwell for a variety of reasons, you get this multiplier effect rather than additive.

Tony Blakely: Yes, you can, all of these things come together, and each one of them mounts on top of the other. The thing about sodium is that actually doing prevention on it is not that hard, because a lot of the sodium is hidden in our food, and our packaged food and can be reduced without much consequence for the taste of the consumer nor the industry.

Norman Swan: Now, the George Institute has been covering this for a long time (and we'll come back to this), swapping potassium salt for sodium salt and various other things, and they've also had an app where you could actually look at the salt content of processed foods, which is where we get most of it from. And in the time they've been monitoring it, it's gone up, it's not gone down.

Tony Blakely: Yeah, because of the way that food is manufactured, the sodium is just creeping up in our diets as we eat more convenience foods. And just to talk about the potassium chloride, we know that you could probably swap a third or 30% of all sodium chloride with potassium chloride and the consumer wouldn't noticed the change in taste very much at all. We modelled 10% substitution on the assumption that that might be more politically feasible, and that got some pretty good gains.

Norman Swan: Okay, so you looked at three ways of intervening here. And really, what we're talking about here is, okay, we shouldn't be adding too much salt to the table but that's not going to make a heck of a difference, it's in the food that we're eating. Talk about the three interventions and the effect that they could have.

Tony Blakely: The three types of interventions we looked at were reformulation. And there are three different targets that we modelled. One is the WHO benchmark, which sees about a 12% reduction in sodium in the diet. The UK target, which sees about 7% or 8%. And then Australia actually has its own voluntary targets which are not in any way being met, which would see about a 3% or 4% reduction of sodium. We also modelled, as I just said, potassium chloride substitution, 10% across the whole food chain, or 30% on that discretionary salt that you put in your own cooking or on food at your own table. And then the third one was looking at a UK program which tried to (and was successful, to be honest) reduce sodium in the population through a combination of voluntary reformulation of the industry with a mass media campaign.

Norman Swan: So if you achieve those targets, what sort of benefits would you see downstream?

Tony Blakely: Let's pick the WHO benchmark which is about 11% or 12% reduction in sodium. If that was made mandatory in Australia, we'd see something like 43,000 health adjusted life years gained over the next 20 years. So it's not as big as tobacco eradication or getting rid of high BMI, but it's still up there with being reasonably sizeable.

Norman Swan: Is it expensive?

Tony Blakely: No, and you can look at it at three different levels, the first level is you just consider the health expenditure. And on that side, you would see something like $1 billion saved in the health budget over the next 20 years. And the cost to government of putting the policy in place would be minor compared to that saving.

Norman Swan: So what about the cost to industry?

Tony Blakely: We put it at roughly about $3 million per year as what we can see might be the type of cost, but there is a wide range. Whichever estimates you use, the costs to industry are far, far less than the gains you'd see in reduced health expenditure. And even if you pull all the way out to a societal perspective, so you include the health expenditure reductions because there's less disease, you include the cost of government of implementing the program, you include the cost to industry which then feeds on to the consumer, and you include the increased incomes to citizens because they've got less sodium related disease, you're talking about a lot of money saved.

Norman Swan: But this isn't going to happen without government regulation, because the voluntary process isn't working.

Tony Blakely: Exactly. Voluntary occasionally works, but usually it doesn't.

Norman Swan: Well, it's gone up, according to the George Institute.

Tony Blakely: It has, as best we know. If we were to take this seriously, it needs to be made mandatory. If you're going to be trying to do stuff in this space, you really do have to shift the playing field for everybody. And that's a common thing with industry is they often would appreciate the same standards for everyone.

Norman Swan: But in the past when I've put this to, say, Food Standards Australia and New Zealand, they say, 'Oh well, we can't just do that unilaterally in little old Australia, because we have to export our food, we export processed foods, and it's got to meet international standards. We can't just arbitrarily do that, we've got to get international agreements going.' And then nothing happens.

Tony Blakely: Yeah, I wouldn't quite completely buy that. So for example, the health star rating is 'just' (quote, unquote) an Australian and New Zealand thing and that was able to be put on without too much discomfort from any party. The majority of our packaged food is specific to the Australia and also New Zealand markets, I don't see why we couldn't be doing mandatory or much stronger enforcement on that type of approach to reducing sodium in food.

Norman Swan: And what do you say to the people who say, well, this is just an example of the nanny state, Blakely wanted us all to wear masks during Covid, and now he wants to force us to eat food that's low in sodium.

Tony Blakely: Yeah, well, let's flip it. I don't think I'd be very happy with my nanny if she was putting more sodium my food than I needed for taste and it was actually increasing my blood pressure and therefore increasing my chance of heart attacks without me even knowing. So I'd actually quite appreciate the nanny state helping out a little bit there.

Norman Swan: So where to from here?

Tony Blakely: We're not the first people to do this type of research. This research that we did this time, this modelling was funded by the Heart Foundation, we'll be trying to use that when the opportune moment arises; policy is a lot about waiting for the right policy window. What our research does is it looks quite closely at the economics of it to show that no matter which way we look at it, health gain here is also associated with economic benefits and a little bit of easing on the health expenditure budget in the future. So that's a win-win-win when you also include the inequalities reduction.

Norman Swan: Tony Blakely, thanks for joining us.

Tony Blakely: A pleasure, thank you very much for your time.

Norman Swan: Professor Tony Blakely, who's at the University of Melbourne's School of Population and Global Health.

Tegan Taylor: So when I'm hearing conversations like these, Norman, I'm always torn between two things. One is the 'worried well Tegan Taylor' who wants to reduce my own salt intake, which I have the power to do, to a certain extent. And then the other is this bigger picture of how a big part of Australian society relies on ultra processed foods because they are cheap and shelf stable, and it's an equity thing that if we want to reduce salt across the population, it's not enough to just say, 'Hey guys, try to reduce it, it's good for you.'

Norman Swan: You're absolutely right, and the analogy I use or the similar situation in public health is fluoride in the water supply. So people who are against fluoride in the water supply, saying it's impure and you're causing problems, for which there is very little evidence of it, by the way, if no evidence…is that the modelling that's been done by public health dentists is that if you actually remove fluoride…because what they say as well, you know, if you just wash your teeth with fluoride toothpaste, you have the same sort of effect, and spend the money that you've spent on fluoride on educating people about washing their teeth with fluoridated toothpaste. However, what the modelling has done there is that middle class people like ourselves, we hear that message, we've got time in our lives, we're able to sit down and be patient with our kids and teach them how to wash their teeth. And what happens when you do that and you remove the fluoride from the water supply, and then rely on education, is that the gap widens in in oral health between the haves and the have-nots. So you've actually got to do something passive where you don't have to make a decision so that we all benefit, because if it relies on agency and personal action, if you've got no money in your pocket and you're stressing about your job, your kids, and your housing is inadequate, you haven't got time to think about this. So you've got to do it passively. It's not the nanny state, it's actually redressing the inequalities that narrow the gap.

Tegan Taylor: Yeah, the path of least resistance becomes the healthiest path.

Norman Swan: Correct.

Tegan Taylor: You're with the Health Report.

So Norman, back in 2022, we were doing Coronacast, the show all about the coronavirus, and one of the things we talked about at the time was a rare but really worrying trend of very young kids coming down with severe liver disease. It was a really similar syndrome happening in kids all over the world. And doctors didn't know what was causing it.

Norman Swan: Yeah, it caused a lot of fear. I think we were slightly less affected by it in Australia than other countries, but it did occur. And people were wondering what was causing it, and they thought that maybe it was a family of viruses called adenoviruses. But these kids were really quite unwell and some needed liver transplants.

Tegan Taylor: Yeah, and some even died. So a group of Australian researchers have just very recently pulled together all of the data that was from that time, 33 studies from all over the world, to see if they could solve the mystery. And I've been speaking to one of the authors, Guy Eslick from the Australian Paediatric Surveillance Unit.

Guy Eslick: So it was pretty scary that all this sort of stuff was happening, and particularly because it only affected kids under the age of 10.

Tegan Taylor: And it was severe.

Guy Eslick: It was severe. So at the end of the outbreak, 6% of these kids needed liver transplants and 2% of them died. And in total…

Tegan Taylor: And to put that into numbers, we're talking 214 kids who had liver transplants and 66 who died. That's pretty awful.

Guy Eslick: That's right. And this happens really quickly. So, if you have acute liver failure, you go from being a very well child to developing diarrhoea and vomiting, you quickly develop jaundice, you become very, very ill. And you could have a liver transplant within a week after developing those symptoms, if you're lucky. You can see how quickly these things happen. And I suppose particularly after Covid, we know what a pandemic is. And this was quickly spreading around the world. And we thought by doing the meta-analysis and systematic review that we would bring everything together and it would hopefully give us a better picture of what was happening, and in some ways it did, and other ways it didn't.

Tegan Taylor: So it's not that uncommon that kids get hepatitis, but this was out of the ordinary, it was a really specific type of hepatitis, it was happening in clusters, and it was happening in the same kind of way in different places all over the world.

Guy Eslick: We looked at all the countries that were involved, and we plotted their lockdowns, and then we plotted when the cases started. And if you look at it, the cases started to appear basically six to eight months after lockdown ceased in all of these countries. And these kids are young, the average age of these kids was three and a half. So they've been in lockdown for more than maybe 12 months in some cases, and some of them may have actually even been born in lockdown. So they've never been exposed to other pathogens in society, and so the hypothesis was basically, well, we came out of lockdown, these kids were let back into the real world, and then they got affected by viruses that then affected their liver because their immune system couldn't cope with it and that's what induced their severe acute hepatitis. And so that's one of the hypotheses that's going around about this potential outbreak.

Tegan Taylor: One of the specific types of virus that you identified as being a common denominator was adenovirus, or adeno-associated virus 2, forms of what we used to just call the common cold, we're narrowing down on them a bit. Is that the leading theory now, that that might have been the trigger?

Guy Eslick: Look, there's still a lot of work going on around this. I mean, certainly what we identified was that up to 83% of the children who were affected with the severe acute hepatitis had the adeno-associated virus 2 in their bloodstream. The perplexing part was that in the children that had had transplants or had died, they could not identify any viruses within their livers. Now, that's not what you'd normally expect, if you get an adenovirus that affects your liver and causes hepatitis, when you look at that liver tissue and you look at it under the microscope, you're going to see adenoviruses, or you could even try and identify them using other molecular methods. That was not the case here, they didn't see anything. So that is also a bit of a mystery, because while the children had the virus within their blood, they didn't have it within their liver tissues.

Tegan Taylor: So in some ways, despite this really careful combing through all the available data, it's still really a mystery, which is pretty unsettling when we're talking about such a severe disease in such young kids. And it's something that Guy Eslick says really speaks to the importance of gathering as much data as possible in any kind of outbreak.

Guy Eslick: The unfortunate component of this is that, as scientists and researchers, ideally what would have happened would have been that tissue samples and blood samples from all of these kids would have been kept, that could be used further down the track to work out; are there other causes, what's happened? That hasn't always been the case, and that is also an issue because when you've got kids coming in with acute liver failure and you're doing transplants and children are dying and you've got a large number of other sick kids in a unit, you're focused on obviously helping and fixing the kids, you're not really thinking, oh, there's a major outbreak of something here, I should be making sure that we keep liver tissue and blood samples and stuff like that. And the problem is that once those tissues and blood samples have been disposed of, you may never solve the mystery, and this may happen again. It's a bit like Covid, in a way; if you don't identify the source, you'll never be able to say it can't happen again.

Tegan Taylor: It's always a bit uneasy when you don't have a nice tidy answer, and I really hoped that you'd be able to give me one.

Guy Eslick: I do feel that. I mean, to be honest, when my student came to me and said, 'Look, this is what we've got,' I'm like, well, that's not really what I want. But it's not about what you want, it's about what you get, and then making the best out of that. I'm currently being asked to review a lot of papers from other researchers that are doing work overseas, so there's still people looking into this and trying to do stuff, and I think that's important, because what I hope doesn't happen is that these kids just get forgotten. And it's like, oh well, that happened, do you remember…we'll be talking about a bit like Covid; do you remember that outbreak that occurred years ago? I don't want that, you don't want this to happen again. The aim should always be to identify a cause and work out how to stop this from happening. So, look, I hope that there's a lot more research going on in the background that I'm not aware of, that comes out into the community. And I hope someone does say, look, we've identified a potential cause, but it is so difficult to do sometimes.

Tegan Taylor: Associate Professor Guy Eslick from the Australian Paediatric Surveillance Unit based at the University of Sydney. And Norman, not the satisfying neat bow that I was hoping for there.

Norman Swan: No, but good that he's reviewed the evidence, and it may illuminate some other problems of the future in terms of immune responses and so on.

Tegan Taylor: Coming up, we are answering your health questions in What's That Rash?, and today I'm giving Norman another opportunity to lay into things sold in pharmacies. The question is, are multivitamins worth it?

Norman Swan: Well, you're gonna have to listen to find out.

Tegan Taylor: So, think about the things that make you feel good, really in charge of your health. For me at least, they're (quote, unquote) healthy behaviours, working up a sweat, putting together a really gorgeous, colourful, veggie-rich meal. And of course, that boost you get from spending time with the people you really like. It's a real privilege to have these things because of course not everyone does. We've reported quite a bit over the years on the idea of social prescribing, where we know things that help us connect with other humans is good for our health, so why couldn't a doctor prescribe that instead of or in adjunct to a script that you fill out at a pharmacy? I've been talking to Ilya, she's an artist based on the Gold Coast, and a few years ago she was diagnosed with fibromyalgia and chronic fatigue syndrome, and coupled with the fact that she's also autistic, she found it increasingly hard to connect with her old social groups. But she found a lifeline in the form of social prescribing, which she actually initially heard about through an ABC podcast.

Ilya: Look, I originally heard about on All in the Mind, and they were talking about how successful it was in the UK. All the time I hear about the value of social engagement and social interaction. And during my illness, I kind of withdrew from the people I knew, and I realised at one point that my social life basically involved just the medical professionals I saw. I didn't actually see anyone socially and I didn't want to, I just withdrew, and I realised that's something that I just wasn't able to address.

I personally got involved in a gardening group. I've got chronic fatigue, so I would need to rest a lot and sit in the shade. And that was okay, because I could paint pebbles. So you weren't obliged to talk to anyone but you were in the company of others that were similar, so it was a very safe kind of space. Some of the other activities I got involved in, there was one called forest bathing where we would go out and explore the forest. We also did a barista course, there was an art course.

Tegan Taylor: How is the social prescribing side of things different to you than just deciding to enrol in a forest bathing session or take an art class off your own bat?

Ilya: Well, it's interesting you say that because I used to be involved in life drawing at a community group, and I still haven't returned to that group. And it's not because of them or anything to do with that group, I love life drawing. However, when you're feeling this kind of 'ugh' and withdrawn from people, you isolate yourself, and you tend not to want to go out, and the social prescribing kind of formalises it. And it's kind of like going back to school where someone says to you, right, you've made this commitment, you need to turn up at this time, here's the form, sign yourself in, sign yourself out.

It's rebuilt my confidence in people, I just got my confidence in creating back, I got my art mojo back. I am really hesitant about spruiking the value of doing social prescribing, simply because I know it's not available everywhere. You know, if you get interested in doing something like this and it's not available, it's really crushing. And I really, really want it to be available to others. I feel so fortunate to have been able to do it. I had that benefit, and I wish others could but I don't want to put people's hopes up when I know it's not easily accessed.

Tegan Taylor: So Ilya is lucky enough to live in a part of Australia with a social prescribing provider. But, as she says, it's not available everywhere. There are lots of small programs around the country, but we don't have consistent coverage. But there is a push to change that with a roundtable in Canberra coming up at the end of the month. Leading the charge is social prescribing researcher, JR Baker.

JR Baker: There's lots of good benefits at the health system level, interestingly, which is a bit of a surprise. So once people are doing stuff that's interesting or matters to them, they're less likely to do extra visits to the GP and usually see a reduction in medication usage or attendances at emergency departments. So one thing that's interesting is it takes a bit of pressure off of the health system. But at the personal level, you see general improvements in quality of life and measures of psychosocial wellbeing, so improvements in mood, connection with others. And then even in the case of people who've had injuries at work, more confidence to return to work and greater ability to return to work and improvements in return-to-work outcomes. So it's quite broad, but at the personal and the system level, generally it means reasonable improvements for everybody.

Tegan Taylor: Who pays for these programs?

JR Baker: So some of the stuff is free and just exists. So social prescribing, on the plus side, can leverage free or low-cost services sitting in communities that are there already that people might not know about, so part of it is creating access to those sorts of things. Your local council might have lots of stuff available that you don't know about. The actual act of connecting itself tends to be paid for at the minute by Commonwealth government funded initiatives, usually through PHNs or Primary Health Networks. So across the country, PHNs are trialling different ways of rolling out social prescribing initiatives for different communities and different sorts of groups of people within the communities, so that's pretty exciting. And then, of course, some people are doing it themselves. So some GPs or primary care nurses or social workers, they've just jumped right into it and they've embraced that idea of asking; what matters to you, and how can we make your life more wonderful?

Tegan Taylor: So what you're kind of running up to at the moment is a big roundtable conversation in Canberra talking about how to make this more consistent across Australia. What are you asking for, if it can be done at a real grassroots level like it is?

JR Baker: It can be done but where the opportunities exist are with scaling things up so that it's accessible to everybody. So right now most of healthcare is delivered still in that biomedical model, where you focus on blood results and weight and disease and genetics and all those sorts of factors. But GPs and primary care providers, they do want to actually address the broader determinants of health and wellbeing, and so it takes resources to actually do that.

So one option is to make Medicare work a bit better for that. So things like creating social wellbeing plans, in addition to chronic disease management plans and mental health treatment plans might be an option, supporting PHNs to actually find more link workers, people who actually connect people to the available services is another option. And of course, putting a robust framework to do research evaluation and to scale things up is another great opportunity. So all those things actually improve the system, the framework it's based on, and the actual capacity and capability of people to leverage it.

Tegan Taylor: So one country that's a couple of years ahead of us in this space is the UK. They've had a national scale version of this for the last few years. What are you seeing there that you hope we could replicate in Australia?

JR Baker: Yeah, the UK has done all sorts of very cool things. So they are seeing those things we talked about earlier, reductions in healthcare utilisation and improvements in social connection and wellbeing. There's lots of really interesting programs. So they have heritage connectors to actually tap you back into history. And they have nature connectors that actually get you out and about in the environment, and that can lead to other activities, like fishing is quite nice and nature based. So I suppose, what you have in the UK, because they have a bit of a head start, is a broad range of activities that you can be referred into, and a much broader range of refers. GP practices can get link workers put right into the practice to help people access all those sorts of rich opportunities. That's fantastic that that funding is at both the medical primary care level and also at the community level, to help people access more opportunities.

Tegan Taylor: Why is now the time for this?

JR Baker: There's a lot of reasons social prescribing is really timely at the minute. I suppose the first is post the Covid pandemic (not that it's ended). We've been talking a lot about the loneliness epidemic, and there's been a tonne of media about it, the World Health Organisation's onto it, the US Surgeon General's onto it, we've all noticed that people are feeling a lot more lonely and socially isolated. So social prescribing is one opportunity at connecting people back into communities.

Then we have the risk of chronic disease and larger ageing populations, increases in mental health issues, and increase in psychosocial injuries in the workplace even. So there has to be another solution to actually supplement what we have in place, and to look at all those other factors that address some of the aspects of health and wellbeing, including social and economic factors, health behaviours, environmental factors.

Then there's the workforce, we keep seeing news articles and hearing about how the workforce isn't going to be sustainable over time, especially in light of the other things I just mentioned, so it's quite important to give additional tools to the primary care workforce at the minute. And I guess the most important factor is everyone deserves a good quality of life. And the Commonwealth Treasury is looking at measuring what matters and a Wellbeing Framework, and the question is, why not now? Why not now invest in healthy, connected communities with high quality of life?

Tegan Taylor: JR Baker is chair of the Australian Social Prescribing Institute of Research and Education or ASPIRE, and he's an Adjunct Associate Professor at Southern Cross University and CEO of Primary and Community Care Services.

Norman Swan: You're listening to the Health Report.

Tegan Taylor: You know when you're making a cake and the cake turns out like a little bit…there's holes here and there, it's a bit dippy in the middle, and you just slather it with icing, and it looks fine from the outside because you just fill in all the gaps with icing?

Norman Swan: I do know that, and sometimes they're the best cakes because it's all squashy in the middle.

Tegan Taylor: That's what I think too. I used to have that approach to taking a multivitamin. When I was in my 20s, I was, like, well, you know, I eat veggies most of the time, blah, blah, blah, but just in case, just to smooth things over…

Norman Swan: So the vitamins were the icing.

Tegan Taylor: …were be icing and the cake was my diet. And most of the time I think the cake was probably fine, but, just to be sure, I slathered that multivitamin over the top.

Norman Swan: Well, I think your success in life can all be put down to multivitamins.

Tegan Taylor: Short episode. That's it, that's the question, that's the answer. No, no, we do need to talk about it properly today.

Norman Swan: Because you are listening to What's That Rash? where we answer your questions on health and wellbeing.

Tegan Taylor: And Liz is asking, surprisingly, about multivitamins. She says: 'I'm an average woman with an average normal diet and average normal lifestyle.' Good on you, Liz. 'I don't have any specific health issues. Should I be taking any regular multivitamins or other vitamins? The pharmacy has a whole aisle of them. Is it all a scam?' So Norman, let's talk today about multivitamins specifically.

Norman Swan: Yes, okay. Thank you very much, Liz, for that question. We're getting really noncontroversial easy questions on What's That Rash?. We should probably call it What's That Scam? because that seems to be a theme over the last couple of weeks.

Tegan Taylor: Well, I know that you love talking about how most of the stuff that's sold in pharmacies isn't evidence based, so why not, why not just dig straight in today!

Norman Swan: Well, the other thing that I commonly say is that Australians have the most expensive urine in the world. Which gives you a flavour of what I think about multivitamins.

Tegan Taylor: I don't want 'urine' and 'flavour' used in the same sentence, thank you. I think what we should do is talk about multivitamins, because that's kind of a question and it's also the way I used to make my diet cake. What's usually in a multivitamin that you can get in a supermarket or pharmacy in Australia?

Norman Swan: Well, it's hard to generalise. But basically there's a few vitamins and there are almost certainly some minerals as well. So I'm just giving you an example of one which probably is not that unusual, where you've got retinol, which is a form of vitamin A, beta-carotene, you've got vitamin D3, then you've got some antioxidants, lutein and lycopene, some calcium, some thymine, nicotinamide, so basically a few vitamins. And then there's some minerals, calcium, magnesium, iron, zinc, manganese, and that sort of thing, micronutrients, selenium, they're pretty popular. And so I think that's what you get. So it's not a multivitamin, it's a multi-element supplement is what usually is in a multivitamin.

Tegan Taylor: Oh, that's not quite as snappy as the word 'multivitamin'.

Norman Swan: No, it's not. And they tend to tailor…you know, you can have it for women, you have it for men, you can have it for kids, they manipulate the recipe.

Tegan Taylor: So it's a catch-all term, but there's not really like a standardisation in Australia.

Norman Swan: No, I mean, and why should there be? There's a multivitamin, it just means that there's many vitamins in it. And as long as there's vitamins in it, it would qualify to be a multivitamin.

Tegan Taylor: So obviously in different times in human history and in certain parts of the world, nutrient deficiencies have been a big problem and can cause big health effects, can cause birth defects in babies. But how much of a problem is nutrient or vitamin deficiency in Australia? Like, for the most part, we have a fairly stable food supply, we have a fairly varied diet.

Norman Swan: Maybe just before we get onto that, the history is quite illuminating.

Tegan Taylor: Oh, well, it does include a character called Dr Funk, so we do need to talk about the history.

Norman Swan: That's right, and you shouldn't get into funk about Dr Funk because…

Tegan Taylor: No, he's funky, I love him.

Norman Swan: He was a pretty good biochemist. But it comes to your issue of deficiency. So he essentially discovered vitamins by looking at very specific deficiency patterns like beriberi, pellagra, scurvy, rickets, where you had a syndrome, and he suspected that there was a substance lacking in the food of those people, and then he investigated it. And he uncovered that there were B vitamins deficient, rickets of course is vitamin D, and others, so he didn't discover all the vitamins but essentially he found a way of discovering the vitamins that caused a specific vitamin deficiency pattern.

Now, we don't see those patterns in Australia. There's been some rickets in kids born to African migrants, women who have come from countries where they're used to exposing their skin to the sun and getting vitamin D. But when they live in small apartments in Melbourne, and they've got their heads, their bodies covered when they go out, they are vitamin D deficient. So we have seen that a little bit. But scurvy, maybe the odd case in elderly people. But by and large we don't see deficiency diseases.

Tegan Taylor: So, what's the point of a multivitamin, at least the vitamin parts of it, when we're not really having people be deficient anyway?

Norman Swan: Well, that's the key question. And all I can do is quote you the people who promote multivitamins. They say, well, there are subclinical deficiencies, meaning, it's so subtle you can't notice it but you should actually replace it, and that the recommended daily requirements as published are actually not enough for some people, because you might be exercising or you might be doing this, that or the other and you need a little bit of extra boosting from the vitamins.

Tegan Taylor: So that's what the companies making these vitamins say, and you do sort of hear that marketing of putting a spring in your step or giving you some vigour or, like you say, if you're a really active person, you've got a busy life, that these vitamins can do that. On the backs of the packets they'll often have the RDI, the recommended daily intake, or a percentage of that. Where did those numbers actually come from?

Norman Swan: So there's a bit of a history to recommend a daily intake. A lot of the requirements for diet emerged…it was British nutritionists who started to find, when you were going into rationing and wartime, what did people actually need? And they extrapolated from the deficiency diseases that we saw in poorer countries and the work of Funk and others, and essentially they've added to that over the years and concluded what might be the recommended daily intake of given vitamins, and then extrapolating from animal studies. There is one big caveat to all this, when they're talking about recommended daily intake, they're talking about it from food, they're not talking about it from a bottle. And when you have it from a bottle, you're actually no longer taking vitamins, you're taking drugs.

Tegan Taylor: That's a spicy comment. What do you mean?

Norman Swan: Vitamins are taken in tiny, tiny amounts into the body in food, with all sorts of other substances in the food which help the vitamins and other micronutrients to be absorbed and utilised. So they're actually tiny amounts. And when you start giving more than tiny amounts, you're not necessarily getting the same effect that you would from the recommended daily intake and taking more might not be better. And I think I've spoken about this before on What's That Rash?, vitamin C in food in low doses is an antioxidant, it slows down the oxidative stress, the internal body rusting that's associated with ageing and premature ageing. However, vitamin C in high doses (and nobody knows really why) is a pro-oxidant, it speeds up oxidative stress.

Tegan Taylor: Oh, that's sad, because that's the one vitamin that actually is yummy. The vitamin C tablets are good.

Norman Swan: Because of the taste of them, yes. Well, to the extent that people are starting to look at whether or not you could use vitamin C as an adjunct to chemotherapy, because it helps to kill cells.

Tegan Taylor: Yeah, good in chemo, not really good in any other application.

Norman Swan: Well, that's right. So that's the whole issue here with multivitamins.

Tegan Taylor: So if you're getting more than you need, what happens to that excess vitamin in your body? You mentioned expensive wee before, which I assume means it just gets excreted in your urine, but not all of them just get excreted in the amounts that you don't need.

Norman Swan: So you've got the water soluble vitamins, particularly vitamin C, vitamin B, the B vitamins, and they get peed out but also they do accumulate in your body, they can cause toxicity at higher levels before they get peed out. So in other words, it doesn't mean that they don't accumulate in your body. Then there's the fat-soluble vitamins, some of which, like vitamin A, can accumulate in your body and really cause quite a lot of damage if you take it in excess quantities. And then there's the one particular form of vitamin B, vitamin B6, if you take it in high amounts it can damage your nerves permanently, cause peripheral neuropathy.

Tegan Taylor: Oh, wow. And so if you're getting this bad effect from the vitamins as a supplement, do you see the same effect if you're eating a lot of foods that are really high in these vitamins?

Norman Swan: Remember, the safety margin on most of the vitamins and most multivitamin tablets is pretty good. Even for vitamin B6, the TGA has been quite strict on controlling that but you've got to watch if there's vitamin B6 in a multivitamin tablet. So, for example, let's just take people who are vegan. People who are vegan run the risk of (probably less of a risk now than years gone by because there's so many vegan products on the market) becoming vitamin B12 deficient. Now, B12 has actually quite a big safety margin if you're taking vitamin B12, a much bigger safety margin than vitamin B6. But it's all different, you can't generalise. But most multivitamins, taken reasonably, are not going to do very much harm, if any harm at all. Are they going to do you any good, though? So coming to your question about food, unless you've got a particular food obsession, it's very hard to take too much in food, because you get full up before you come anywhere close to it. It's a bit like the equivalent of taking fruit juice versus whole fruit; it's much easier to swallow a glass of juice than it is to eat four oranges.

Tegan Taylor: Yeah, exactly. So my overall impression, Norman, is that you are a little dim on multivitamins. Is there any evidence to support them?

Norman Swan: There's a little bit but it's quite specific. So for example, there's been quite a good randomised trial done with good researchers, Harvard based researchers, looking at dietary flavonoids, those are antioxidants, and also multivitamin preparations, to see whether it has an effect on memory. And what they found was that in people with poorer quality diets they did see some improvement in memory. But in people who are reasonably well nourished, they didn't see pretty much any benefit at all.

The strongest evidence is actually in macular degeneration. So macular degeneration is a genetic disease at the back of the eye, the retina. And if you look at nutritional intake of large populations, the populations with the healthiest diet and the highest intake of antioxidants seem to have the lowest rate of age-related macular degeneration. So eye surgeons around the world said, well, what happens if we actually supplement with antioxidants? So to summarise the studies, there is a mix of antioxidants called AREDS2, vitamin C, vitamin E, and zinc and copper. And that seems to reduce the risk of macular degeneration in people who are at high risk, and it seems to slow the progression of some forms of macular degeneration, if they're put onto this early enough.

And because they've done these large-scale studies, giving particularly older people these multivitamins, they've also looked at some of the other benefits such as does it prolong your life? The answer is no. There's no evidence that multivitamin preparations prolong your life, make you live longer. And there is some risk, so beta-carotene, if you've been a smoker, it increases your risk of lung cancer. So in AREDS formulations for macular degeneration, they've tended to remove beta-carotene, and replace it with other antioxidants.

Tegan Taylor: So, a fair few caveats there, it sounds like there is a basis for some very specific formulations of antioxidants for some very specific reasons. But to come back to Liz's question, for that average woman, average normal diet, average normal lifestyle, is there any benefit at all in taking multivitamins?

Norman Swan: Save it up for the kids' birthday presents. Seriously, you're not going to do yourself any harm, you're almost certainly not going to do yourself any good at all, but you're taking something you just don't need to take. Because if you take a highly varied diet, very diverse in vegetables, not too much red meat, then you're going to be getting very potent forms of these antioxidants. You cannot buy in the chemist an antioxidant that's as powerful as the antioxidants you get in tomato or capsicum when you sprinkle olive oil on them and grill them.

Tegan Taylor: And I can tell you they're a lot tastier than swallowing a pill.

Norman Swan: They are.

Tegan Taylor: Liz, thank you so much for your question. And if you have a question, you can send it to us, thatrash@abc.net.au, which is also where you can write to us with things that aren't questions, like Kim has. Kim has written in, Norman, off the back of our chat about chiropractic. And Kim said they had 20 years persistent back pain, had gone to a physio, gone to a deep massage place, finally went to a chiropractor and was quite nervous and ended up coming away pain free after three treatments. And it was Kim's massage therapist who recommended that they try chiro, and he lost a customer by doing it.

Norman Swan: Well, some chiropractors pride themselves in saying, 'If I can't help you, I'll tell you, and I'm going to try and get you better in two or three sessions. You're not going to have to come to me for life.' And this is called the Gonstead method I think is what Kim had, where they carefully assess you, and they're trying to do it in a minimum number of sessions. So they're not trying to keep you as a customer for life.

Tegan Taylor: They're doing themselves out of a job. We also got an email from Ian who is listening from Sweden. Hello, thanks very much. Ian sent us a link to an Ig Noble Prize from 2009, there was a doctor Donald Unger who received the Medicine Prize for cracking the knuckles of his left hand only, not his right, for 60 years to see if the habit contributed to arthritis.

Norman Swan: A non-randomised but controlled trial…

Tegan Taylor: A very controlled trial.

Norman Swan: So was his left hand limp and useless?

Tegan Taylor: No, it was the same. No, it didn't contribute to arthritis in his left hand.

Norman Swan: Well, he deserves an Ig Noble for that.

Tegan Taylor: So crack away, folks. And be like Kim and Ian, send us an email and tell us if you're still going to take your multivitamin or if Norman is single-handedly putting the pharmaceutical business in Australia out of business, thatrash@abc.net.au.

Norman Swan: And if you've got your own concoction, do let us know, we'd be fascinated. You know, have you combined your multivitamin with cracking your knuckles and did that make a difference?

Tegan Taylor: Do you know, I actually have concocted my own multivitamin, Norman?

Norman Swan: Oh, have you?

Tegan Taylor: It's called a salad.

Norman Swan: Followed by a heavily iced sponge cake.

Tegan Taylor: Exactly.

Norman Swan: That's the Health Report for this week. And don't forget, if you want to hear What's That Rash? earlier on in the week, you can always subscribe to it on the ABC's Listen app.

Tegan Taylor: And you can subscribe to the Health Report podcast while you're there too.

Norman Swan: And we'll see you next week.

Tegan Taylor: See you then.