Program: Can collagen supplements keep your skin supple?

Tegan Taylor: I know that you only make evidence-based decisions about your own health, because that's what you ask the rest of Australia to do. But I want to know…

Norman Swan: Hold on a second, do as I say, not as I do. But anyway, that's just between you and me, nobody's listening to this conversation.

Tegan Taylor: I want to know if you've ever been influenced by either an influencer or just like a health trend.

Norman Swan: Well, you know, not so much influenced but I've spent my life wishing that I had a six-pack abdomen. Is that being influenced? I suppose. And all I've ever been able to achieve is a Pinot Noir abdomen. So, that's been my aspiration. So occasionally I will look at videos which teach me how, just with an armchair, how to get a six-pack. 

Tegan Taylor: You never bought one of those…? 

Norman Swan: No, I never bought one of those. Don't use them in the gym either, no.

Tegan Taylor: You can't see what I'm doing right now, like one of those roller kind of like apparatus…

Norman Swan: Yes, where you're forcing yourself down. I am a great believer in free weights and not having those machines. 

Tegan Taylor: It's very sensible and evidence-based of you, and not very fun for me. I feel like I'm influenced every week.

Norman Swan: Who are you influenced by?

Tegan Taylor: Oh, every week from our show, people write in and they're like, 'Oh, what do you think about apple cider vinegar?' And I go home and I'm like, oh, I'm gonna try it, aren't I. But this week the reason why we're having this conversation is because our producer Shelby Traynor, who helps us with our research, has been influenced by this week's topic. 

Norman Swan: Yes, and this week's topic is: do collagen supplements work?

Tegan Taylor: So we're gonna dig into it on What's That Rash?, the show where we answer the health questions everyone is asking. And when I say 'everyone is asking', Norman, I really mean it this week, because we have had this question from Janine, Claire, Belinda, Natasha and Trish, which makes me feel like…you know that song, 'Mambo No. 5'? A little bit of Monica… They're all asking, are collagen supplements worth taking for your skin and general health? 

Norman Swan: So they must be watching somebody on YouTube or social or…

Tegan Taylor: I do think, like, we should call it out. They're all female names. Like, I think that this stuff is marketed really heavily towards women. I certainly get a lot of it. Do you get much of it? 

Norman Swan: No, because I don't go on social.

Tegan Taylor: But yeah, it's marketed to women. We can talk about the claims more broadly in a sec, but I think one of the big claims around collagen is skin elasticity, looking younger. It's a beauty supplement.

Norman Swan: Yeah, and, like a lot of things, there's science behind this. So the integrity of our skin, how solid our skin looks, how many creases we've got, the age of our skin is partly determined by the collagen underneath…

Tegan Taylor: Because collagen is like a protein that gives our skin structure, is that right?

Norman Swan: It's a much-misunderstood substance.

Tegan Taylor: Okay, well, maybe we need to talk about what it is.

Norman Swan: Yeah, because there's multiple forms of collagen, and they all work in slightly different ways. So we tend to think of collagen…when you think of collagen, most people quite rightly think of connective tissue.

Tegan Taylor: Like literally holding your skin together?

Norman Swan: Well, it's not holding our skin together, it's like the tissues under our skin, but collagen is involved in blood clotting, it provides the structure for blood clots. It actually holds the cells of our body together. So the organs of our bodies are held together by different kinds of collagen. We think of this as an inert substance, that all it does is actually provide fullness for our skin, but it actually integrates between our cells. And there's evidence that it helps cells to communicate and talk to each other. 

Tegan Taylor: How?

Norman Swan: Well, that it's an active tissue and it transmits chemicals and messengers and can interfere with that or not. Some people believe that there are forms of collagen which make certain cancers hard to treat because they're so active they throw out the chemotherapy drugs. So collagen has lots of stuff going on in the body. What our many What's That Rashers are asking about is the collagen that holds the tissues under our skin together, but there's collagen in our muscles, for example. And when our muscles get weakened and damaged and aged, muscle tissue is replaced by collagen, and therefore that's one reason why our muscles get weaker. 

Tegan Taylor: What, because of the collagen in your muscles?

Norman Swan: Yes. So we are worried about the loss of collagen in our skin, but in fact in some situations you can get collagen replacing muscle tissue, so collagen is actually the problem, not the answer. 

Tegan Taylor: For about a minute there you had me really on board with collagen, and now I'm scared of it again. 

Norman Swan: Well, it's not getting scared of it, it's just that it's complicated. And what we're being asked is do collagen supplements help when it comes to your appearance.

Tegan Taylor: So collagen is like a strand structure, isn't it? 

Norman Swan: Yes, in most situations.

Tegan Taylor: And so I guess my question is, if something is like quite a big molecule, how much can you actually access it in that finished format of being collagen? Because wouldn't it get broken down in your body or be too big to sort of be entered into your body and synthesised by it? When we're talking about collagen supplements, are they collagen, or are they like precursors, like when we talked about NAD+ a couple of weeks ago, we talked about precursors, the sort of building blocks that your body uses to make that substance.

Norman Swan: Before I answer that question, I just need to explain what we're talking about here in the skin or under the skin as we age. So two or three things are happening here. One is as you age, the cells that produce collagen, which are called fibroblasts, reduce in number, so you lose these cells, so you've got fewer cells producing collagen as you age. When you expose yourself to the sun, the ultraviolet light damages these fibroblasts and they produce less collagen. So there's damage, and there's aging, and those things work together. And then there's your lifestyle as well. So smoking reduces collagen production and damages collagen production, and there are other things which might enhance it, which is related to nutrition. So to come back to your question about collagen supplements. It's really controversial. Let's look at muscle, for example, before we get to collagen, let's look at muscle. We know when you exercise, particularly resistance exercise, food is a stimulant to muscle growth in addition to the resistance exercise. 

Tegan Taylor: Oh, so you do a workout, you're working your muscles, we think about that a lot when it comes to building muscle, but what you're saying is eating protein is also a signal to the body to build muscle.

Norman Swan: And it gives the body the raw material to build the muscle. So whilst the natural reaction to collagen supplements is to be sceptical about them, why would it be any different for connective tissue, the tissue that holds the body together? Why wouldn't that be stimulated by your diet? Because there are protein building blocks called amino acids which are used to make collagen.

Tegan Taylor: Oh, because it's a protein. It's not an analogy, it's literally a protein. 

Norman Swan: And two of the amino acids are hydroxyproline and proline, but there are others as well. Now, if you look at food types that are biased towards those amino acids, milk actually has a lot of proline and hydroxyproline when you look at the league table of foods that contain this. So if you actually take in these amino acids, could that promote collagen synthesis? And then there's the whole collagen itself.

Tegan Taylor: So as a supplement, you're taking a whole collagen. What is that even doing in the body?

Norman Swan: Yeah, and one form of that is gelatine. Jelly, as we would say in Scotland. Because, you know, there's a lot of collagen in gelatine. 

Tegan Taylor: Oh, I'm seeing the little girl on the swing. She was right when she said it was a health food.

Norman Swan: And the thing about collagen is the body doesn't really break it down in the digestive system. You think, well, acid and enzymes break down the collagen. It doesn't get broken down that much. And consequently we don't absorb that much of it. We maybe absorb maybe 10% of whole collagen.

Tegan Taylor: If you're having jelly, yeah, fine, it is collagen, you can eat it, it tastes good, but you're not actually getting much collagen. 

Norman Swan: You're not getting much whole collagen absorbed, is the evidence. And then the question is, even with what's absorbed, does that stimulate collagen production? There is a little bit of evidence that it might. Then some people said, well, what happens when you take the raw material? So, say the amino acids that produce that. And also vitamin C helps to produce collagen as well. And what happens when you take them? Is there evidence that when you take those precursors, the raw material for collagen, does that actually increase the production of collagen. And there's not strong evidence that it does. There's a little bit of evidence that it does, but not strong evidence that it does. 

Tegan Taylor: So this is supplements, this is supplementing with precursors, and you're saying it's not doing much. So what can you do? 

Norman Swan: Well, when you look at the tissue itself in the laboratory, taken out of the body, and you look at what stimulates collagen production, it's true that if you add the precursors, the raw material for collagen, that does stimulate production, but mechanical stress in the tissue, stretching, pulling, seems to stimulate the fibroblasts to produce collagen. 

Tegan Taylor: So wait, are you telling me I need to…oh, is this why Gua Sha works? Does Gua Sha work? Do you know what I'm talking about?

Norman Swan: Yes, the facial massage thing, yeah…

Tegan Taylor: Yeah, like the jade scrapey thingy.

Norman Swan: Well, can we come back to that? Don't let me forget it. So, the idea here is the mechanical stress can produce collagen. And what they've shown with muscle strengthening is that when you take the precursors for muscle building, which is protein, which would include the sort of precursors for connective tissue, and you take that in association with resistance exercise, muscle strengthening exercises, you also get growth of connective tissue, so collagen grows. 

Tegan Taylor: So should I be doing like muscle strengthening exercises on my face if I want to have less wrinkles?

Norman Swan: Well, if you smile a lot, you get…

Tegan Taylor: More wrinkles.

Norman Swan: Exactly. So I'm not sure about it on the face. But actually in terms of what counts, which is muscle strength, where you want maximal muscle strength and you want strong integrity around the muscles, then physical exercise can improve collagen production under the skin. 

Tegan Taylor: Okay, so what I'm hearing is collagen is important for your body's integrity, and also it is an important part of your skin looking juicy…

Norman Swan: Although there are some parts of your body where too much collagen is not good, such as in your muscles.

Tegan Taylor: And supplements, either in the whole form or precursor form, aren't doing much, but moving is. My question is, if I'm going for a run, is that increasing collagen production in my whole body and my face will look younger as a result of it, or is it only improving it in the muscles that are involved in running?

Norman Swan: Nobody knows the answer to that question. So they've studied resistance exercises itself and then done muscle biopsies. So if you've done weight training, for example, and then done biopsies, connective tissue seems to grow, collagen seems to grow as well as muscle tissue. Whether or not you go for a run, actually making yourself look younger would probably as much depend on whether you're using block-out. 

Tegan Taylor: That's true, and I do, and it definitely makes me look redder and shinier. So Gua Sha, you promised.

Norman Swan: Well, that's passive, isn't it? 

Tegan Taylor: Yeah, but you still like…I don't know, you're kind of manipulating your skin. I don't know what it's meant to be doing. I think it's lymphatic drainage. I wonder if there's any collagen involved in that process. I haven't tried it. 

Norman Swan: No, should we start a trend here? 

Tegan Taylor: Should we start it? We should do an n equals two…actually, no, oh my gosh, we should do half our face each and see which side looks smoother.

Norman Swan: So, which is your best side?

Tegan Taylor: I feel like this side is my best side. 

Norman Swan: Yeah, I think my left side is the best side. So I'll do my right and you do your left.

Tegan Taylor: Okay, and then we'll come in and look like Two Face from Batman. 

Norman Swan: That's right.

Tegan Taylor: Okay, so we've talked supplements. That's not much use. The jury is still out, we still need to do our study on whether facial manipulation does anything. What about real food? What can we do in our diet to help with collagen production? 

Norman Swan: Well, fish, chicken, regular meats will have collagen in them. And so you're getting a reasonable dose there…

Tegan Taylor: But you're saying it's not well absorbed. 

Norman Swan: It's not necessarily well absorbed from there, that's the fibrous material in it, but you will get some from it. There are various forms of gelatine and people taking bone broth, for example, to get their collagen precursors, and there's been a study of that. And bone broth doesn't consistently give you the full spectrum of precursors that you actually are looking for if you're serious about taking collagen precursors. Milk, funnily enough, contains quite a lot of hydroxyproline and proline. 

Tegan Taylor: I'm hearing a lot of animal products here, what if you don't want to have meat, or you don't want to have any…like, what if you're vegan? Are there any options there?

Norman Swan: Well, I think you probably have to take synthetic amino acids, the amino acids themselves, rather than…

Tegan Taylor: It isn't that sea moss stuff collagen? So, I mean, I'm looking at sea moss and people selling it, and they're like, yeah, it's great for you, it helps build collagen, it's rich in amino acids. So, I don't know.

Norman Swan: Well, things could be rich in amino acids, but are they rich in amino acids that are truly the precursors of collagen? And as we say, the two key ones are hydroxyproline and proline. And if you look at the data here, it's dairy where you're getting a lot of it from. So milk is the highest, casein and whey, egg is much lower, beef is much lower in terms of those particular amino acids. So dairy is actually where you get a lot of it from in an easily absorbable form.

Tegan Taylor: Okay. Is this just…I know the answer is yes…is this just another thing for us to be worried about? Like, we've been eating real food basically since we evolved and people's limbs rarely fall off by themselves. Like, how important is focusing on collagen in and of itself, versus just all the things that we already know about, about just eating a healthy diet and moving our bodies?

Norman Swan: It turns out that the sort of things that you would do, you want to keep your muscles as strong as possible for as long as possible in your life, and that is going to build up collagen, at least next to the muscles, but we've got muscles everywhere in our bodies. And to your point earlier, or your question earlier, we don't know whether there's a side effect on our face of strengthening the muscles in our arms and legs. A well-balanced vegetarian diet is likely, particularly through dairy, to give you the precursors that you're looking for from collagen. It might be harder for people who are vegan to do that, but not impossible. 

And then there are the environmental toxins for collagen, which are probably far more important than anything, which is how much sunlight are you allowing on your skin? Are you smoking? Are you living in an area where you've got high levels of fine particulate air pollution, which is just like smoking, and causing inflammation and affecting your collagen production? It's also probably genetics as well. 

Tegan Taylor: So coming back to Janine, Claire, Belinda, Natasha and Trish, what do we say to them about collagen supplements?

Norman Swan: Well, I think you've got to look at what's in the supplements. If they're the precursors, like the amino acids hydroxyproline and proline, and if you've got enough vitamin C on board, but not through supplements, through eating [bell rings] the Mediterranean diet, then there is a possibility that you are increasing collagen production there. But you want to be exercising, you want to be staying out of the sun and doing everything else. If you are smoking a lot and hoping for some supplement to help you out with your collagen, forget it. Stop smoking first. So, it's not a mad idea, there is some substance potentially to it, unlikely to be doing you any harm.

Tegan Taylor: So it's mailbag time, Norman, and we had quite a bit of feedback on our episode on melatonin, which we did quite a few weeks ago now. A GP wrote in saying: 'Norman, cough, cough, I think your privilege is showing and I felt I needed to explain the issue with melatonin and why you can't just get it on a script. Melatonin is available on a script as Circadin in Australia, two milligrams sustained release, and it's $36 for 30 tablets. You can get it compounded in other strengths, but likely you'd be looking at $30 per month. You often need to buy 100 at a time to make the compounding cost effective.' And this person encourages patients to go to a specific company online that has gummies, dissolvable gluten-free melatonin, so that they don't have to take it in tablet form, an extended release, and you can get 60 for $4.16. So what do you say to that?

Norman Swan: Well, with all due respect to our general practitioner colleague, I don't think we can recommend online purchasing of any drug, because the evidence is you don't know what you're getting. The level of counterfeit drugs in the online market is huge, and you can just be getting…you might get no melatonin, or you might get drugs that you might not wish to consume in your body. I mean, I would be going to a regular pharmacy. But online, I wouldn't be doing it. 

Tegan Taylor: So you're doubling down on your privilege. You stand by your…

Norman Swan: I'm standing by my privilege. 

Tegan Taylor: Caitlin's also messaged in saying she asked her GP (I wonder if it's the same one) to prescribe melatonin, and his response was while he'd happily do it, it wasn't covered by PBS, and I'd save a lot of money getting it online for a quarter of the cost. He gave me the name of a website he trusted and has been managing the dosage, just like any other drug. I would love if Caitlin's GP was our GP, but maybe it's actually just more widespread than we thought.

Norman Swan: Who knows? I just think you've just got to be prudent. And how do you know that the online supplier is a reliable supplier and there's melatonin in there? I'm not sure how you'd know that. 

Tegan Taylor: Well, if you would like to challenge Norman's privilege on any of the topics we discuss on What's That Rash?, you can send us an email anytime, we are thatrash@abc.net.au.

Norman Swan: Yeah, just hit me, hit me, hit me. 

Tegan Taylor: It's also where you can send your questions. And speaking of skin care, Norman, and how youthful our skin looks…

Norman Swan: Yes, how collagen-full my skin is.

Tegan Taylor: People can check for themselves this week, because we did a video of this episode.

Norman Swan: We did, and you can see it on the ABC YouTube channel.

Tegan Taylor: I hope people aren't disappointed with what they see. People see you on TV all the time. I think every time I meet someone who knows about the show, they're like, 'You look different to what I expected.' And I'm like, 'You mean less hot, right?' That's on the ABC Science YouTube channel. The link is in the bio, and yes, send us an email and tell us how pretty and young and lovely our skin looks. 

Norman Swan: We'll see you next time.

Tegan Taylor: See you then.