This week’s ABC Four Corners episode Pain Factory highlighted that our health system is failing Australians with chronic pain. Patients are receiving costly, ineffective and risky care instead of effective, low-risk treatments for chronic pain.

The challenge is considering how we might reimagine health-care delivery so the effective and safe treatments for chronic pain are available to millions of Australians who suffer from chronic pain.

One in five Australians aged 45 and over have chronic pain (pain lasting three or more months). This costs an estimated A$139 billion a year, including $12 billion in direct health-care costs.

The most common complaint among people with chronic pain is low back pain. So what treatments do – and don’t – work?

Opioids and invasive procedures

Treatments offered to people with chronic pain include strong pain medicines such as opioids and invasive procedures such as spinal cord stimulators or spinal fusion surgery. Unfortunately, these treatments have little if any benefit and are associated with a risk of significant harm.

Spinal fusion surgery and spinal cord stimulators are also extremely costly procedures, costing tens of thousands of dollars each to the health system as well as incurring costs to the individual.

Addressing the contributors to pain

Recommendations from the latest Australian and World Health Organization clinical guidelines for low back pain focus on alternatives to drug and surgical treatments such as:

• education
• advice
• structured exercise programs
• physical, psychological or multidisciplinary interventions that address the physical or psychological contributors to ongoing pain.

Two recent Australian trials support these recommendations and have found that interventions that address each person’s physical and psychological contributors to pain produce large and sustained improvements in pain and function in people with chronic low back pain.

The interventions have minimal side effects and are cost-effective.

In the RESOLVE trial, the intervention consists of pain education and graded sensory and movement “retraining” aimed to help people understand that it’s safe to move.

In the RESTORE trial, the intervention (cognitive functional therapy) involves assisting the person to understand the range of physical and psychological contributing factors related to their condition. It guides patients to relearn how to move and to build confidence in their back, without over-protecting it.

Why isn’t everyone with chronic pain getting this care?

While these trials provide new hope for people with chronic low back pain, and effective alternatives to spinal surgery and opioids, a barrier for implementation is the out-of-pocket costs. The interventions take up to 12 sessions, lasting up to 26 weeks. One physiotherapy session can cost $90–$150.

In contrast, Medicare provides rebates for just five allied health visits (such as physiotherapists or exercise physiologists) for eligible patients per year, to be used for all chronic conditions.

Private health insurers also limit access to reimbursement for these services by typically only covering a proportion of the cost and providing a cap on annual benefits. So even those with private health insurance would usually have substantial out-of-pocket costs.

Access to trained clinicians is another barrier. This problem is particularly evident in regional and rural Australia, where access to allied health services, pain specialists and multidisciplinary pain clinics is limited.

Higher costs and lack of access are associated with the increased use of available and subsidised treatments, such as pain medicines, even if they are ineffective and harmful. The rate of opioid use, for example, is higher in regional Australia and in areas of socioeconomic disadvantage than metropolitan centres and affluent areas.

So what can we do about it?

We need to reform Australia’s health system, private and public, to improve access to effective treatments for chronic pain, while removing access to ineffective, costly and high-risk treatments.

Better training of the clinical workforce, and using technology such as telehealth and artificial intelligence to train clinicians or deliver treatment may also improve access to effective treatments. A recent Australian trial, for example, found telehealth delivered via video conferencing was as effective as in-person physiotherapy consultations for improving pain and function in people with chronic knee pain.

Advocacy and improving the public’s understanding of effective treatments for chronic pain may also be helpful. Our hope is that coordinated efforts will promote the uptake of effective treatments and improve the care of patients with chronic pain.

Christine Lin, Professor, University of Sydney; Christopher Maher, Professor, Sydney School of Public Health, University of Sydney; Fiona Blyth, Professor, University of Sydney; James Mcauley, Professor of Psychology, UNSW Sydney, and Mark Hancock, Professor of Physiotherapy, Macquarie University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

It’s a well-known fact that to lose weight, you either need to eat less or move more. But how many calories do you really need to cut out of your diet each day to lose weight? It may be less than you think.

To determine how much energy (calories) your body requires, you need to calculate your total daily energy expenditure (TDEE). This is comprised of your basal metabolic rate (BMR) – the energy needed to sustain your body’s metabolic processes at rest – and your physical activity level. Many online calculators can help determine your daily calorie needs.

If you reduce your energy intake (or increase the amount you burn through exercise) by 500-1,000 calories per day, you’ll see a weekly weight loss of around one pound (0.45kg).

But studies show that even small calorie deficits (of 100-200 calories daily) can lead to long-term, sustainable weight-loss success. And although you might not lose as much weight in the short-term by only decreasing calories slightly each day, these gradual reductions are more effective than drastic cuts as they tend to be easier to stick with.

Hormonal changes

When you decrease your calorie intake, the body’s BMR often decreases. This phenomenon is known as adaptive thermogenesis. This adaptation slows down weight loss so the body can conserve energy in response to what it perceives as starvation. This can lead to a weight-loss plateau – even when calorie intake remains reduced.

Caloric restriction can also lead to hormonal changes that influence metabolism and appetite. For instance, thyroid hormones, which regulate metabolism, can decrease – leading to a slower metabolic rate. Additionally, leptin levels drop, reducing satiety, increasing hunger and decreasing metabolic rate.

Ghrelin, known as the “hunger hormone”, also increases when caloric intake is reduced, signalling the brain to stimulate appetite and increase food intake. Higher ghrelin levels make it challenging to maintain a reduced calorie diet, as the body constantly feels hungrier.

Insulin, which helps regulate blood sugar levels and fat storage, can improve in sensitivity when we reduce calorie intake. But sometimes, insulin levels decrease instead, affecting metabolism and leading to a reduction in daily energy expenditure. Cortisol, the stress hormone, can also spike – especially when we’re in a significant caloric deficit. This may break down muscles and lead to fat retention, particularly in the stomach.

Lastly, hormones such as peptide YY and cholecystokinin, which make us feel full when we’ve eaten, can decrease when we lower calorie intake. This may make us feel hungrier.

Fortunately, there are many things we can do to address these metabolic adaptations so we can continue losing weight.

Weight loss strategies

Maintaining muscle mass (either through resistance training or eating plenty of protein) is essential to counteract the physiological adaptations that slow weight loss down. This is because muscle burns more calories at rest compared to fat tissue – which may help mitigate decreased metabolic rate.

Gradual caloric restriction (reducing daily calories by only around 200-300 a day), focusing on nutrient-dense foods (particularly those high in protein and fibre), and eating regular meals can all also help to mitigate these hormonal challenges.

But if you aren’t someone who wants to track calories each day, here are some easy strategies that can help you decrease daily calorie intake without thinking too much about it:

1. Portion control: reducing portion sizes is a straightforward way of reducing calorie intake. Use smaller plates or measure serving sizes to help reduce daily calorie intake.

2. Healthy swaps: substituting high-calorie foods with lower-calorie alternatives can help reduce overall caloric intake without feeling deprived. For example, replacing sugary snacks with fruits or swapping soda with water can make a substantial difference to your calorie intake. Fibre-rich foods can also reduce the calorie density of your meal.

3. Mindful eating: practising mindful eating involves paying attention to hunger and fullness cues, eating slowly, and avoiding distractions during meals. This approach helps prevent overeating and promotes better control over food intake.

4. Have some water: having a drink with your meal can increase satiety and reduce total food intake at a given meal. In addition, replacing sugary beverages with water has been shown to reduce calorie intake from sugars.

4. Intermittent fasting: restricting eating to specific windows can reduce your caloric intake and have positive effects on your metabolism. There are different types of intermittent fasting you can do, but one of the easiest types is restricting your mealtimes to a specific window of time (such as only eating between 12 noon and 8pm). This reduces night-time snacking, so is particularly helpful if you tend to get the snacks out late in the evening.

Long-term behavioural changes are crucial for maintaining weight loss. Successful strategies include regular physical activity, continued mindful eating, and periodically being diligent about your weight and food intake. Having a support system to help you stay on track can also play a big role in helping you maintain weight loss.

Modest weight loss of 5-10% body weight in people who are overweight or obese offers significant health benefits, including improved metabolic health and reduced risk of chronic diseases. But it can be hard to lose weight – especially given all the adaptations our body has to prevent it from happening.

Thankfully, small, sustainable changes that lead to gradual weight loss appear to be more effective in the long run, compared with more drastic lifestyle changes.

Alexandra Cremona, Lecturer, Human Nutrition and Dietetics, University of Limerick

This article is republished from The Conversation under a Creative Commons license. Read the original article.