Thunderstorm asthma, bariatric surgery and years lost to suicide

Norman Swan: Hello, and welcome to this week's Health Report podcast, I'm Norman Swan, and Tegan Taylor will be along later.

Today, the biggest cause of productive years of life lost in Australia, and it's way out in front of heart disease and cancer.

Just as we emerged from the worst of the Covid second wave, could we be in store for a season of thunderstorm asthma events worse than last time?

Research showing bariatric surgery for obesity extends lives, but Australian surgeons are asking why it isn't more available in the public sector.

A couple of years ago on a special Health Report feature called the Glasgow Effect, we talked about the life expectancy gap in the west of Scotland and how it wasn't due to older people losing some years of life, it was because younger people were dying tragically early, and not from heart disease or cancer but of drug use and mental health issues. Well, data released last week by the Australian Bureau of Statistics showed that we are little different. The issue causing the greatest loss of productive years of life last year, pre-Covid, was suicide. Professor Ian Hickie is at the Brain and Mind Centre at the University of Sydney. Welcome back to the Health Report, Ian.

Ian Hickie: Thank you Norman.

Norman Swan: So talk us through this data.

Ian Hickie: This is the table that everyone in Australian health should read. Intentional self-harm led to 115,000 lost years of potential life last year, 115,000 in one year. Ischaemic heart disease, which we always talk about as the biggest killer, led to 78,000, and in fact the press release put out by the Bureau of Statistics last week drew attention to dementia which in fact only accounted to 7,000.

So of course this has got to do with…we live, most of us, long lives now and may dying of heart disease or cancer eventually. In fact life expectancy for many in Australia is now 79 years and for women 85 years. But the average death for suicide is 44. And in fact in the last decade, young people's deaths have increased.

Norman Swan: So talk us through this 115,000 figure, how does it get to that point?

Ian Hickie: Well, you would think for every single person, what would they have lived to? And for Australian men that would be 79, for Australian women that would be 85, and then you look at when people die for any particular cause of death, and the average age for suicide, the median age is 44, and a very high proportion of that now is under the age of 30, particularly in the 18 to 30 age range.

So you work out for each person then how many years could they have lived, if you multiply that by the total number of people that died that way and very tragically more than 3,300 people died by suicide last year, you can see on average if they are up in the 30 to 40 years of life lost, then you get up to this 115,000 figure. And that's really, really different then to the causes of death when you are much older. Although it may be equally tragic and there may be important issues to still be addressed in those areas, very few years of productive life are lost from most of ischaemic heart disease or cancer.

Norman Swan: And the age at suicide is falling.

Ian Hickie: It's falling. So if you track over the last 10 years, sadly I'll say first of all the rate of suicide in Australian pre-Covid for 2019 was still rising, as it has been over some years now, and particularly if you look at the last decade, then the rates of suicide adjusted per 100,000 have been rising in younger cohorts over the last decade, and that matches other national survey and international survey data about increased rates of anxiety and depression in young people. So something is going on in young people that has been going on for a decade, and pre-Covid was already leading to increased deaths as well as increased lives interfered with by anxiety, depression and substance misuse.

Norman Swan: But what you're saying is we don't know exactly why.

Ian Hickie: No. Everyone contends why, so social media get blamed, all sorts of social change, whatever is going on socially, and it's not clear why. What we do know is that it's changing and in the wrong direction, and that was pre-Covid. The modelling I'm associated with, which accurately predicted these actual outcomes this year suggests that in the Covid environment with changes in education, changes in employment, changes in social dislocation, it may well get worse. So it's a real wake-up call. What are we doing now at a public health level and what do we do at a health services level to try and reduce this degree of impact?

Norman Swan: So what does this mean for our priorities?

Ian Hickie: Well, it would be really interesting to go out in the wider world and just simply ask people; do you realise what is the most common cause of productive life lost, economically, socially? And I think people will often go back to cancer and things they are afraid off and, no, actually mental health, suicide, drug and alcohol addiction, they are the really big issues. So I think our health priorities, our health research priorities and public health priorities and our health service priorities, people will be really surprised because mental health accounts for about 7% only of total health spending in Australia. And that's pretty true internationally as well. So, mental health and suicide prevention have never been the really big priorities they should be if you care about premature life lost, if you care about the social and economic productivity that comes from losing lives early.

Norman Swan: And you've spoken about the modelling before, the government is still not using that modelling?

Ian Hickie: No. So the modelling is not only predicting what is the future, it's choosing what will be most likely to change this. It's all very well to track these figures and produce them on a Friday afternoon, this came out last Friday afternoon, the real question is what would make a difference? And our modelling goes to immediately in suicide prevention there are two things in the Covid environment, economic and educational support, particularly for young people, but also following people up after attempted suicide. That has the biggest impact immediately and would save lives this year and next year. So we have in Australia reacted really quickly, and this was demonstrated today in Victoria, effectively to the physical health threat of the virus. I'd suggest that 2021, 2022 is all going to be about the mental health effects of this economic and social change.

Norman Swan: So, suicide in young people is a priority of the Prime Minister. What was in the budget that goes to an evidence-based approach to this?

Ian Hickie: Very little. So nothing specific. The Prime Minister has received another report from the National Mental Health Commission and his suicide prevention advisor, Christine Morgan, is the Productivity Commission report which has been sitting with the Treasurer since 30 June. The government has said and has said in fact in the Senate again today, it has that particular report and it will be released in due course.

Well, I'd suggest there is some urgency about that due course, things were not good pre-Covid, it was already actually getting worse, and now Covid has a whole additional challenge that we need to face, and much of that is being played out in young people. 45% of the job losses in young people, it has affected women, it's affected regional and rural Australia, so we would really hope that the government does actually take effective actions and, to take your point, they are evidence-based actions that would be likely to change these numbers.

Norman Swan: Just briefly, last week on the Health Report we talked about evidence about brief interventions in the emergency department that could help in terms of connecting people, following them through and providing support. Do they work?

Ian Hickie: Yes. I'm so glad you emphasised that last week, they do work. What happens in emergency departments and follow-ups and one of the big recommendations we've made in a collection of mental health stakeholders to the government is that should be in the order of about $800 million nationally. It works. In the emergency department, proper protocols, just like for heart disease, just like for other problems in the emergency departments, and the effective follow-up. So those brief interventions—focus on emergency departments, proper follow-through – save lives.

Norman Swan: Ian, thanks for joining us.

Ian Hickie: Thank you so much, Norman.

Norman Swan: Professor Ian Hickie is co-director of health and policy at the Brain and Mind Centre at the University of Sydney. And if anything we've discussed upsets you or you think you need support, you always can call the Lifeline on 13 11 14.

You're with RN's Health Report, I'm Norman Swann. Our email address for your questions and comments is healthreport@abc.net.au.

It's an oft-cited statistic that one in three Australians are obese, putting them at higher risk of conditions like diabetes, heart disease and indeed cancer. But significant weight loss that is actually durable is elusive. The treatment that most reliably yields large lasting weight loss is bariatric surgery, where the body's ability to take in or absorb food is dramatically reduced.

A new paper from a large long-term study is shedding more light on how long people live after having bariatric surgery compared to those who don't, speaking of life expectancy. Tegan Taylor has been taking a look. Hi Tegan.

Tegan Taylor: Hi Norman.

Norman Swan: So tell us, what did they do in this study?

Tegan Taylor: This is a big study that has been going for a really long time, so the earliest people in the study were recruited back in the 1980s, and basically they've been following these people since their surgery, so they've had 2,000 people who had weight loss surgery, and they matched them with people with similar conditions, similar levels of obesity and disease, and they followed them over these past few decades…

Norman Swan: As only the Scandinavians can do.

Tegan Taylor: We love talking about Scandinavian studies on this show, don't we. And they also compared them to a large reference group that was meant to represent the general population, and found that the people who had the surgery lived an average of three years longer than the matched controls, the obese people who didn't have the surgery. But both of those groups didn't live as long as the general population did.

Norman Swan: So having been obese for a significant period of your life is a problem in terms of the years of life that you're going to lose, but bariatric surgery does help.

Tegan Taylor: That's right, you are able to regain some of those years.

Norman Swan: Did they control for weight loss? In other words, people who didn't receive bariatric surgery might have been on diets and exercise and might have lost weight. Did they control for weight loss?

Tegan Taylor: Well, actually that reference group was given conventional obesity treatments. So, yes, they were at least trying to lose weight, but they found that over the course of the study those people's BMIs have remained about the same, whereas the people who had the surgeries, their BMIs dropped and then kind of regained, but at about the eight-year market they found a sort of equilibrium that was significantly lower than their starting weight which, as you said at the start just now, is the real challenge with weight loss. It's not that hard to get people to lose weight, it's very, very difficult for them to remain at that lower weight.

Norman Swan: And it's interesting what they didn't die of, or what they reduced the risk of, which was around about 30%; it was both heart disease and cancer.

Tegan Taylor: That's right, and that doesn't really come as a huge surprise because we know that those are conditions that increase your likelihood of getting them by having obesity. But it's interesting that, like you said before, these people have lived a lifetime in bigger bodies before they had the surgery and it was still able to make a difference at that adult surgery stage.

Norman Swan: And how safe was the surgery and how often did people need to have repeat surgery? Because in these registries that the Swedes have, they can measure that sort of thing.

Tegan Taylor: Yes, so the surgeries that they did in the study, they were doing them 20, 30 years ago, they are much different to the bariatric surgeries that we do today, so they weren't laparoscopic surgeries then, and they did a lot more gastric banding, which isn't done as often now. These days we are much more likely to see people have the sleeve gastrectomy where they take out about 80% of the stomach, or the gastric bypass which has been done for a really long time as well.

Norman Swan: And even then, the rates were pretty good, even though they are old techniques.

Tegan Taylor: I've lost that chart, Norman, you'll have to remind me.

Norman Swan: I've got in front of me, it's only 0.2% in terms of the three-month mortality rate, which is small by major surgery standards, and only 3% required repeat surgery, so it's pretty good results.

Tegan Taylor: That's right, and the experts that I was talking to here in Australia are saying that the surgeries that we do today are even safer and have better outcomes than what they were doing back then. So there is no doubt it's a major surgery that people aren't going to enter into lightly, but it's actually got quite a good safety profile.

Norman Swan: And what are the implications for Australia, do you think?

Tegan Taylor: Well, there's a few things to take from this. One is that just to reframe the risk factor, so obviously if someone is considering the surgery for themselves it's really important for them to be able to make an informed decision, but that this is showing that it can be quite safe, it can lengthen your life, and it is not for everyone but it is a really good tool that provides long-term weight loss, and it adds to quite a large body of evidence, that these surgeries don't just improve health measures and quality of life when you're alive, which there is evidence to show that it does that. It also helps you to live longer.

One of the issues in Australia that the experts that I spoke to mentioned is that one of the biggest problems is that weight and the health implications of it carry a real stigma, that it's sort of seen to be by the person themselves and then often even by their caregivers and the people around them, that if they could just pull themselves up by their own bootstraps, they could get a handle on this, or if they just had better self-control they could get a handle on this. But for many, many people it's genetic, they haven't chosen it for themselves, and that these tools should be considered as treating this as a disease, just the same way that we would treat any other disease like cancer.

Norman Swan: Well, we're going to come to that in the next story. Tegan, thanks for joining us.

Tegan Taylor: Thanks for having me.

Norman Swan: Tegan Taylor is a health reporter with the ABC science unit and my co-host on Coronacast.

So, talking about access here, 90% of bariatric surgery in Australia is performed in the private sector, which is a problem since obesity is more likely to affect people who lack economic resources. Last year only 22 public hospitals performed bariatric surgery, and only 10 of those had numbers that would give the hospitals enough experience to keep safety and quality high. And while there are lots of things that can be done for people struggling with the complications of obesity, such as diabetes, heart disease and cancer, surgery, as you've just heard, is effective. A group of surgeons in the Australian and New Zealand Metabolic and Obesity Surgery Society have developed a framework to allow the more widespread introduction of bariatric surgery into the public system. Ahmed Aly is head of upper GI surgery, gastrointestinal surgery at the Austin Hospital in Melbourne, and led this project for the Society. Welcome to the Health Report, Ahmed.

Ahmed Aly: Thank you Norman, lovely to be here.

Norman Swan: Now, given that there is a lot (and we've covered this before) that public hospitals do that wastes money, what's called low-value care, why were they holding out on this effective treatment? Are they just afraid that it opens the floodgates?

Ahmed Aly: Norman, that's a really good question, and yes, the floodgate concern is part of it. But I think when we first started exploring this area, we realised there was in fact a number of barriers in accessing care in the public system for bariatric surgery. Clearly there is a paucity of services. But one of the really important barriers that came up was that in fact policymakers at state government levels and even at federal government levels understand the benefits of bariatric surgery, and there is actually goodwill in that regard.

What was difficult was the 'how to'. Yes, the floodgate concern was part of it, how do we deliver bariatric surgery to patients that need it most or are most likely to benefit, how can we be sure of that and how do we do that in a sustainable way? There was clear uncertainty and confusion about that, and I think that creates some of the hesitancy in implementation.

Norman Swan: Well, let's go through what you came up with, because you did talk to health service managers in developing this framework. Who should get it in the public sector?

Ahmed Aly: Well, firstly the taskforce was made of a very wide group of people. We had a consensus nationally with national representation, we had representation from a number of obesity clinical stakeholder organisations. And, as you quite rightly mentioned, also from governance levels and health administration. It is very heavily evidence-based. But when it comes to the area of being certain about how to deliver it to those most likely to benefit, as you can imagine you can get into a wide range of debate.

What we settled on was using the Edmonton staging system for obesity. This is a relatively new idea. The traditional indications for surgery are established from back in the '90s and haven't really be re-examined for a long time. What's unique about the Edmonton score is that it focuses on mortality as an outcome. What is the risk of mortality at any particular stage of obesity and disease? Mortality is a very hard endpoint and we can of course value things in many other ways, but this is something that has been validated, it's a clear endpoint, we can demonstrate saving of lives. And so it was incorporated into our selection process or the advice that we gave on selection for patients.

Norman Swan: So we don't have time to go through all that and we'll have a link to your framework on the Health Report's website. There are reasons why people shouldn't have surgery, aren't there.

Ahmed Aly: Of course, surgery doesn't suit everybody and surgery isn't for everybody. In fact, if you look at the potential eligible population, that is the group of patients suffering obesity who potentially could benefit from surgery, it's around 1.4 million people in Australia. Clearly we are not going to deliver surgery to 1.4 million people. And even with relatively good access, it's unlikely that more than 1% to 2% of patients will ultimately take up surgery. So you need to be prepared for surgery, it needs to be something that you feel is right for you, and there's a whole process for that.

Norman Swan: In terms of the hospitals, do they need…it's not like you've got bowel cancer, you go in, the colorectal surgeon removes the bowel cancer and then you go onto the oncology team. Preoperative assessment, following people through to make sure they don't start homogenising their French fries and things like that, there's more of an extended care and a team-based care around bariatric surgery, is there not, and that's presumably is something that public hospitals would have to build.

Ahmed Aly: Absolutely, and so this is something that is directly addressed within the framework, so we describe models of care, we emphasise the multidisciplinary nature of bariatric surgery and all of that, and importantly preoperative assessment. A very large component of the framework focuses on exactly what you've just mentioned, and that is engagement from the patient in the entire process, not just the surgery itself but in the entire process of lifestyle management, engagement with the clinicians and ongoing care. This is critical for the outcome of bariatric surgery, and again, when you're thinking about how do we deliver it to those most likely to benefit, education and engagement is a critical part of that process.

Norman Swan: Does that actually happen in the private sector though, and how much of it is just the individual surgeon delivering it and then walking away from it? I mean, I know that gastric banding has lost a lot of popularity amongst bariatric surgeons because it does require such intensive follow-up care, and the band can come off and have problems and you move much more to the gastric sleeve operation. To what extent even does this happen in the private sector?

Ahmed Aly: Look, certainly the position of Edmonton and the professional societies to absolutely emphasise the importance of multidisciplinary care and establish it as a standard of care, but this in many ways, Norman, is one of the reasons that it's vitally important that we increase bariatric surgery within our public system. This is the place where we train our surgeons, this is the place that we can monitor and develop standards, this is the area in which we can set these as absolutes and encourage further uptake of such an approach.

Norman Swan: So young registrars training would see how it should be done.

Ahmed Aly: Absolutely. And having said that though, I would say that many, many surgeons, certainly I would believe the majority of surgeons do hold this as a philosophy. We can't enforce it absolutely, but we can educate it and we can promote it, and having it in public will help enhance that.

Norman Swan: Which state is best at it at the moment in terms of providing it?

Ahmed Aly: In terms of public bariatric surgery? Victoria is the best served currently but it is still lacking in absolute service numbers in terms of who could benefit and what the demand potentially is. Unfortunately there are some states around the country that don't have any structured elective bariatric surgery programs, and that's a situation we really need to change.

Norman Swan: Let's hope the framework makes a difference. Ahmed, thanks for joining us.

Ahmed Aly: Thanks very much, Norman.

Norman Swan: Ahmed Aly is head of upper gastrointestinal surgery at the Austin Hospital in Melbourne.

The peak of the hayfever season is nearly upon us, which brings with it the risk of a thunderstorm asthma event. It's been four years since the 2016 Melbourne thunderstorm asthma event which resulted in over 3,500 emergency presentations, 35 ICU admissions and 10 deaths. We look back at this event and what we've learned and what a 2020 thunderstorm asthma event might be like in the context of COVID-19, in this report by the ABC Science's Suzannah Lyons.

Michelle Griffiths: I do remember being quite hayfevery and agitated in my sinuses, and at that time we had big glass doors that would open out to a balcony just near our lounge room, and having those doors open to air the house after the warm day.

Suzannah Lyons: Michelle Griffiths describing her experiences during the 2016 thunderstorm asthma event in Melbourne.

Michelle Griffiths: And I just remember just getting very tight in my chest and wheezing. And I've had a little bit of wheezing from asthma before, just from exercise, however it was different, it was just like, oh, this isn't right. And I knew at that point that I needed to shut the doors because we have all of the air blowing through the house, which is the worst thing you can do. And I did have my asthma pump, luckily I had one there. So I just remembered being a bit scared and obsessed about trying to get my airways clear.

Suzannah Lyons: Michelle had been diagnosed with mild asthma as a child, but she was shocked when she got thunderstorm asthma in 2010, and again in 2016. Melbourne's 2016 thunderstorm asthma event was the most catastrophic ever recorded worldwide.

Jo Douglas: Tragically 10 people lost their lives associated with that event, and there had been one or two reports of deaths associated with thunderstorm asthma previously in the distant past, but never so many on one night.

Suzannah Lyons: Professor Jo Douglas is a physician in allergy and clinical immunology at the University of Melbourne and the Royal Melbourne Hospital.

Jo Douglas: I think one of the big risks about thunderstorm asthma is that for many people it's completely unexpected, and so they may not have awareness of or access to reliever treatment, the blue puffers, the reliever puffers, or an action plan to keep themselves safe. And of course in the 2016 event and perhaps in those similarly earlier, 2010, emergency departments and emergency facilities were somewhat overwhelmed by the volume of asthma sufferers who presented.

Suzannah Lyons: But Professor Douglas says we've learnt a lot from previous thunderstorm asthma events.

Jo Douglas: I think it changed our perception of hayfever as being a benign but troublesome condition, as being related to thunderstorm asthma, which can potentially overwhelm emergency departments. So I think it has caused us to recognise the risk of hayfever and asthma when they are together to try and remember people with asthma are at great risk of thunderstorm asthma and to really encourage both prediction so people can stay out of harm's way, and also preventative treatment to keep people with asthma safe.

Suzannah Lyons: Melbourne is known for the severity and regularity of its thunderstorm asthma events, but they've been reported in other parts of Australia too, including Wagga Wagga and Sydney. So what causes such events to occur?

Jo Douglas: It's usually in Australia due to grass pollens, although in other places it can be due to other pollens and even funguses. They usually occur after a few days of high pollen count, usually about three days. They are usually warm days. They occur with a severe storm, so a change in humidity and a drop in pressure. We know that the bulk of people present within a few hours of the event passing, but the asthma admissions or asthma presentations remain very high for the subsequent day. So there is both an early acute phase and also a later phase of asthma as well, which fits with what we know about the allergic response to grass pollens.

Suzannah Lyons: And are there any long-term effects for people who maybe suffer an asthma attack during these thunderstorm asthma events?

Jo Douglas: So what we know has shown that people who have had thunderstorm asthma symptoms, seem to have very unsettled asthma symptoms in the years subsequent to this, as if this is a trigger for worsening asthma overall. And so it does suggest that there is something very important about this initial exposure that might actually be triggering asthma symptoms or airway hyperresponsiveness in people. Airway hyperresponsiveness is a cardinal feature of asthma, and I often describe it as the airway being twitchy, so super-sensitive, more sensitive than someone who doesn't have asthma to environmental triggers, things like allergens but also things like cold air that will cause the airways to constrict.

Suzannah Lyons: This year we are approaching the height of the hayfever season, with the added burden of the coronavirus pandemic, which troubles Professor Douglas.

Jo Douglas: So I think the spectre of an overwhelming emergency presentation in the setting of the potential Covid academic is particularly concerning because, as you know, emergency department resources are somewhat stretched by Covid, and the necessity of managing people who are potentially infected, and that already is a drain on resources, and every emergency department in Victoria has been reconfigured to manage that risk. Further overwhelming that with people with respiratory difficulties will make it even harder to manage a very big event.

Suzannah Lyons: There are three things Professor Douglas would like people to remember this year. If you have hayfever and asthma, recognise that you could be at risk of thunderstorm asthma. Speak to your doctor, have an asthma plan and reliever medication on hand so you know what to do if you have sudden asthma symptoms. Number two, heed the thunderstorm asthma warnings available in your local area. For example, warnings are available in Victoria on the Melbourne Pollen and Vic Emergency apps. And if a warning is in place, stay indoors at the time the thunderstorm is predicted.

Jo Douglas: And the third one I think we have to say in this time of Covid is that some symptoms of Covid and hayfever overlap, and this year particularly it would be really good to see people managing their hayfever well with antihistamines and also the nose sprays to keep their symptoms under control, so there is no doubt then that if they've got hayfever they are not confusing it with Covid.

Suzannah Lyons: Having reliever medication on hand is advice that Michelle has taken to heart.

Michelle Griffiths: I can't remember the last time that I have had to have some of my asthma pump, so I could go through summer, autumn and winter with no allergies or anything like that, but when it hits spring, I am now very aware of it, and I do go and buy new Ventolin. Just having it around gives me peace of mind for those times just in case. We can't control the weather but you can have your asthma pump around.

Norman Swan: Michelle Griffiths ending that report by ABC Science's Suzannah Lyons. Now listen, don't just rely on your blue puffer, if you've got any asthma symptoms at all during the day or at night and you're coughing, coughing on exercise, talk to your GP about getting onto one of the brown puffers, one of the preventers there to actually treat the asthma itself, because one of the reasons for the thunderstorm asthma event was that people thought they were okay with their asthma but in fact they won't.

And Tegan, that's all that Victoria needs now, is a thunderstorm asthma event, my God.

Tegan Taylor: I know, can you imagine. So yes, making sure that's properly managed now is good protection for the future.

Norman Swan: It is indeed. So, just to remind you, the email address to send in your questions and comments is healthreport@abc.net.au. What questions and comments have we got this week?

Tegan Taylor: Well, Andrea has had a comment about the segment that we did last week on meat-only diets, one of my favourite topics is, I don't know, just different weird diets, and it sounds like Andrea is the same. She's making some points. She said; what's possible in terms of a diet that provides essential nutrients shouldn't be confused with what is an optimal diet for long-term health. And I think that's a really good point to make because it's possible to tick all the boxes but it's not necessarily going to be the thing that gives you the longest possible life, is it.

Norman Swan: It is not indeed, and it's complicated because…and this is what we talked about a few weeks ago, which is that how you cook, how you bring vegetables, herbs and other things together with things like virgin olive oil, do cook up essentially a cocktail of antioxidants and other substances which are about living younger, longer. And a meat diet is probably not going to cut that, it's not going to give you that. And in fact thinking of paleo diets, even when there was truly a Palaeolithic diet, people were eating stuff that they were gathering as well, fresh herbs, fresh vegetables and so on. So the notion that it was purely meat is just wrong. And while you might be able to get away with it for a while, not forever.

Tegan Taylor: Yes, and Andrea makes the additional comment that maybe if people are feeling better when they are following a meat-only diet, it might be because they have experienced the benefits of eliminating things that might have been causing intolerances for them. And to that I would just say, please people, don't take your medical advice from a podcast, go and talk to your doctor, because if you think that maybe you do have intolerances, you need to work with a professional to figure out what they are.

Norman Swan: Yes, and they are less common than you think. So take gluten, for example, true gluten intolerance that you can measure is probably only 3% of the community. There is probably maybe another 15% of people who do not tolerate wheat that well, but it's not 50%, 60%, 70% of the community. And going on a gluten-free diet is not going to change your life that much, but if you think you've got multiple food intolerances, which are really quite rare, you can really affect your diet seriously. So you've just got to be careful about that. One reason that you might feel better on a meat-only diet is you might go a bit keto, and being on a ketogenic diet does after two or three days make you feel quite good but it's not sustainable.

Tegan Taylor: And we've got an interesting letter here from Elna who has had an experience at the dentist. They've gone to see their new dentist about headaches, teeth grinding and clenching. The dentist has done some tests to gather data but also did a strange test that Elna wasn't sure if it was the real deal or not. Tell me if you've ever heard of this, Norman. He got Elna to hold their arm out at their side and press upwards while the dentist pressed downwards, and then Elna had to open their mouth while the dentist placed his hand in front of Elna's mouth, and then the outcome was meant to be that if Elna stopped pressing upwards, then that was some sort of diagnostic win, but Elna didn't. And then the dentist said that the test wasn't working because their energy wasn't flowing right and Elna probably just didn't have a good night's rest. Is this complete hocus-pocus, or is there anything to this test to diagnose jaw clenching?

Norman Swan: I'm not aware of it. Knowing that this question was coming, I researched it, and most people who talk about…so there's two or three things going on here, one is called bruxism, you're grinding and clenching…the first thing I'll say is beware of dentists who've done a weekend course in what's called temporal mandibular joint dysfunction. They go off and do a course and then they offer their patients grinding of their teeth. And, by the way, once you've had your teeth ground there is no going back.

Tegan Taylor: I think my dentist did that to me.

Norman Swan: You've just got to be really careful about this because there are some dentists who have been on a weekend course and think they know what to do. Diagnosing tooth grinding, bruxism, temporomandibular joint dysfunction is really about the history, it's about feeling the facial muscles, it's about examining the jaw properly, that's what it's about, maybe sometimes x-rays to see whether or not there is tooth damage and cracks in the teeth.

Temporomandibular joint dysfunction is controversial and has got to be treated with care by somebody who is really experienced. You've got people offering to do joint replacements in the jaw. Be very careful before you let anybody touch your mouth or your jaw if you've got one of these problems.

You can get mouthguards that are properly fitted, your GP can talk to you and indeed good dentists will talk to you about relaxation, whether or not you are under particular stress at the moment. And some people do just grind their teeth, and there may be a genetic element to that as well, so you've just got to be super careful. And if anybody wants to actually do some surgery on it, including grinding your teeth, you need to talk to them about what their qualifications are for that because this is something that is highly specialised.

Tegan Taylor: But it can cause headaches, can't it, when you got a lot of tightness in your jaw and you are clenching, especially at night.

Norman Swan: Sure, and it can cause cracked teeth, it's a serious issue and it's not a pleasant thing to do. And people with properly fitted mouthguards can get some relief of that, although some people find it really not that easy to hold the guard in their mouth.

Tegan Taylor: A comment here from Keith who I think might be responding to the study that we talked about a few weeks ago about high intensity interval training in older adults, and we made a comment in that story about how these people often lose fitness as they age. And Keith is saying we only start to lose muscle in middle age because we exercise differently and, all things being equal, a healthy man can maintain muscle mass and add enough additional muscle for it to be obvious to other people, even into their early 70s. And Keith ends with the statement, 'The sarcopenia (so, muscle loss) story is one of surrender, despair, excuses and self-disempowerment,' which I don't think really stacks up with the evidence.

Norman Swan: No, I think sarcopenia is a phenomenon of ageing but it's not an inevitable part of ageing, and it is a way towards frailty, but you can do something about it, so where Keith is absolutely right is that if you maintain muscle strength and you exercise accordingly, so it's not just aerobic exercise, it's also muscle strengthening, you will minimise sarcopenia, in fact you can abolish it altogether and you can maintain the sort of muscles that somebody else might have 20 years earlier, so all that is possible. It is not an inevitable part of ageing.

But to take it broadly and kind of blame individuals for it themselves I think is going a bit far, Keith. It's better framed that this is something that you can do something about and prevent, and it's certainly true, and as one of the people that you quoted I think in that study, Maria Fiatarone Singh of the University of Sydney, she showed that you can actually help this phenomenon even into people's 90s when they are already frail. So it's not just into the 70s, it's beyond that. It's never hopeless.

Tegan Taylor: That's right, but Keith's comment did make me have a bit of a look for myself and I was really interested to see what changes are happening in people's bodies as they age that does contribute to sarcopenia, and there's differences in your metabolism, there's differences in your oxygen supply to your muscles, there's differences in the types of fibres in your muscles and they move towards being those slower moving fibres, all of which can contribute to this loss of strength. But, like you say, the answer is sufficient protein and weight training exercise to keep those muscles strong.

Norman Swan: That's right, and arthritis is another reason why people go off their exercise, but it's shown that if you keep jogging on hard surfaces and have high impact, you can even prevent or minimise the effects of arthritis, so lots of things that you can do.

Tegan Taylor: And one final question from Todd; do you feel like there is any value in gene sites like 23andMe for disease risk assessment?

Norman Swan: Oh, very crudely probably. 23andMe and other sites have had a problem a couple of years ago, I can't remember exactly when, COVID-19 every month is a year, so I'm not really sure, but it's a couple of years ago, they were held up by the regulators because they were giving too much disease risk assessment. They can probably tell you whether you've got ApoE4 which might increase your risk of dementia unless you keep your cardiac risk factors there. There are some elements that can do that. You can maybe pick up breast cancer genes but I'm not sure that they do that. I'm not totally aware how they've changed over the time but it's not a great way to assess it.

The best thing to know here about disease risk is to know what happens in your family, and to know what people died of in your family. And if there is a pattern in your family of early death, and these days early death could be under 65, in the old days they used to say under 50, but if there is a pattern of coronary heart disease in your family and people die young, you need to get checked up as young as possible if you know that pattern exists, and you and your GP can decide whether or not you need genetic counselling.

But if you know that that pattern exists, then there are cardiologists who are experts in this sort of area who can look for particular lipid tests and so on that you might have particularly high that don't form the normal set of lipid blood fat tests that your GP might do.

And if there is cancer in your family at an earlier age—so uterine cancer, ovarian cancer, prostate cancer and other things—then that is the sort of situation where you might want to discuss with your GP getting referred to a cancer genetic service. And then they would do a much more rational assessment, and often it doesn't involve a blood test because if there is a breast cancer, for example, running in your family and there's two or three people with it, what are you going to do if you don't come up positive for BRCA1 or BRCA2, the two commonest breast cancer genes, because often that risk is maybe several genes working together.

So what you need to do as a woman at risk of breast cancer because it runs in your family is actually early checking of your breasts. There are ways of actually…protocols there, maybe MRI scans, ultrasound, that sort of thing, and maybe even if it's very high and you are still negative, still thinking through with the genetic counsellors whether or not you think of a prophylactic mastectomy after you've had your children. Those are the sorts of things. And the tests themselves help a bit but they are not the complete story. Again, it's common sense. If it's running in your family, it's running in your family. The genetic tests may help, but just because they are negative doesn't mean you are not carrying a genetic risk.

Tegan Taylor: Well, thank you all for your questions and comments and we welcome more and more. Please email us at healthreport@abc.net.au.

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

Tegan Taylor: See you then.