Is it 10 thousand steps or 30 mins? How advice on regular exercise varies.
What's being done in response to medication shortages.
Deprescribing is when you wean off a prescription medication you no longer need, but it needs to be done safely, and it can be difficult to find the right advice.
Experts want women to know they don't have to suffer through heavy periods.
And when all the tests come back negative, initially it's a weight off your mind, but then you start to wonder, 'what the hell is wrong with me?'
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Norman Swan: So Shelby, do you remember when we were first told to walk 10,000 steps? I mean, were you even born, I suppose, is the question to ask.
Shelby Traynor: If I was born then I doubt I was walking.
Norman Swan: Well, in those ancient days when your mum was pushing your pram, she'd have been wearing a pedometer, a little box on her hip.
Shelby Traynor: I know that she has one now in her phone and on her watch.
Norman Swan: So we all know how many steps we're taking.
Shelby Traynor: Yeah, and that's what we're talking about today, we're talking step counts and whether they can be used in our National Physical Activity Guidelines to maybe encourage people to exercise more.
Norman Swan: That's just part of this week's Health Report with me, Norman Swan, on Gadigal land.
Shelby Traynor: And me, Shelby Traynor, also on Gadigal land. Today, how do you know when something is normal? Experts want women to know that heavy periods aren't and you don't have to put up with them. But what are the best treatment options?
Norman Swan: Also, Shelby, you might have gone to the doctor with symptoms, expecting a clear diagnosis, but gone away with nothing. It can be frustrating, especially when those symptoms don't go away. We'll try to answer the question; what the heck is wrong with you?
Shelby Traynor: But first, we've been hearing a lot about drug shortages lately. In particular we've heard GPs in New South Wales have been told to limit the prescription of certain antibiotics because cases of pneumonia and whooping cough are putting strain on supply. On top of that, we've also gotten a few emails about shortages of certain medications for migraine. So I'm wondering what the broader context is here, because drug shortages aren't new.
Norman Swan: This is about national drug shortages, they're just not available, and they were first recorded in 1914 before the First World War. And during wartime you do get drug shortages, but they've come and gone since, and it's been a particular problem globally. So Australia's not alone here, this is an international problem.
Shelby Traynor: But we do import a lot of medications, don't we.
Norman Swan: But most countries do, if you balance it out. India is a big producer of medications to the rest of the world. China, in terms of raw materials. Most countries, in one way or another, are dependent on importation of some kind. So you think, well, what are the reasons? And in fact there's no one single reason for drug shortages. With the GLP-1 agonists like Ozempic and Wegovy, the weight loss and the diabetes drugs, demand has outstripped the ability…
Shelby Traynor: They are in vogue.
Norman Swan: They're in vogue, and it's outstripped the ability to produce the drugs, so there's a manufacturing problem, which they say is going to be solved. We've spoken of this a little bit before in the Health Report, there's also an issue, particularly in the United States, about pricing and concentration of ownership, particularly of some generic drugs, and that they're holding out for higher prices. So there's an element of profiteering in this as well.
There are sometimes quality issues where a manufacturer has been taken offline because inspections have shown their quality control to be poor, and they control the market, so they're not supplying the market for that particular drug, and there aren't many alternatives. So, lots of reasons, and sometimes you know them, and sometimes they're worrying drugs like penicillin and cancer drugs.
So we got in touch with the Therapeutic Goods Administration. We actually asked for an interview, they declined an interview but sent us a long missive in answer to our questions, which we'll put on our website. And what they try to do is find alternative sources of supply. They allow, in some situations, for critical drugs, unapproved medications from a manufacturer that hasn't asked for approval of their drug.
Shelby Traynor: And this tends to be drugs that are already approved in some form, right?
Norman Swan: That's right.
Shelby Traynor: It's just a different type of the same medication.
Norman Swan: That's right. So you can't call it a shortage if a drug has not been approved for marketing in Australia, that's not a shortage, it just hasn't gone through the regulatory mechanisms. So you're absolutely right there. And they also allow, within reason, you to go to a compounding pharmacy to replace that shortage. Now, what we had with Ozempi (and I refer people to the Four Corners that was made on Ozempic a few weeks ago) is that it became an industry, compounding Ozempic, and the reliability of the product from one particular supplier was problematic, so you weren't sure what you were getting. So compounding is under-regulated compared to the regular drug market, so you've got to be careful what you do. And you've also got to be really careful about importing drugs from overseas. The fake medicine market is enormous. And I was speaking at a malaria conference, and they were saying that a disturbingly high percentage of the medicines going to low to middle income countries to combat malaria are not the drugs that people think they're buying, or if they are they're tainted or they're in lower doses. So you cannot necessarily trust what you import from overseas, so just be careful. And of course the issue here is about criticality; how critical is this drug for you?
Shelby Traynor: Yeah, I suppose we take for granted that you'll go to the pharmacy and your drugs will be available, and if it's not available there, you can go to another pharmacy. It's quite scary to think that critical drugs could just not be there at all.
Norman Swan: Yeah, but rather than panic about this, when you look through the list of drugs currently on the TGA website, there are usually alternatives. It's a particular preparation of penicillin, but there are some shortages which are worrying specialists in hospitals, of drugs that are not commonly prescribed by GPs but are out there. And it's a market that can be quite volatile.
Shelby Traynor: One of the issues with shortages could be that there's such a high demand for medications and that demand might be higher than it should be.
Norman Swan: Yes, the paper has come out looking at the issue of what's called deprescribing, so you can have artificially high demand if you're on a medication that you actually don't need to be on, or perhaps you need to be on a lower dose. And the emphasis around drugs is getting you on the drug, but you may want to come off a drug, or you may need to come off a drug. The lead researcher on this paper where they reviewed, I think, about 80 guidelines to see whether they advised on deprescribing and what they advised was Dr Aili Langford, who's a lecturer in the pharmacy school at the University of Sydney.
Aili Langford: There was a large study in the UK recently that estimated that 10% of all medications are potentially inappropriate, and there's a little bit more data, particularly in older adults, to say that nearly half to one-third of older adults are taking at least one inappropriate medication that may be suitable for deprescribing.
Norman Swan: So that's an enormous impact on the individual, as well as on our budget.
Aili Langford: Definitely. Of course there's harms to the individuals, like side effects. Some medications increase the risk of falls. If someone's having a fall and then going into the hospital system, as you said, there's huge potential implications on the costs at the healthcare system level as well.
Norman Swan: But we're also being denied expensive drugs when there's waste going on.
Aili Langford: Yes, and there's a huge amount of research as well about the potential environmental impacts of overprescribing as well. So I think the potential implications are quite significant.
Norman Swan: You've looked in this study at the advice doctors get about deprescribing, and it's not a pretty picture.
Aili Langford: That's correct, so we wanted to find out whether guidelines in general contain deprescribing recommendations, and of the ones that do, what do those recommendations look and sound like. So we searched a range of different guideline registries and databases, and we found that a little bit less than a third of guidelines contain recommendations about deprescribing. And then perhaps one of the more concerning findings was of those that do, a lot of them don't have detailed information about how to actually go about deprescribing.
Norman Swan: So they say you should get off this drug when you need to, but don't tell you how.
Aili Langford: Exactly. And I think that's concerning, because a lot of medications we know need to be perhaps tapered slowly, or if they're stopped abruptly they can lead to withdrawal effects or other patient harms.
Norman Swan: We've spoken about some of this before in the Health Report, particularly with antidepressants, the new form of antidepressants, how you really cannot stop those suddenly, you've got to taper them and so on. Opioid painkillers are obviously another one. Are those the two main ones? Or are there other medications as well?
Aili Langford: Yes, from our review we did find that neurological drugs were the ones that most commonly had deprescribing recommendations, things like antiepileptics were also a focus within the review. And then we did, of course, find types of medication classes or disease states where perhaps there were less focus on deprescribing recommendations, so things more like cardiovascular disease, respiratory conditions.
Norman Swan: Do we know how to deprescribe with most medications, or is it guesswork?
Aili Langford: That is a good question, and many of the recommendations that we did find were based on low certainty evidence, and there's a few reasons potentially for that, that people aren't conducting studies to look at continuation versus deprescribing of a medication and the benefits and harms of that. Another consideration is that often deprescribing will probably have to be individualised. There may not be a one-size-fits-all solution in terms of the exact approach of how to, say, stop an antidepressant. Some people may need to go slightly slower, or may be able to tolerate faster tapers than others. But I think it's still important for clinicians to have guidance around a general approach or a range that might be safe and appropriate to guide patients on how they may begin to reduce their doses.
Norman Swan: Of course, people get a bit anxious at the thought that you're going to stop my drug.
Aili Langford: Yes, I think they can be. And on the other hand, I think there's some people who perhaps have taken medications for a long time and then make a decision that they may want to trial reducing or stopping it, and say that 'I've never been given any information about when and how I could go about this process.' So I think both sides are true.
Norman Swan: Now, the whole system is focused on getting you on drugs rather than getting you off drugs. It's in the pharmaceutical industry's interests, the trials are biassed towards getting on drugs and seeing the benefit versus placebo. Are deprescribing studies easy to do, and who's going to fund them?
Aili Langford: Well, there is a lot of emerging evidence and research being conducted currently looking at deprescribing, both here in Australia and internationally, and even in Australia there's been a range of other initiatives recently to try and promote deprescribing. In March this year, the Society of Hospital Pharmacists of Australia worked with a range of different organisations under a campaign called Meds Aware Week, which was trying to empower people to ask their healthcare professionals; do I still need to be on this medication? Because I think they think that's an important first step to having these conversations about deprescribing.
Norman Swan: Giving the doctor the permission to do it.
Aili Langford: Yes, exactly.
Norman Swan: Which was going to be my final question, which is what's your practical advice for somebody listening to this who thinks they've been on it too long, or they want to try time off it?
Aili Langford: When a medication is first prescribed, I think it's really important for people to have a conversation about what is the expectation around the duration of use. And I think by having that conversation early on, you can sort of plan ahead for whether deprescribing may be appropriate. I think one of the main findings from our review, though, is that if that evidence isn't available for healthcare professionals in their clinical practice guidelines, that then makes it potentially difficult for them to support their patients to deprescribe, if that is what they indeed want to pursue.
Norman Swan: Aili, thanks for joining us.
Aili Langford: Thank you very much.
Norman Swan: Dr Aili Langford is a lecturer in Pharmacy at the University of Sydney.
Shelby Traynor: You're listening to the Health Report on RN.
Norman Swan: So this next story is a really important one for women's health.
Shelby Traynor: Yeah, a lot of women might not be aware that they're dealing with heavy menstrual bleeding.
Norman Swan: Why not?
Shelby Traynor: Well, if you're not talking to your friends about it, chances are you may not be talking to your doctor about it, but it's so normalised to just deal with it and not question it.
Norman Swan: So, compared to others, you might be dealing with heavy bleeding, but for you it feels normal.
Shelby Traynor: Yeah, there's no comparison, you only know your own body. But there are actually treatments available to deal with this, to make it easier and more comfortable.
Norman Swan: I mean, the whole thing about heavy menstrual bleeding, it's sometimes called menorrhagia, is that there are lots of different causes. IUDs can cause bleeding, but IUDs are also a treatment for menorrhagia in older women, but never to be ignored, even in younger women, particularly with the increase in cancers in younger people, it can be a tumour. It could be a benign tumour, like a fibroid, unusual in younger women. Infections, I mean, dengue fever rarely can cause menorrhagia. So, not an issue for most of Australia, but Northern Queensland. Pelvic inflammatory disease, problems with the cervix. You could actually have nothing wrong with your uterus at all and you've got a bleeding disorder, or it could be iatrogenic (in other words, doctor caused); you could be on aspirin or a blood thinner, and that's causing it. So it's a complicated story where you should be recognising whether you've got it, but it requires the GP to do quite a lot of investigating.
Shelby Traynor: But even if it's not caused by any of these things, even if it's just something that your body does and it's affecting your life, you should be able to get help to deal with it. And that's what Liz Marles is saying. She's a GP, and also Clinical Director of the Australian Commission on Safety and Quality in Healthcare.
Norman Swan: Former President of the College of GPs.
Shelby Traynor: Yes. She's played a part in developing new guidelines around heavy periods so more people have received the right treatment.
Liz Marles: It's really about the impact that it's having on that woman's life. If she is having to restrict what she does, you know, take time off work, restrict her social activities or her dress choices, there's a lot that we can do to help her so that it's not such a difficult time of the month.
Shelby Traynor: And so is this a separate classification to if you're experiencing very bad cramps or back pain or headaches?
Liz Marles: No, I think bad cramping and passing clots is often associated with heavy menstrual bleeding. We know that 60% of the women who have heavy menstrual bleeding are actually iron deficient as well, and they may be experiencing fatigue, and that could go on beyond the time of their period as well.
Shelby Traynor: Do we know anything about the amount of people who do come forward and seek help for this? Is it a large percentage, or is it in the minority?
Liz Marles: Yes, so we actually think that it's less than half of women who are experiencing heavy menstrual bleeding actually seek help. These women are missing out on treatment that could be life changing for them. One of the things that we really want to encourage is for women to feel comfortable to raise this, knowing that there are actually lots of treatment options available, it's not just about having a hysterectomy. We can do a lot to make life better without going to a major operation as the only treatment.
Shelby Traynor: So you mentioned a hysterectomy, is that the most extreme treatment option? And if we can just give an overview of what else there is out there for people.
Liz Marles: So there are lots of treatment options available for heavy menstrual bleeding, and it starts with really simple treatments like taking anti-inflammatories or tranexamic acid around the time of the period, through to hormonal treatments like the contraceptive pill. The hormonal IUD is a really effective treatment for heavy menstrual bleeding and will probably manage the problem for the vast majority of women. If those treatments don't work, then we can move to other, more procedural treatments, minor surgical procedures, to get rid of polyps, maybe deal with fibroids. And there is a treatment called an endometrial ablation, which removes the lining of the uterus, and again, for most women that will solve the problem. It's just a day procedure, it does involve an anaesthetic, but it's much less invasive than actually having a hysterectomy. In this clinical care standard we've also talked a little bit about a new procedure, which is not widely available, so we haven't put a lot of emphasis on it, but that's a uterine artery embolization, where they reduce the blood flow to fibroids, for instance, which will reduce bleeding.
Shelby Traynor: You've looked at rates of hysterectomies versus ablations over quite an extensive period of time. What did you see?
Liz Marles: Since I think 2013 we first started monitoring this, and we've seen that over an eight-year period there's been a 20% reduction in hysterectomy rates, and at the same time we've probably seen a 10% rise in endometrial ablation. Both of those things are positive. We're very happy to see the decrease, but it still leaves us with substantially higher rates of hysterectomy than comparable countries like the UK and New Zealand. And whilst we've seen that 10% increase in endometrial ablation, we know that there's a huge variation across the country in endometrial ablation rates. There's a 20-fold difference from the area with the highest rates of endometrial ablation and the areas with the lowest rates, so we know that that procedure is not being offered equally across the country. All of this is speculation because we don't actually know the reasons why, but it is possible that a lot of the women in rural areas have to travel, and maybe that means that they're more inclined to get a more definitive treatment. We've also seen that there's a 9% higher rate of hysterectomy in First Nations women compared to other Australian women in this latest data, and we know that a lot of First Nations women will be accessing the public system, and so, again, it's whether that full spectrum of treatment options is available.
Shelby Traynor: And there's new clinical care standards that came out last week. How are you hoping that will guide these interactions with patients?
Liz Marles: So the clinical care standards have got a big focus on women making an informed choice, and really emphasise the need to have discussions with women that highlight the range of treatment options. They also emphasise that we should start treatment the first time a woman presents, so not wait for all the investigations to be completed. We can start with some of those simple treatments, like using anti-inflammatory medications around the time of the period. There's a lot of guidance around cultural safety and equity, noting that there are some particular groups who may find talking about this quite difficult, and that includes women who come from culturally and linguistically diverse backgrounds, women who maybe have a disability, trans and non-binary people who are still menstruating who might find it difficult to discuss those issues or even have a clinical examination, and First Nations women. So we're really trying to broaden the horizons of the clinician in terms of thinking about all the people who may be experiencing heavy menstrual bleeding.
Shelby Traynor: Thank you so much, Liz.
Liz Marles: That's a pleasure.
Shelby Traynor: That was Associate Professor Liz Marles from the Commission on Safety and Quality in Healthcare.
Shelby Traynor: Norman, what the hell is wrong with me?
Norman Swan: If you don't know, how am I going to know?
Shelby Traynor: Spoken like a true GP.
Norman Swan: Well, I've never been a GP, it's too hard a job. But it's a really important issue, which is that when people go to their doctor with symptoms they think they're going to get a clear diagnosis, and sometimes they're not, and this is a source of both conflict and frustration and worry. So I've got a symptom. Is this something serious? Do I have cancer? Do I have heart disease? What's going on? And in the end, it could be that there's no physical diagnosis to be made. You've got a pattern of symptoms. What's going on?
One person with a strong interest in this area is Gillian Deakin, who's a general practitioner and has researched this area, and she's the author of What the Hell is Wrong With Me?, in fact, she co-wrote a piece in The Lancet on this recently. So this is really about how to recover from pain, fatigue, weakness and other undiagnosed symptoms which don't have an easy label. I spoke to Gillian recently.
Gillian Deakin: Look, I've been a GP for over 40 years now, and every single day of my working life, I have people coming in with symptoms that simply have no medical diagnosis.
Norman Swan: Every day?
Gillian Deakin: Every day. It's much, much more common than people realise. Some people are left with symptoms that go on for weeks, months and even years, and sometimes these symptoms are very, very disabling.
Norman Swan: So what sort of symptoms are we talking about?
Gillian Deakin: Well, look, the symptoms I'm talking about really range right across the board, and nearly every single symptom known to humankind can be a functional symptom, so this is the problem. You could even go so far as collapsing, having seizures, losing the use of a limb, having a disturbed gait. More commonly, people get headaches, disturbed gut, upset stomach, itches, rashes, things like that. Fatigue is a big one.
Norman Swan: Okay, I mean, you're calling them functional disorders and that used to be code for…I mean, in the 19th century people like Freud called these hysterical disorders. Some others have called it psychosomatic disorders, and then the immediate assumption by the person with the symptoms is, 'Well, Doctor, you're denying the existence of these symptoms and you think it's all in my head, or you're demeaning me, because you really think it's hysterical, you don't think it's real at all.' And the big one is fatigue, where people with fatigue feel that their situation is being denied and possibly makes them worse, having that feeling.
Gillian Deakin: This is why I've written the book, because we have to resolve this conundrum, because doctors often avoid giving people any diagnosis when they have these symptoms. And the reason is they just don't want the consultation to veer off into kind of acrimony. We're talking about a physical response within the body, genuine symptoms. They're not faked, they're not imagined, they're as real as the symptoms would be if you had a medical illness. I want to make that very clear, that's the first thing. So it feels real because it is real.
The body still is perfectly intact, everything's healthy in the body, but it's not functioning well, so that's why it's called a functional illness. The analogy I use is like a computer. Your computer might stop working. If there's a hardware problem, like the hard drive is blown up, or something, you've got to replace it. That's like a medical condition. But if the computer just needs a reboot or reprogramming, a software problem, that's more akin to what is a functional condition. So we need to learn how to reprogram the body so it works normally again.
Norman Swan: But here's the problem. I mean, I personally don't want a GP who's trigger-happy in terms of functional disorders, because as medical knowledge expands…for example, non-specific bowel symptoms can be the first symptoms of pancreatic or ovarian cancer. So I don't want a GP who jumps to the conclusion that I've got nothing; 'Don't worry about it, this is just irritable bowel syndrome.' And then a year later, I'm dead, or I'm diagnosed with an advanced cancer.
Gillian Deakin: That's exactly right.
Norman Swan: On the other side you've got GPs who fear this and fear missing something, and you get on a diagnostic merry-go-round, in fact you use that word 'merry-go-round' in your book, where the doctor and the person themselves are so terrified of missing something physical, you don't know when to stop in terms of investigations. Well, just try one more thing or one more specialist, and it never ends, and nobody comes to the conclusion. How do you know when to stop and say; 'This is something functional and we need to take this seriously as a software problem between the body and the brain, or the body and the mind, and we need to sort this out because your body's not working properly, but it's not something that we can operate on'?
Gillian Deakin: One of the things I've written in my book is how to pace that investigative process and how to build a relationship with the patient with the symptoms that they keep going back to the same doctor and keep getting evaluated. Because, as I said, a lot of these symptoms do go away within a reasonable period of time, so watchful expectation is actually a form of time-honoured treatment. And the whole thing is it has to be watched, you're quite right. If there's any progression, further testing needs to be done. That's the first thing. The second thing is we use the term 'red flags' to look for symptoms that show something more serious is afoot. So if there's red flags, doctors definitely should be progressing with the investigations.
Norman Swan: So this is things like bruising, bleeding, loss of weight, unexpected and unplanned loss of weight, things like that.
Gillian Deakin: Exactly. What happens, though, unfortunately, is that people come in, doctors do their due diligence, rule out most known physical conditions, but then the patient is not given a diagnosis, and the patient wanders off to the next doctor, and the whole process can start again and it's very unsatisfactory. So what I'm hoping to achieve is that patients are given; look, you appear to have a functional condition, we're going to see you back in an agreed period of time, and you're going to keep track of the symptoms, and in the meantime we're going to manage it like this. And if we get in early, the treatment is effective.
Norman Swan: But you're talking about a variety of problems. You're talking about fatigue, you're talking about pain, you're talking about problems swallowing, you're talking about abdominal symptoms, and you describe this in your book as a stress response. What evidence is there that it's a stress response? Because, again, this is something that can get people's hackles up.
Gillian Deakin: Yes, I don't actually say it's a stress response, I say it's a body stress response, and I think that's a very important distinction. Cold weather is a stress upon the body. It's not the way most people think of the word 'stress'. A vaccination is a stress upon the body, and it is. Surgery is certainly a stress upon the body. The body needs to always respond to whatever happens to it, but extreme stressors can trigger an excessive and persistent response which causes all manner of symptoms.
Norman Swan: So what are those stressors? What are the predisposing factors to having symptoms which are functional, where there isn't an easy fix with a medication or a scalpel?
Gillian Deakin: We think they're very diverse; genetics, epigenetics, nutrition, lack of sleep, competitive sports. Yes, past trauma, yes, stress, yes, anxiety and depression, those factors do come in, but only in about 50% of people they have that. But the rest of us who get functional symptoms don't have any overt stress, and people are quite right to object to doctors insisting on that, and this is the trouble, in a 15-minute GP consultation, to collect all the possible risk factors that are going on in someone's life is quite complex and difficult. This is why it's much better if people have an ongoing relationship with their GP where this sort of information's already been collected.
Norman Swan: If you've got one of these symptom sets, and you think you've had the tests that really explore every avenue, but you don't know what the cause is, how can you, as a GP, start treatment?
Gillian Deakin: You start to treat it in the time-honoured fashion that's been established. And I use Professor Kozlowska's work out at Westmead to do this, she talks about the body stress systems, and we seek to resolve and settle those back into normal. The basic way of doing that is get adequate sleep, make sure your diet's good, and exercise in a safe fashion. And that's the starting point. But then, of course, as you say, with swallowing we might use speech therapists, gait disturbance, you use a skilled physiotherapist who has knowledge about functional disturbances. There's a lot of means that we can use to address some of the symptoms. I've got patients who have symptoms we never resolve, but they don't worry about them. They have to put up with them, but they don't worry about them, and that itself is a big help.
Norman Swan: Which is, in fact, the modern approach to chronic pain, not promising to solve the problem, and in fact tinnitus is another one, you learn not to allow it to fill your life.
Gillian Deakin: That's right. And when people are left undiagnosed, it's very hard for them to accept that. So people can take it to the doctor. If they walk in and say, 'Do you think my symptoms could be functional, Doctor?' I think that would be a big sigh of relief for the doctors to say that people are open to that idea, and then the relationship can move forward in a more productive fashion.
Norman Swan: Some of the angriest responses we get to the Health Report are from people with functional disorders who feel that they've been demeaned or we're blaming it on something in the brain, and I've always assumed that this is the result of trauma from the medical system, that they've been demeaned so often, and now they think they hear it on air.
Gillian Deakin: That's right, and that's why I object to the word, using 'stress'. I don't use it in the book. I talk about the body reacting to stressors, but I don't use the word just simply 'stress', because there is an implied blame for that, and we have to learn to move forward with that. We won't always have an explanation. I wish we did, I wish we had a better explanation, but my book is a start, and I'd love people to just try some of the things I've mentioned and go forward from there.
Norman Swan: But you've got to change doctor's attitudes.
Gillian Deakin: Yes.
Norman Swan: When you talk to GPs about this problem, they have a term…so just to be transparent, they have a term for patients like this, and they're called heart-sink patients. Your heart sinks when they walk into the surgery. And that's more a reflection of the helplessness of the doctor, and they don't like looking after them and they can see this long consultation and the waiting period in the waiting room going up and up and up. How do you argue those doctors out of the heart-sink point of view to a therapeutic approach?
Gillian Deakin: Well, the good news is that in Germany all the doctors receive guidelines on how to manage functional symptoms, and once we start to follow and treat these people just like any other patient with any symptom, that's the first step, that these patients all deserve the same sort of approach as any other patient. 'Here's your diagnosis. This is a treatment we're going to start with. Let's see how it goes. Come back and tell me how it went.' This is what we do with every single patient, and these patients deserve that just as much. But that won't happen until patients accept that functional conditions are a thing, and I can only say they are because I've treated them, I guess, hundreds of patients, I haven't counted them, but today I had two or three patients in my room who had classic functional symptoms, and my patients are happy to accept that and accept the treatment, and it's quite a productive encounter.
Norman Swan: Gillian, thank you very much indeed.
Gillian Deakin: Thank you very much, Norman.
Norman Swan: Gillian Deakin, whose book is What the Hell is Wrong With Me?.
Shelby Traynor: A part of me wonders if some of these things that are being diagnosed as functional disorders might eventually have a diagnosis down the track. There's a lot that we don't know about health.
Norman Swan: That is absolutely right, and I was trying to make that point with Gillian, and she accepts that at some point you might find there's a clear cause, and that's the whole debate and anger in the chronic myalgic encephalomyelitis community, they're really angry when they're told they have a functional disorder because they think it's a physical disorder with a physical cause that just hasn't been found yet. And they've got justice on their side, because with long covid and the studies of long covid, we're finding abnormalities there which may also apply to chronic fatigue syndrome, which is to your point.
Shelby Traynor: We may just not know the pathways of these things, but it does go to the point that you guys also made, which is you don't necessarily need that name to start treatments that you know will work.
Norman Swan: Yeah, and this is the problem with some of these areas, is if you hang in there, hang in there, waiting for something new to be discovered, you're missing the opportunity just to get a bit better, or be able to cope better with the symptoms rather than a cure.
Shelby Traynor: Yeah, it's a tricky situation, though, for patients and for doctors.
Norman Swan: It is.
Shelby Traynor: You're listening to the Health Report on RN.
We have physical activity guidelines in Australia, which is great. Sometimes I do think they just exist to guilt-trip me because I'm not meeting them. What are the guidelines for someone like me? What are the guidelines for adults?
Norman Swan: Well, the guidelines for someone like you, even though you weren't born when…
Shelby Traynor: Pedometers existed? I definitely was.
Norman Swan: They are 150 minutes a week of moderately intense exercise. Another way of looking at this is 45 minutes of moderate exercise on most days of the week. It's got to be a pattern.
Shelby Traynor: And something that I hadn't thought about until I started looking into this was that those guidelines are in durations. Lots of people measure their workouts by distance, especially if you're a runner, laps if you're a swimmer, and step count if you're a walker. But those aren't in the guidelines.
Norman Swan: No. They are in public health messaging in some countries and to some extent in Australia, but they're not part of the official one, so you do have a disconnect there.
Shelby Traynor: Yeah, and that's because there's evidence to back up exercising for this amount of time means this health outcome.
Norman Swan: And you want simplicity, because there is evidence, for example, that high intensity interval training, you can shorten that 150 minutes, but you've got to do it properly otherwise you're not getting the benefit. So the simplest thing is to state what it is, moderate exercise. And moderate exercise is moderate for you, so that instantly tailors it. So if you've never exercised and you get up off the couch, just going for a walk along the flat, it's going to be hard to have a conversation, you're going to be breathless, but after two weeks of doing that, you're not going to be so breathless, so you've got to push yourself. And so you find after six months you're actually doing much more than you were doing when you first got off the couch.
Shelby Traynor: Well, researchers in the US have been trying to see if we can include step counts in these guidelines. So they're trying to find evidence that a certain amount of steps will equal benefits in terms of your health.
Norman Swan: And the problem there, of course, is the whole intensity equation.
Shelby Traynor: Yes, you could be on a leisurely walk, you could be on a brisk walk…
Norman Swan: You could be walking uphill and up stairs.
Shelby Traynor: It could be really, really hot, and you could be sweating. So there's a lot of…to preface this, there's a lot of external circumstances, but it helps that this is data from a really big study. So this was a study based on data from the Women's Health Study which followed more than 14,000 people.
Norman Swan: Yeah, we've spoken about this many times, and actually quite recently on the Health Report, this was about assessing low-dose aspirin, vitamin E and hormone replacement therapy in a large group of women, and they've been extracting subsets of data from this as well.
Shelby Traynor: And they decided, well, we've already recruited all of these people into this study, let's just ask them to do another thing. And so they monitored them with an accelerometer to measure their physical activity, and that was between 2011 and 2015 and then they kept track of their health outcomes up until 2022.
Norman Swan: And what did they find?
Shelby Traynor: So they found, at least for older women, this was women aged 62 and up, the health benefits of a high step count were pretty much on par with the benefits of moderate to vigorous exercise, and the health benefits they were measuring were all-cause mortality and cardiovascular disease. I spoke to one of the authors of the study, Dr Rikuta Hamaya.
Rikuta Hamaya: The higher physical activity in time or steps was associated with reduced risk of mortality and CVD, and the magnitude was similar. Our evidence suggests that setting a step as a goal can be another good metric, as good as a time-based goal. So that's a major take-home message.
Norman Swan: So was this evenly spread, or was it the highest group when they tracked the number of steps? And what about the 10,000 measurement?
Shelby Traynor: For the people in the highest percentile, so basically the people getting the highest amount of moderate to vigorous activity, the people that we all…
Norman Swan: Aspire to be.
Shelby Traynor: Yeah, aspire to be and hate…
Norman Swan: Or you feel guilty about.
Shelby Traynor: Yes. They were getting about two-and-a-half hours of exercise per week, and their all-cause mortality was 4.8% at follow up. So 4.8% of people in that group died within those nine years. And for people in the highest percentile of step counts, it was 4%.
Norman Swan: So they did a bit better. Was that statistically significant?
Shelby Traynor: I'm not sure, I'm not sure. But their step count was about 7,000 so they didn't even do the 10,000 steps, the people in the highest percentile.
Norman Swan: Yeah, I think 10,000 can be a bit arbitrary, and this is not the first study to say, well, maybe 7,000 is about right there.
Shelby Traynor: Yeah. And it is about the population. These are women over the age of 62 and the median was about 71. But yeah, it speaks to how difficult exercise adherence is. It's a difficulty in everybody's everyday life. It's a difficulty in these studies as well. But one of the hopes would be that if you can put step count as a guideline, people can choose, hey, is it easier for me to meet a step count? Am I more motivated by that? Or am I more motivated to have 150 minutes of exercise each week?
Rikuta Hamaya: Physical activity adherence is low over all the population, and the adherence is currently measured using only time. But our study suggests that step-based goals can be another goal. Older adults are more likely to engage in walking. Having that concrete goal and very visible goals can be a good motivation.
Shelby Traynor: Dr Rikuta Hamaya, who works in preventative medicine at Brigham and Women's Hospital, which is a teaching hospital of Harvard Medical School.
Norman Swan: Well, that's the Health Report for this week. I'm away for three weeks or so, and Tegan will be back, don't worry, and Shelby is going to be the rock of consistency across the show. So, keep on sending your emails in to…
Shelby Traynor: Healthreport@abc.net.au. And we also have another show where we specifically answer your questions, no matter how gross. It's called, What's That Rash?, and this week we're talking about the gluten free diet. Please send us your favourite gluten free bread recipes, and I'll forward them straight to Norman.
Norman Swan: And I'd love to hear whether or not you've got a gluten free tiramisu recipe, which will really complicate things. They will see you next week. I'll see you soon.
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