GLP-1 Medications in Practice: A New Zealand View with Dr Lara Courtenay

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Episode Summary
Dr Lara Courtenay is a New Zealand-trained GP and bariatric physician with the Weightless Specialist Team at the MacMurray Centre in Auckland, and she has worked in obesity medicine since 2020. Mikki has talked about GLP-1 medications with plenty of international researchers and doctors, so after hearing Lara speak for the Goodfellow Unit she wanted a New Zealand view from someone working with patients every day. Lara explains why GP knowledge of these medications here is variable, and why, in her clinic, the dietitians and psychologists around the medication matter as much as the prescription itself.
They talk about perimenopausal women who are doing everything right and still cannot shift fat, and Lara's analogy of the medication letting go of the handbrake. They also cover prescribing criteria and the limits of BMI, dose escalation and cost, appetite and food noise, and why some plateaus come from eating too little, where Lara's clinic often lowers the dose and has people eat more. Lara is candid about what she does not know. She says the evidence suggests most people need to stay on something long term, that she cannot predict who will manage without it, and that her view on high-intensity exercise is clinic advice she "could be wrong" about. The conversation finishes with regular eating and breakfast, exercise intensity and HRT.
Key Topics
  • Why knowledge of GLP-1 medications among New Zealand GPs is "variable": some GPs will not discuss them and refer on, while others are highly skilled prescribers
  • How Lara came into obesity medicine through gastric balloons in 2020, and a clinic model where patients could not get the medication without seeing a dietitian
  • Older options such as Saxenda and Contrave, which could work well, and how much of the shift to the weekly drugs is effectiveness versus marketing and online hype
  • Perimenopausal women who exercise, eat well and still cannot lose fat, and Lara's explanation that the medication lets go of the handbrake
  • Prescribing from a person's heaviest documented weight, taking ethnicity into account, and why both Lara and Mikki see BMI and the word "obesity" as flawed
  • Dose escalation in practice: a set schedule to start, then stopping wherever each person needs to stop, with nutritional needs always met, and cost as one of the biggest barriers
  • Whether people can come off these medications: Lara has seen some "unicorns" do it, but she says the evidence points to most people needing something long term and she cannot tell in advance who will manage
  • Appetite and food noise: most people get some appetite restriction, being hungry on the medication is not a failure, and Lara is now seeing patients who escalated without support and under-ate
  • Why people plateau, including strict eaters falling short on fats and nutrients, and why Lara's clinic often lowers the dose and tells people to eat more
  • The clinic dietitians' advice on regular eating and eating before 10am, why high-intensity exercise is not always the best fit during weight loss, and Lara's strong support for HRT
Chapters
00:00 Introduction
02:58 GLP-1 knowledge among New Zealand GPs
05:31 From gastric balloons to obesity medicine
08:24 Older drugs, newer drugs and support
11:43 Perimenopause and releasing the handbrake
13:39 Prescribing criteria, BMI and the scales
18:03 Dose escalation and cost
20:53 Coming off the medication
25:59 Appetite, under-eating and food noise
32:28 Why people plateau
37:08 Regular eating and breakfast
41:33 Exercise intensity and cortisol
45:04 HRT and contacting the clinic
Guest / Resources
  • Dr Lara Courtenay at the MacMurray Centre: macmurray.co.nz/doctors/lara-courtenay
  • The MacMurray Centre, Auckland: macmurray.co.nz. Lara says patients can call the clinic and ask for the weight loss doctor, and the dietitians can see patients whose own GP is prescribing
  • The Goodfellow Unit, where Mikki first heard Lara speak: goodfellowunit.org
  • Medications discussed: semaglutide, tirzepatide, Saxenda and Contrave
  • TJ Power, The DOSE Effect, the book Lara mentions reading
  • Mikki's earlier episode with Prof Eric Ravussin, on body weight regulation and the "settling point": Beyond Calories: The Biology of Weight Regulation with Prof Eric Ravussin