Program: Is botox worth a shot?

Norman Swan: It's August the 14th, 1922 it's the Loch Maree Hotel in the north west of Scotland. There are 13 fishermen, two wives, some climbers and 17 gillies, and they're setting off for their day. Two in particular set off on a boat with their gillie, Major Fearnley Anderson and his wife Rosamund. Major Anderson was on leave from India, and they were off in a boat to fish. Around about 12:45 this little fishing group stopped for lunch. Lunch was a packed lunch from the hotel. And in fact all of the people going off for that day had a packed lunch from the hotel. Major Anderson had the beef, Mrs Anderson had the potted meat sandwiches. After their day in the water, they went back to the hotel, but two days later, Mrs Anderson was dead, and so were some of the others, and over the next week a total of seven of them were to die. A professor of medicine who was holidaying nearby was called in. Some suspected mass murder.

Tegan Taylor: Okay, a weird way to start the show. Spooky. What happened in the end of the story?

Norman Swan: I'll tell you at the end. But this is a mystery.

Tegan Taylor: I love it. Okay, well, I think for the keen-eared among our listeners, they might get a hint of where we're going with this. So this question comes from Dani, who says, 'I'm getting on a little in age, and although I'm okay with some of the signs of ageing…' and she feels privileged to have made it this far in life, Dani is not keen on how her frown lines have set in, they make her appear angry, and the muscles around her face have started to pull down, making her appear sad. So Dani's question is, how safe is Botox? Is there any truth to it being preventative? I.e. if you start it earlier, it prevents those wrinkles from being so deep. So yes, we're talking about cosmetic surgery, but we're also talking about a toxin.

Norman Swan: Yeah, one of the strongest toxins that we know. 

Tegan Taylor: So I want to start with some biology and history, because I always do. And with this topic especially there's so much to talk about. And I suppose where we should start is, what is Botox? And it comes from a bacterium, Clostridium botulinum, which is related to some other pretty bad guys. 

Norman Swan: Yeah, it's same family as Clostridium tetani, which produces tetanus. And the feature of both these bugs is that the bugs produce a toxin. So it's not so much the bug that kills you, it's the toxin that comes from the bug,

Tegan Taylor: And so the toxin in both cases causes paralysis, and in Clostridium botulinum…

Norman Swan: Well, just to be clear, in tetanus it still acts on the muscles, but it causes muscle tension, muscle spasm.

Tegan Taylor: Whereas botulinum causes something that is delightfully called flaccid paralysis. 

Norman Swan: Yeah, it sounds wonderful, doesn't it?

Tegan Taylor: So how does it actually work in the body? 

Norman Swan: So essentially it blocks the normal contraction of muscles, the neurological mechanism that makes muscles work.

Tegan Taylor: And so what it does is it stops the muscle from being able to contract. The reason why people use it is because it relaxes muscles. But before we started using it as a therapeutic, obviously it was really toxic. It's actually something that humans are bystanders for in an ecological sense, it's something that tends more to affect waterfowl, and the cycle behind that is really interesting, with the maggots that feed on the body, and then the fowl feed on the maggots and then accidentally ingest this toxin, which then paralyses them, which provides more food for more maggots, hooray if you're a maggot or a bacterium. But then when it does pop up in a human context, it can be really deadly.

Norman Swan: So how do we get from waterfowl to humans, Tegan? 

Tegan Taylor: It has to do with the way that this bacterium reproduces. So it's an anaerobic bacteria, it likes to reproduce in places where there isn't much oxygen…

Norman Swan: Which is just like tetanus. It lives in the soil, and when you get a deep wound, it lives in that deep wound and can multiply, causing tetanus.

Tegan Taylor: Right. And so another place where sometimes there isn't much oxygen is in foods that we have tried to preserve, but maybe have not preserved properly. And so one of the first places where botulinum toxin or botulism poisoning was first recognised as a thing was in Europe in around the 1800s and people would often enough get it from sausages. So you tried to cure a meat so you can eat through the winter or whatever, and if you haven't done it perfectly, then you can have this bacterium creating this toxin. And it was actually called 'sausage poisoning'. And the reason it's called botulism, it actually comes from the Latin word botulus, which means sausage. It was literally called sausage poisoning. 

Norman Swan: And the doctor who made the link gave it to himself to test it.

Tegan Taylor: He gave it to himself. He also gave it to a lot of different animals. And I think the professor who was supervising his work was like, 'Dude, you need to stop doing that. You'll kill yourself.' But not only did he test it on himself and test it on animals, he figured out what he was pretty sure the mechanism of action was, which was that something was interrupting the muscles ability to work, incredible, this is in 1820. But he also hypothesised that it could be used therapeutically, like 150 years before we actually did.

Norman Swan: And before they knew there were such things as germs, as bacteria.

Tegan Taylor: And when they realised how toxic it was…the dose that's required to have a fatal effect is minuscule. I'm pretty sure that if you wanted to wipe out the entirety of the human population, you would only need about 40 grams of botulinum toxin. 

Norman Swan: Okay, let's not get any ideas. But in fact, it was developed as a biological weapon at one point.

Tegan Taylor: Right, because it is incredibly toxic, and small doses can be quite powerful. But then actually making that into a weapon proved to be pretty difficult. But yeah, around the time of World War Two, the toxin was isolated, it was purified. And so, as with so many things, it was actually the military refining this substance, it didn't work as a weapon, and that was the groundwork that was needed that eventually led to it being a therapeutic. 

Norman Swan: And in fact, one of its first uses was in children with cerebral palsy, where they were limited in their ability to get around because of spasticity. In other words, their muscles were over-contracting, and injecting botulinum toxin into their muscles relaxed them and gave them more mobility. It's also used in ophthalmology, in the eye muscles when you've got a squint or double vision. So it has had and continues to have several medical indications.

Tegan Taylor: I don't know if this is true or not, Norman, but I heard a rumour that one of the reasons they figured out that it could be used as a wrinkle relaxant was because they were doing experiments on squinting in apes, and found that the apes that they put the Botox in, in their foreheads to stop their squint, it also made them have less wrinkles, and then they were like, a-ha, we could sell this to people who are worried about ageing.

Norman Swan: It makes a great story and let's not spoil a great story. But then it was launched, maybe 9 million procedures worldwide using Botox, increasing at an amazing rate. So it's a very common cosmetic procedure today.

Tegan Taylor: I am actually surprised at how recently it was approved for cosmetic use, because, like you said, it has been used therapeutically for some decades now. I think that early treatment was pioneered in around the early 1970s but it was actually only in the early 2000s that it was approved for cosmetic use. And so when we're talking about preventative Botox, it hasn't been around for long enough for us to know what happens when people have it for many decades in a row.

Norman Swan: Although there is growing evidence here, as you're about to hear. So let's start with the actual cosmetic treatment. So it does work on wrinkles, not every wrinkle, but it does work by relaxing the muscles around the wrinkle. What's increasingly recognised is that there are side effects, but they're rare in careful hands. You do not want to go to somebody who's setting up a cheap clinic for Botox and really doesn't know what they're doing. People who have this on a regular basis talk about getting very small doses of Botox so you can come back for more. There is a recognised complication rate of what's called ptosis, which can occur when you have Botox in the forehead and the upper eyelid droops over your eye. 

Tegan Taylor: It's like the opposite of what you want. 

Norman Swan: That's right. Now, most of the time that's a temporary side effect, but sometimes it's not. You can get numbness, you can get bruising, you can get headache, you can get allergic reactions to the Botox, you can get infection under the skin. But the evidence suggests that in good hands, people who know what they're doing and do it a lot, the risk of complications is low. 

Interestingly, the risk of complications is highest when you're using it therapeutically, say, in kids with cerebral palsy, and that's thought to be because you're using a larger dose, because the botulinum toxin (and there are various versions of the botulinum toxin) can spread. It's in such a low dose that botulism itself, which is the serious and life-threatening illness associated with Botox, it is a very, very rare complication of Botox injections, but it can happen if too large a dose is given.

Tegan Taylor: So, it blocks this nerve transmission. How long do you get from a dose of Botox?

Norman Swan: A few weeks or months, depending on the person and depending on the dose that you get. Now, some people get a bit hooked on the idea that they like the look of their face when they've had Botox. The problem is, if you have it too widely on the face, your muscles are not contracting, and therefore you have problems with facial movement. And this can become a much more serious problem if you have repeated Botox injections. So Botox works by blocking the nerve telling the muscle to contract. Let's say you cut the nerve to a muscle. That muscle wastes away because it's lost its stimulus from the nervous system to contract. And when it loses that stimulus, it wastes away, it atrophies, so it needs that nerve impulse to maintain its bulk and its strength. 

Tegan Taylor: You need your facial muscles to stay swole and juicy.

Norman Swan: And there is evidence that having Botox too often can cause muscle atrophy, which can change the shape of your face, which is why intelligent consumers of Botox say tiny doses and be careful how often you have it. 

Tegan Taylor: So I guess that comes to this idea of preventative Botox, or starting early to prevent wrinkles from forming, that you're going to end up having more treatments over the course of your life.

Norman Swan: Well, as we've spoken about before on What's That Rash?, there's a trend of younger and younger women in particular asking for anti-ageing products, and so it is with Botox. You find younger and younger people coming forward for Botox, either because they think they've got a wrinkle or they want to prevent it, and the evidence is you're potentially just going to make things worse because you're blocking the nerve supply to the muscles. The muscles will potentially waste away a little bit, that will come back, but you're not doing yourself any good, you are potentially doing yourself a fair bit of harm for the future by reducing your facial musculature.

Tegan Taylor: So, for Dani, who describes herself as getting on a little in age, what's the takeaway? Should she give it a go?

Norman Swan: So, as you say often, Tegan; don't get your medical advice from a podcast. But my view is I don't take a judgmental view of cosmetic procedures. So if you want to try Botox and you've got some wrinkles, just talk to friends and family, who's gone to whom. You want to go to someone who's reliable, who's done a lot and is thoughtful about the process and doesn't go nuts on you, and is not running a cut price enterprise. So try it out and see. 

But if you find your skin sagging and you don't like it, and you've got maybe loose skin under the neck, and you can afford it, there are plastics procedures from a plastic surgeon, not a cosmetic surgeon but a plastic surgeon who's properly trained in surgery and doing this stuff, because it's not easy surgery, to do a lift and tighten the skin, not over-done. The idea here is you go to somebody who promises to do it so that nobody will recognise you've had it done. The key here is you go to work the next day or not the next day but a week or so later, and people say, oh, you must have been on holiday, you're looking really well.

Tegan Taylor: That's what they say to you after you have procedures, isn't it?

Norman Swan: That's right, which I have once a year associated with my holiday. You think I'm going away for my holidays? No, I'm going for my lift.

Tegan Taylor: I'm on to you, Dr Swan.

Norman Swan: But seriously, it's the same principle as Botox, you don't go too much, you don't go too far.

Tegan Taylor: Or you could just embrace your wrinkles. I mean, for sure, people want to get this done, go for your life. But also, bodies age, it's normal, don't sweat it too much. 

Norman Swan: Yeah, I just wonder the extent to which Major Anderson's wife Rosamund embraced her wrinkles.

Tegan Taylor: Norman, that is macabre, but also, yes, I was going to ask you, you've got to finish the story. It was like a true crime podcast, I was very much feeling it. What happened to Major Anderson's wife and the other people who died?

Norman Swan: Well, there was a major investigation. It got headlines around the country, and nobody was too sure what it was, but they studied the packed lunches.

Tegan Taylor: Obviously, it was botulism, right? Like, that's why we're telling the story. 

Norman Swan: It was botulism. And the reason Major Anderson didn't get it and his wife did is that he had the beef sandwiches and she had the potted meat, and the potted meat was duck.

Tegan Taylor: Waterfowl!

Norman Swan: That's right. And so it was the duck pate or duck paste that caused it, and there was clearly some breach in the tin of potted meat, Clostridium botulinum got in and grew, and there was a lot of toxin in the duck paste. And this reportedly was the first outbreak of botulism in the United Kingdom.

Tegan Taylor: So that was in 1920, did you say?

Norman Swan: 1922.

Tegan Taylor: Do you remember it?

Norman Swan: I remember, I remember it well.

Tegan Taylor: You were the doctor that did the investigation. 

Norman Swan: I used to go climbing a lot, particularly in the highlands, and whenever we drove past Loch Maree we said, we're not going into the Loch Maree Hotel for a drink.

Tegan Taylor: That poor place has been tainted by this story ever since.

Norman Swan: That's right, and a lot of Scots were off duck pate. So, What's That Rash? becomes true crime. 

Tegan Taylor: I'm loving it. I reckon we should do this every week. 

Norman Swan: Okay, I'll work on it. 

Tegan Taylor: Well, if you have a question that you think Norman could find a story to tell around it, email us, we are thatrash@abc.net.au. Or if you want to give us some feedback on something we've already talked about, we welcome it. Dr Yianna Zhang from the University of Melbourne has actually emailed, Norman, in response to our chat that we had a couple of weeks ago about vinegar and the health benefits of vinegar. Dr Zhang is a food scientist who specialises in bioavailability, as in how your body can actually take up things that are in the foods that we eat. And they wanted to add that in addition to the direct mechanisms on our body that you mentioned of how vinegar might be working, another reason why vinegar is likely to control glucose is due to its effects on the digestion of complex carbohydrates. So Dr Zhang is saying its effectiveness may be dependent on when and how the vinegar is consumed, as well as the meal that you're having. So there's a couple of moving parts here.

Norman Swan: And Dr Zhang makes a link also between vinegar consumption and feeling full. There may be a process, which is not fully understood, where, if you're changing the digestion of complex carbohydrates, in other words, ones that are difficult to digest, that might trigger the release of hormones like GLP1, which is the hormone behind Ozempic, that also delay gastric emptying. So there is a theoretical loop there back to weight loss.

Tegan Taylor: It is interesting. More research is required, but maybe Dr Zhang will do it.

Norman Swan: Indeed. 

Tegan Taylor: And Wayne also emailed about apple cider vinegar, saying that he's been taking it in tablet form for about a year now for osteoarthritis, there was no drug or lotion that seemed to make a difference, but this apple cider vinegar tablet seems to have reduced the swelling and he's having almost no pain anymore, and he remembered his Nan used to take the vinegar in a glass of water every day for a similar condition when he was young. So I don't know what could be happening there, but it's a pretty interesting link.

Norman Swan: Yeah. And as we said on the show, vinegar contains lots of bioactive compounds, some of which reduce inflammation. If it works, why knock it? The only thing you've got to be careful of is taking it in too concentrated a form, because that can erode the lower end of your oesophagus, and it can also rot your teeth. So you've just got to be a little bit careful how you take it. So taking a small amount in a glass of water is reasonable, which is what you did, and you quite enjoyed it. 

Tegan Taylor: Yeah, I did, and I've actually gone back and had it again since.

Norman Swan: You didn't tell me that…

Tegan Taylor: I did…

Norman Swan: You were secretly swigging.

Tegan Taylor: Not swigging, just little sips. 

Norman Swan: So you're becoming a vinaholic.

Tegan Taylor: Yeah, maybe I am. Is that a thing? Maybe we'll make it a thing. 

Norman Swan: We're making lots of things on What's That Rash?. Send in your questions. In the meantime, we'll see you next week.

Tegan Taylor: We'll see you then.