Hey everyone, it's Mikki here, you're listening to Mikkipedia, and this week on the podcast, I speak to Dr. Lara Courtenay about GLP-1 medications and obesity medicine from a New Zealand perspective.

So, Dr. Lara works for McMurray Clinic, and she shares her experience working in this space since 2020, and discusses just how variable knowledge and confidence around GLP-1 medications can be among New Zealand general practitioners.

We explore why medication alone is really the whole answer, surprise, and how dietetic and psychological support can make a substantial difference to patient outcomes.

We also dig into what Lara sees in perimenopausal women who appear to be doing everything right but still struggle to lose fat, and her useful analogy of GLP-1 medications helping to release the metabolic handbrake.

We discuss prescribing criteria, the limitations of BMI, dose escalation, and cost, as well as why more medication isn't necessarily better.

We tackle food noise, hunger, ADHD, and emotional eating.

Why some people plateau.

Why some people plateau because they're actually eating too little.

And also the big question, can people ever successfully come off these medications?

I really enjoyed chatting to Lara because she is such a wealth of information, and she is on the floor helping people at the McMurray Clinic every day, supporting them with their GLP-1 journey.

So, Dr. Lara Courtenay is a New Zealand-trained general practitioner and bariatric physician with more than a decade of experience working across general practice in hospitals.

So, Dr. Lara Courtenay is a New Zealand-trained general practitioner and bariatric physician with more than a decade of experience working across general practice in hospitals.

She's part of the Weightless Specialist Team at the McMurray Centre, where she takes a patient-centred, holistic approach to weight management and long-term metabolic health.

Her areas of expertise include weight loss medications, menopause and perimenopause-related weight gain, mental health conditions associated with addiction and weight gain, as well as skincare and cosmetic medicine.

Lara is particularly passionate about personalised treatment, ongoing patient support, and building long-term relationships.

Lara is also passionate about personalised treatment, ongoing patient support, and building long-term relationships.

Lara is also passionate about personalised treatment, ongoing patient support, and building long-term relationships.

I've popped a link to the McMurray Centre and Dr. Lara Courtenay in the show notes.

You guys are really going to enjoy this conversation.

And before we crack on into it, I would like to remind you that the best way to support this podcast is to hit the subscribe button on your favourite podcast listening platform and leave a five-star review if you haven't yet already.

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gain a bit of reach in amongst literally thousands of other podcasts out there

so more people get to hear from the guests that I have on the show

like Dr. Lara Courtenay. All right guys, enjoy this conversation.

Dr. Lara, thank you so much for taking time this afternoon to chat to me. I'm

really excited. So I have spoken, I'm a huge supporter of my clients utilizing GLP-1 light

medications to help with their journey on fat loss and on the podcast I have spoken to

researchers, obesity doctors, other people who are really well informed but all of them

pretty much have been international. So when I heard your talk for Goodfellas Unit a few weeks

ago, I'm like I really want to chat to this doctor because I just think it's really a great

opportunity to get a New Zealand lens on it because I do think we're a little bit different

of what's going on overseas. Oh yeah, definitely. Yeah, we're definitely a bit behind I think as

well. Well, you say that actually and I'm curious as to what you think because the way that you

spoke about it sounded very current with the challenges that people have and the things that

I see in my clinic but also the knowledge around what's actually going on. So there wasn't any

hyperbole around some of those side effects.

You were just very reasoned in how you approached people's questions about GLP-1s

and you certainly didn't hype up things like muscle loss or other things which I see other

people talking about. What is your take on the general level of knowledge that doctors and

normal GPs would have in New Zealand about these drugs? What do you think?

I think everyone wants to learn more and I think a lot of people know it's going to be

a big part of the future in medicine because the latest studies that show the benefits

far beyond weight loss are quite huge. But I think in general, given I am general practice

trained, it does take time to understand these medicines. So I think the amount of knowledge

out there is variable and I do education events and everyone is trying to get out there and

get the information out there. So I think I'd just say variable because I have a lot

of patients that say they go to their GP and their GP say, oh no, I'm not going to talk

about this. You need to go to someone who understands. And then we've got others who

are very highly skilled and enjoy managing patients on these medications. So I think

it's variable, but I think the ones that do prescribe it do have quite good knowledge.

Yeah. And you've been in obesity medicine for years at this point.

Yeah, since 2020. So it was a bit of an accident. So we talk about some of the gastroenterologists

at our clinic were doing gastric balloons. And then they knew me because I was quite

interested in sort of wellness at that point and holistic care. And then they said, well,

would you come and take care of our patients from a gastric balloon point of view? And

then coincidentally, just the end of that year, all the sort of sex ender and the once

a day injectables came and were released. And then we just so happened. And then our

clinic is very multidisciplinary. We've got dieticians, psychologists.

And me and then obviously the gastros had also been doing weight loss for a while. So

we then with the medications, we started quite a strict process where patients couldn't get

the medications without seeing the dietician. And so and we very much work together as a

team. So that's kind of how it started. And so I was lucky in a way to be. And this is

all I've done for the last six years now. So it's been really interesting. And what

is really fascinating is the conversations I had with patients years ago. Now the studies

are coming out with the benefits that they were sharing with me, especially in regards

to like inflammation and things like that. So that was that's quite cool. So I'd say

to patients, you know, this happens, but there's no research yet. And now I can say, oh, the

research is coming, you know, that is doing this. So it has been it has been really fun

and it's been really fun helping people be a better version of themselves, because in

general practice, I love general practice. And my dad's a GP and, you know, he was just

here and we were talking about it like it's a fun job, but it's.

Often you do feel like you're sort of band-aiding things. And it's good to what I say to people

now is how aging healthier. I think that's what's quite amazing about these medications.

Yeah, no, I completely agree with that. And I will. I've got a couple of comments. One

is on just, I guess, GP in general. And this is just through the lens of someone who works

with people who, you know, I'm often saying these are things which I think would be really

useful to get tested, et cetera. And sometimes I think people maybe.

Underestimate the amount of knowledge they expect their GP to have on certain issues

around nutrition and maybe weight loss and stuff as well. You know, they they go to them

for a solution. I'm like, well, the GPs aren't actually trained in that. So I wonder whether

there's a little bit of over indexing in that space.

Oh, totally. Like I didn't know this before. So I can I can say that, you know, before

this job, I didn't I understood certain things and I learned a lot about sort of iron and

some nutritional things that I realized were quite common issues.

In general practice. But I don't think it's a huge part of the training program. I'm sure

it will become now. But yeah, it hasn't been a huge part. And because you've got to kind

of have you do it. You have to understand everything and not everyone understands everything.

So it's just the way it is. Yeah, completely. And then what I find interesting,

Lara, is that I never really thought about weight loss medication until these drugs sort

of just exploded on the scene. But that wasn't. But I'm talking about the the later drugs.

Like the semaglutide and the jazepatide, whereas, of course, Saxenda and you mentioned

Contrave.

Yeah, Contrave never really sort of permeated into my practice to this. And I'm specifically

sort of, you know, a huge arm of mine is fat loss. So it's the effectiveness of these second

generation or third generation or whatever medications that are really why there's so

much more.

I think we did get quite good results on Saxenda. I just think it wasn't probably quite as well

tolerated and people didn't want to inject themselves once a day. Same with Contrave.

Like if you respond to Contrave, you can get amazing results. And I've still got some people

on that long term. I think the thing, the difference between with the weekly is that

the marketing just in general, because of the online hype overseas.

And then when it arrived here, I think that was very powerful. And I think that has brought

a lot of people in. And yes, they are more effective, definitely as well. But I do think

you could get good results before. It is, yeah, it is interesting that it wasn't as

well known because I had someone call, I talked to someone earlier this week, but they were

saying that the prescriptions have increased three times this year to last year. So in

terms of the amount of prescriptions.

The amount of people on the GLP one. So it is good that it's been taken up more than I probably

thought it would. Yeah, you're right. Given Saxenda wasn't as big, but now everyone all

of a sudden is talking about it, which I think is a good thing.

Yeah. And interesting. I've just like over, even over the last year, I've seen way more

billboards for Contrave than I, I never saw them before. And I think I might've noticed them given

the area that I'm in, but I just, I'd never seen them. And do you think it's the model that is set

up?

At McMurray Clinic that makes those, I mean, obviously all of those medications successful,

but particularly those earlier stage ones, because there was so much support around it as well.

Oh, totally. Yeah. Yeah. So we did our own studies on the patients we saw and, and our results were

better than the like actual studies because it was because of the support and that's what people

need. You know, that was like, people need good dietetic nutrition support because yeah, you can

take the medicine and just lose weight, but you're not going to lose weight.

You're not doing it in the healthiest way and it's not going to be good for your body. So, and,

and because as you know, people won't, don't eat as much on the medicine, what they are eating

needs to be good quality. And most of what people are eating nowadays is bad quality, pretty much

like everyone, like me as well, you know, I'm not perfect. So, and the, and the other thing

with our clinic is also, we try really hard to sort of remove the shame and the stigma around

all of it, because a lot of people have tried a lot of their life to lose weight and, and,

and this sort of empowers them to believe it's possible.

I completely agree with that last comment. And I, you know, I see, and I'm not sure how you feel

about this, but I'll tell you my perspective. You know, I speak to a lot of women, perimenopausal

age, because that's the age we are. And, and they literally have all of the, they have the pillars,

you know, they do exercise actually. And for the most part, they are eating protein and they are

trying to eat in a way that means that they're,

they're burning more calories and then they're putting in, et cetera. But that it's almost like

the grasp on all those things is so fragile that one thing will just knock them over and they're

unable to actually progress with, with fat loss. And I think it's just the time of life, you know,

the sandwich, what do they call it? Like, what are we?

Oh yeah, I see, I see this every, I see this every day, every day. So those women are often

really good. They're doing everything. They're exercising, they're eating way better than me.

Like they're doing everything. And then their body just won't let them lose weight. And I think

it's, I mean, through menopause, your hormones obviously change. They do say your resting

fidget rate drops quite a lot. So your metabolism actually does slow heaps. And it does seem like

you said, like one little thing will just flick them right off and they've got lots of stress

and they're working, they're sandwiched from like kids and parents and everything. And then,

so those people benefit massively from these medicines because you just give them a little

bit and they boom, all the hard work.

It works. And I sort of explain it. And I don't know if this is, I guess the new research is it

is, it is accurate, but how I used to say to people was, um, how do I explain it? I say to

people, you know, you're putting all the effort in, but your body's not letting you lose weight.

And then I sort of say the medicine, let's go of your handbrake. That's how I sort of explain it.

And that's what I think with those women. Yeah. And you're, you're so right. It's a huge field

and it's, it's, it's disheartening.

I know. And I, and I, I don't know how you feel about this next statement, um, because not

everyone responds favorably, but you know, I know there's certain, um, uh, weight categories that

need to be met in order for someone to be prescribed the medicine. Although, I mean,

I don't know how well regulated that is with some of these online places or whatever, but I think I

see women who have eight or 10 kilos to lose who would actually really benefit from the, from the

leading goal of that handbrake.

And that, but the weight is actually too low to actually get it prescribed by a doctor,

but that eight to 10 kilos that they're carrying is really like causing them a lot. Like it's the

quality of life actually is really, um, really diminished.

I think it's, again, that's a personal prescribing, um, decision. I think you should always take

someone's history based on the heaviest weight they've ever been. So I have some people who

have come to me and said, I don't know, I don't know, I don't know. I don't know. I don't know.

I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know.

And their previous heaviest weight was a lot heavier and, and I've got it clearly documented

and I've lost weight. And so I think from like an obesity as a chronic disease point of view,

you should always take it from that heaviest weight. So say that heaviest weight was a BMI of

over 30 or whatever, then, then I'd be, I'd be more than happy to prescribe.

I also think we've got to take in the, um, ethnic considerations because,

you know, Asian, um, and people with Asian ancestry, you know, their BMI can be lower and

they're considered higher. So I think it's, I think it's, I think it's, I think it's, I think it's, I think it's,

it's a higher risk of, uh, other serious comorbidities. So I think you take into that

into consideration, but yeah, I, I, at our clinic, we tend to sort of stick to the, the rules, the,

the, but, but off label, I'm sure there are people that are prescribing it. And I think that in the

future, it will be different. And I also think in particular because of the other benefits. So

someone who, if they've got liver disease, if they've got heart disease, all those things,

then we will be putting people on these medicines with a BMI that doesn't fit that

exact criteria. Yeah. Yeah. It's, um, I, you know, it's funny because people, I actually have

a question about, um, sort of using BMI to define obesity. And I do think you spoke about it in the

Good Paladins. It's a bad, it's a bad indicator really, but it's, it's what we've got and it is

changing. They are trying to change it. Yeah. And it's like that preclinical and clinical or

something. Do you know, I was actually at a conference a couple of weeks ago on incretin

theories. Um, and it was, it was all therapies. I'm sorry. Super interesting. One person got up,

I don't like obesity. So I'm going to use the term metabolic dysfunction instead because there's

so much stigma around obesity. And I'm like, you can't call it metabolic dysfunction. Like

that is so like, because body weight doesn't define dysfunction when it comes to metabolism

or whatever. Like, Oh, totally. I see in my letters, I used to be quite, I put, just put

raised BMI. Cause I also find using the term obesity. I don't like that that much either

because there's sort of stigma around it. But I think,

I also say to patients, I don't really like talking about weight. Um, I have to ask,

but I have lots of patients that don't even weigh themselves because a lot of people have a lot of

sort of trauma and has over scales and, and we don't want to make that any worse. Um, so a lot,

and a lot of people, you know, they're losing fat and that's more important. It's not about

the scales and, and you, you probably see this all the time as well. Like people will be,

the scales won't be budging cause they're gaining muscle and yet their

pant size is going down. So I spend a lot of time sort of calming people down when the scales

won't shift and be like, you know, why don't you actually just look at waist circumference or get

a body composition if you want, but everyone should just manage it. How is best for them

really and their journey. Cause everyone's so different.

Yeah, I completely agree. And you know, I have people get really hyper-focused on the scales.

They may on the same morning, put on a pair of pants that never fit. They look in the mirror

and go, wow, I look amazing. Then they jump on the scales and it hasn't shifted. And then

everything is sort of like, everything is bad from here on in. So I'm like, no,

it's bad psychologically. I say, just get rid of the scales. Like, I mean, they can, they,

they create a lot of stress unnecessarily. And, and, and you, um, yeah, I think then

there's so much natural fluctuation as well. Hey, Lara, with regards to dose escalation

in your clinic and how you approach it, like, do you have a set, um,

schedule with when people go up or do you monitor sort of progress and, and,

and side effects and use that as your, your gauge?

Yeah. So I'm, I'm sort of give everyone the set escalation initially, and then I give them my

email and then we just see how they go and they've got the dietician's email. So we very much want

people to be meeting the nutritional requirements. We don't want people under eating. So we're quite

strict on that. And we don't actually increase past wherever they are. They, they, they,

they just stop where they need to stop. That's kind of how we work it because at the end of the

day, everyone's so different. Some people will be on quite low doses and get good results. And some

people have to go right up to the top and it just, as long as they're doing it in a healthy, safe way,

that's all that matters. Yeah. I have a client and she is on, uh, 0.25 semaglutide and she's

been on it since February and has lost 17 kilos. And in fact, her GP prescribed her, um, a pen with

one milligram dose in it. And so, so she just multi-clicks, um, up to 18 or 19. And do you know,

for her, the cost came down from $390 a month to, I think it was, uh, I'll get the math wrong. Oh,

it was $430 for 16 weeks in total. Yeah. I mean, I think, I think that's very common. Like I think,

um, it's obviously off label. So as long as you sort of patients are warned,

off label and the company has, I think, is it 56 days? I forget the exact amount they've got

amount of days it's allowed open for. Yeah. And as long as they're changing the needles and being

careful, I just tell people maybe don't take it too far, but you know, very, very common for

counting. And I think it's, everyone's doing it. Yeah. And, and it really changes the game in terms

of cost, right? Because that is one of the biggest barriers to utilizing these medications is if

someone thinks that they're looking at $100 a week, that's not an insignificant amount of

money. It's huge. It's huge money. Yeah. Yeah. Whereas this particular client now pays $28 a

week for it, which is the cost of a cup of coffee a day. Oh, totally. I think that, I guess the

thing is, is you just don't know. And I do say this to patients, you don't know what sort of

responder you're going to be. So for an ultra responder like that, yeah, you're going to save

money, but some people need the 2.4. So yeah. So I think, but I totally, and then also in

terms of maintenance, I mean, that's a great way to do maintenance. And when we had the

once a day injectable that didn't have the same kind of rules around shelf life, people used to

do that, like drop it right down and do second, every second day low dose. So we've been doing

that wean down low dose. I've been doing that for years with people. Yeah. And do you, and how do

you view Lara in your practice with the people who come to see you? Do you have, can you spot

indefinitely? Do you, can you sort of tell if someone might actually be all right, sort of

coming off? Like, is there a way to delineate between these groups outside of what I might

read in a paper? No, I mean, the evidence would show that everyone needs to be on something long

term. Saying that I have had people come off them and be okay, especially when I had just the once

a day. I would, it's a hard one.

You've got to be someone who, so the evidence is, you know, you've got to be exercising 30

minutes a day, every day, eating 500 calories a day. Then before you put on weight, having all

your health perfect, including like all your vitamins, all your nutrients, everything, not

be super stressed, be sleeping really, really well. You know, and so like a unicorn, a unicorn

situation. Yeah, exactly. And then, and then, then your body's not going to, because I always say it

tries to get you heavy because it's trying to protect you. So yes, people can keep it off. And

I have had people,

be amazing and do that. But I always just say to them, okay, you might keep it off for two or three

years, but then if things wobble, come back. And because we just don't want that yo-yoing because

of the, then you're at risk of all the other problems with, you know, when you lose weight,

you lose bone density and muscle mass. So I think I have had unicorns and they do work. And as long

as I just warn people, you're very much at risk. But you're asking, you asked me, can I tell who

that unicorn is? I don't think so. I think,

maybe initially, or maybe it is the person on the bloods who's kind of just comes in quite well

and does exercise every day and doesn't have a super stressful life, but that's pretty uncommon

to be honest. But, but saying also the other thing is we could swap to other medicines. So

sometimes, you know, like I said, with Contra, if you could swap to that, if you're a responder to

that, the responder rates aren't as high as with the other medicines. So yeah, it's, it's,

I don't, yeah, I don't think you can really tell. Most people want to give it a go,

most people want to come off it. But most people, I think though, like, like you said,

the perimenopausal, that's a pretty hard time. I think, I think that's pretty uncommon.

I did go to a talk a while ago where they talked about, and you might, you probably know more,

more about this than me. Two years after menopause, you've got to, it's important to try

to lose your, the weight and the fat within that two years after menopause, because

your body can sort of reset. Have you heard that?

No, I haven't. No. Yeah.

So I sort of say to some people, I think from a cardiovascular risk point of view,

because post-menopause, your cardiovascular risk goes up quite a lot. And so if you can try,

drop the weight within that two years, I think that's quite good from a risk point of view.

But I don't think your set point ever changes.

Yeah, that's, it's an interesting one, isn't it? Like I was speaking to, I think it was Professor

Eric Robusson, and he's done a bunch of studies in metabolism and body, body weight, changing over

the years. And he, he,

he likes to term it like a settling point. Like your body reaches this point where it,

it defends weight loss, but it's not ever, but it's not like it's this one set number for life.

It's not like if you were 80 kilos and you got to 60, that your body will always try to revert

back to 80. It may shift over time. Is that how you think about it, Lara?

I haven't come across that yet. I mean, most people just seem to, their body always seems to try,

drag them back up. I'm not sure that that is even what we've seen in our clinic.

Yeah. And I think that's the thing, right? Like it's the difference between like, I guess the

academic start researcher perspective, and then you work with like real people.

I think, yeah, I think research, you can only research so much, pretty much. And then the

problem is the people that are in the clinical practice of medicine are so busy that they don't

tend to research either. So it's a bit of a, that's kind of,

Yeah.

what I think, like when you talk to my dad, who's been around for years and years,

you see that in general practice as well, because the researchers tend to be

attached to specialties rather than general practice.

Yeah. And I feel like the, just working with people in the real world is just a,

it's just different to, to working with people in clinical trials and when everything is very

well controlled, like not everything is controlled in the real world.

Oh, totally. Totally. Like the real world, like, you know, you talk about diet,

people have lives they have to get on with, you know, and, and they can't, and not everyone can

stick with the perfect meals and the perfect this and the perfect that. So you have to kind of

definitely, that's what we do very much in our clinic is it's everyone's got their own sort of,

we work with people's lives rather than forcing what we want them to do.

Yeah. Yeah. No, that makes, um, that sounds really reasonable. Um, Lara,

you mentioned,

that you work with dieticians and you've got a whole sort of holistic team set up,

like in your experience with regards to the side effects and actually people eating. So

how much of an issue do you see with people eating full meals? And just as a context,

you know, I've got varying clients who, who have either tried it or are on it. Um, and I've had

people who barely, who didn't eat, um, like had to force feed themselves small amounts of food.

Versus people who could actually still eat what we would consider reasonable meals. Like what is,

what is the difference here? Have you sort of thought about that?

I think again, it depends on what sort of responder you are, but I think most people

get a restriction in eating. Um, there's a small percentage that don't, like really tiny percentage,

like two or 3% that may be on, you know, the, like the highest dose might still be able to

eat, but most people get a lot of restriction. We wouldn't allow, I would hope, maybe it does

happen, people to get to the point where they can't eat. Some, because we hopefully say to them,

you know, give us a call and we'll drop the dose down. But I think the risk with that is the people

that are getting these medicines without any support. I think a lot of them are going up

really high dosing and not eating. And then we're actually seeing patients now who are trying to

kind of mop up because they sort of have under eaten for some reason. And so I think that's a

long now, the nutritional markers all going off, they're clearly under eating. And then we're

trying to sort of drop the dose and get them to eat more. Um, because the thing is you don't want

people to just stop the medicine and put all the weight back on. You want them to just have a

healthier relationship with food. Yeah. Yeah, for sure. And how many of your clients or patients

that you see is, is the main issue, a food noise issue, which is of course a term.

We might not have used two years ago, but it's, it's out there. I think, I think a lot of people

will say, I didn't think I had food noise, but I did do have it. But I think it's very,

a different term for different people. Some people come because they've read about it and

they're like, Oh, I've got it. And then some are like, I don't have it. And then they take it. And

then they say, Oh, I actually did think about food more than I thought. But, um, everyone's quite

different again. Yeah. Yeah. Because I, um, I think some people, it's just in their head that

this is a sign that they need the drug and they might be quite favorable to it. So they're like,

well, clearly I've got food noise. Whereas I think just being a normal person in this world,

I mean, food, I mean, you're going to get some food noise at some point. I wonder whether it's,

you know, the clinical definition is more like if it overwhelms a lot of your other thoughts and,

and sort of directs your behavior. Like, is that, is that more of an issue?

Yeah. So have you thought about like other,

well, not that it's a psychiatric disease, but if you think about those sort of diseases,

it's like you said, it's, it's an issue if it's controlling your life or, um, changing your

behavior. And yeah, so I think, and I guess it's not a psychiatric disease, but I think if you

talk about like maybe similar to OCD thoughts or things like that, maybe, maybe it's along that

point of view for some people, but like you said, it's actually normal to want to be hungry. And I

think that's what I get a lot of people that are like, Oh, but I'm, I'm on these medicines.

And I'm still hungry. I'm like, well, that's not a bad thing. You still need to like know when to

eat. Um, yeah. So, and again, everyone's really different. So some people take it and don't get

any desire to eat and some are still hungry and then they get upset. And I'm like, well,

we still want, in the end of the day, we still want you to have a normal relationship with food.

Yeah. Yeah, for sure. And when they are hungry, that's their opportunity to eat the things and

start building those habits. Yeah. The right things. Yeah, exactly. That you want them to

be eating, which is why.

And redirect away from the things they shouldn't be eating. But I do, I totally agree with you. It

is definitely a new thing with food boys, but there is a lot of, again, a lot of research

coming out about it. Yeah. Yeah. It's a fascinating space. Yeah. Yeah, for sure. Now you mentioned OCD.

Is it really, do you like, I'm curious, have you seen any research on sort of how these drugs

might interact with those types of, because I haven't. I don't know. I was just thinking about

OCD because I was reading, I've been reading that book, um, that guide,

the dose book, you know, the, um, dopamine TJ power. Okay. And he talks about him having OCD

and OCD thoughts and how it's like, and so that's what made me think of it. Um, and then again,

guess it made me think of food noises. People think of it as something that they're thinking

of all the time, which is a form of that. So, um, I don't know, there will be studies coming out

about it. Um, it's also like, I see a lot of patients with ADHD and,

it definitely helps patients with binge eating, you know, binge eating and contrave, um, that's

got a lot of research around sort of emotional eating. Um, so I think, I think there will be

research coming out, but I'm sure, I'm sure it does definitely help those sorts of people

because it definitely helps the ADHD patients. Yeah. That's, that's interesting. I wondered

that about ADHD. Everyone talks about different types of ADHD and sometimes it's, you know,

helpful sometimes that, but it's all quite a theoretical, you know, people hypothesize,

you know, people hypothesize, you know, people hypothesize, you know, people hypothesize,

could be helpful, but until you're in front of someone who has ADHD taking it, then you're not

really going to have a, you know. Yeah. I think there's different issues, like you said, with

different types of ADHD. So there's some of the people who I see a lot of medicated people,

unmedicated people, some people are so, they forget to eat all day because of the ADHD and

some people, um, want to eat all day because their ADHD. So you just don't know. It depends on the

type and depends on the person. So they've got that diagnosis, but I don't think it would change

what you do.

Really? Because, because you just manage each person as, as they are, but they definitely, um,

ADHD, I mean, it's, it's a common thing. Neurodiversity is very common. Isn't it like

one in five or something? So, um, I, I mainly talk to patients about it if they've got a diagnosis

or if they're concerned about having one and yeah.

Yeah. No, that makes sense. Um, Lara, what about, you, you've talked about, um, non-responders

a little bit. I'm curious as to the people who plateau, like what if like, cause I actually at

the conference I was at a couple of weeks ago, I think there was showing research that showed

after about nine months on a medication at a, I can't recall what the dose was. I don't believe

it was a dose that they could therefore go up a dose. Like it might've been the highest dose,

but they found that, you know, people started saying that their food noise came back and they

started getting hungry. Like, is this, what do you see in clinic?

I think that, well, with plateaus, I think it's, I've seen it all the time, especially with the

balloons. I think everyone's quite different. I think when I had balloons and we didn't have

medication, a lot of people tended to plateau on 10% weight loss. I don't know why it was just a

thing we commonly saw. Um, often it was people weren't exercising. Um, sometimes it's weirdly

some plateaus because people aren't eating enough. You talked briefly about,

nine months, we haven't sort of studied it, but I do think there's a point where if people,

again, it's very personality dependent. If you've got a very type A who's like very rigid and very

strict, I do think, and you understand this a lot more than me. There is a point where people are

so strict on the nutrition and they don't like eat anything that is off the diet. I think they

start needing to relax a bit because from what I can tell, again, talking to our dietitians,

they are not getting enough fats and then they're getting deficient.

Certain fat soluble vitamins and things like that. And then they can get tired and fatigued

and then plateaus happen because of that. So I think it's quite complicated. And we often with

plateaus, I then get a dietitian review after a good meal diary and exercise diary. We often have

to drop the dose and tell people to eat more weirdly, and then they lose more weight. So I

think plateaus happen, but I think they're all very different and for lots of different reasons.

Do you think, Lara, that part of it,

is that drop in non-exercise activity that might not be captured well with some of that diet?

Because I think about this a bit, right? Because obviously when you don't, when you're not eating

because you don't have an appetite, I mean, immediately your energy drops and you might

You don't want to exercise.

No, but also if you do exercise, that might be the only thing that you do that day. Whereas

you might then just sit at your desk most of the day, drive wherever, feel really flat. You just

lose all of that incidental activity. And if we think about,

how we burn calories, exercise, like you've got that activity component might be 20 or 30%

of energy expended, but about, but two thirds of that is actually that incidental stuff. So

Oh yeah, the up-down, yeah, the getting up-down, doing things. Oh yeah, no, I'm sure that does

play a part and I'm sure we don't understand all of it really. Like I think, I think it's

very complicated. I think the science around these medications is very new and I don't think

we fully understand it. But I think plateaus,

plateaus are for lots of different reasons, whether it's stress, sleep. I always say to

patients, if you have a plateau, reach out, we'll get some extended nutritional bloods. We can

normally tell from those what's been going on, like whether they're under eating, whether they're

iron deficient, you know, all those sorts of things. Talk to them about stress, sleep,

and then also just allowing people to say it's kind of okay and just to wait. Because I think

sometimes your body then will start losing again.

Yeah.

I agree with that too. Just what I know of weight loss, like everybody is different as to how linear

the process is. And I get people who will lose and then they'll just hold for a few weeks and

then they'll lose again and it will be a real loss and it will be a substantial amount.

Yeah, huge, like kilograms. Yeah, we get that often. And then we used to, again, this was with

the balloons because we did that for a long time, was we'd do often this like shake protocols and

things like that. So sometimes we'd do that for a long time. And then we'd do that for a long time.

Sometimes if people had a plateau, I haven't done it too much with the injectables, but we'd put them

on like a weight loss shake for two to four weeks. And then it seemed to push people through. And my

theory behind that was the vitamins again. I just don't think people eat what they should be eating.

I like none of us do just because the food we have access to isn't as good as it used to be.

And so that's why I think those shakes that have high, lots of vitamins in them kind of

refill everyone back up again.

And then allow their body to lose weight.

Lara, you mentioned actually in your talk about the food side of things. And I mean,

every time you mentioned food, et cetera, you always deferred to your dieticians, which was

great. But I would like to ask you, like you mentioned that regular eating and eating before

10 o'clock was something that you found to be really helpful. So can we just chat a little

bit about that?

Yeah, I mean, again, as a practice, we kind of,

mirror each other because it's, I think people get better results, obviously, if you're all on

the same page. I'm pretty sure it's about, again, you probably know a lot, you will know a lot more

about this than me, is about 5%. Fasting works about 5% of people. Is that right? It's like

actually a very small percentage of people that are fasting. And a lot of people we see who struggle

with weight don't eat regularly. A lot of people will not eat all day because their hunger hormones

are all confusing, then they'll eat at night. And so we do a lot of counseling, we do a lot of

counseling around regular eating. My before 10am thing is because that's what the dietitians say.

Yeah, nice.

And I like to, I like to, we all give the same advice. And my understanding is that it's important

to eat early in the day, because you want to make sure that throughout the day, you get enough

nutrients so that in the evening, you don't play catch up in regards to eating. From the, I say to

people to wake the metabolism up. That's just a way I like to communicate with people around it. But

I'm sure it actually helps.

Yeah, I think it does.

It actually does. Like if you think about eating, and you eat a food, food that's ideally low in GI

and complex, so your body starts turning. I'm sure that is the case. I mean, is it the case?

Yeah, yeah.

I mean, I would say, because a lot of people don't eat before exercise. I'm like, why are you not

eating? You've got to kind of get your body working and realize it's, I always think of us as cave

people. And I'm like, if you're a cave person, and you went out running, it would do all it can to

conserve energy. If you didn't have food, but if it had food, it would start using more energy. So

that's sort of how I explain this. Yeah. And I liked your, like, I often,

people often get panicked when I tell them to start eating breakfast. And they're like,

I'm just going to be hungry if I eat breakfast. And I'm like, that's actually the point. The point

is that your body has, to your point, woken up, and it started to burn more energy. And I do think

it also plays into...

That amount of calories you burn across a day, because when you do have calories in,

you're more likely to be active outside.

Oh, totally. Yeah, yeah. You're going to do more, and you're going to feel better. I can't,

we did learn all those pathways at medical school, to be honest.

Oh, I'm sure. But I mean, I'm sure we did too.

I don't remember all of them.

No.

Yeah, I just think a lot of it, again, is just habit change and trying to make, help people

be healthier. And hopefully the medications allow them to do that.

Yeah. And I do, and you know, if you look at literature around successful weight loss

maintainers, eating breakfast is actually a really big part of it. So, you know, it's one

of the key pillars. Eat breakfast, be active, change your identity. Not that that's no easy

ask, but you know, it's one of the pillars.

I always say to people, you know, I'm a bad, I don't want to eat in the morning, but you

force yourself and eventually you're fine. And then a lot of people are, how do I explain

it?

Well, you know, they've got lifelong issues around diet, not issues, a lifelong history

of dieting and thinking that they should eat less calories. And so they're scared, like

you said, to eat. But, but I think telling them when, you know, you're on the medicine

now, your body is going to start losing weight. They kind of can make those changes because

they see that their body is changing. So then they're happier to eat breakfast. So I think

it does kind of all tie in together.

I agree. It's that building that.

Yeah.

Confidence, evidence builds confidence, right? That's exactly sort of what we see.

Yeah. And I think a lot of the, a lot of the medication is also allowing them to get their

confidence and then, and then make the changes that are therefore healthier for them overall.

Because a lot of them have tried heaps, but just nothing ever worked. So I think, I think

they are game changers, the medications and yeah, I definitely think they're here to stay.

So, and it is quite exciting.

I totally agree.

Exciting field.

Now I'm mindful of your time, Lara, but I do just want to ask you a couple more questions.

You mentioned that very high intensity exercise might not be the best approach or from your

clinical experience. So, I mean, I've got some thoughts on this and I'd just love to

hear what you think.

Yes. Cause you're an exercise. So pretty much again, I was trained by the other health professionals

in our clinic. There is some evidence that for weight loss, high intensity exercise does

make weight loss harder.

And it's better to have 30 minutes of moderate intensity exercise every day. As far as my

understanding of it, and I could be wrong, it's because when you do high intensity exercise,

you often get quite hungry afterwards.

Yes.

The baby in the background. You often get quite hungry. And then you, and then therefore

you want to eat, a lot of people will get like sugar cravings and often probably eat

the things they shouldn't be eating. I know if you were the perfect person, you maybe

not do that.

Yeah.

If you were the perfect person and doing all that, you might not get that. And the other

thing is, is the cortisol, like some people, and it's not all people, like have very high

cortisol all the time. And that's a reason why their body's not losing weight. And sometimes

the high intensity exercise does that. But I always, when I talk to patients, I always

say to them, if you're the sort of person that loves it, don't stop it. Like we don't

want you to stop it if you love it, if it's a huge part of your life. I'm just saying,

well, then we need some more specialist, dietetic or nutritional input as to how to do that.

Yeah.

And how we're going to help you. That's pretty much how I word it.

Yeah. Nice one. And so I've been to a ton of metabolic health conferences over the years.

And in fact, one of the most recommendations, because of course we're talking about severely

insulin resistant folks, people who do carry a lot of excess body weight that really does

impact on their health. And basically they get this massive glycolytic response as soon

as they get up out of the chair. So for someone who's got a lot of weight to lose, hasn't

been exercising and is insulin resistant, the last thing they want to do is jump on

and do some sort of HIIT session. So that, which is an agreeance with you, right? Like,

like just getting their, getting their body moving, I think is important. And to your

point about the cortisol thing, so many, particularly women that I see that are desperate to lose

weight will be doing HIIT based training five or six times a week, wondering why on earth,

you know, things aren't budging, but to your point, they're just placing so much stress

load on their body.

Yeah.

Like their body's just holding on.

Yeah, totally. And people, I have seen so many people stop it and then lose weight.

So it's, it's, I think obviously exercise is fabulous and good for you and we should

all be doing more, but I think there is a fine balance with it.

Yeah. And also it's a season thing as well, right? Like I often say to people, you can't

chase two rabbits at once and let's lose the weight in a way that you're still active.

And then you can bring other things back in.

Like that high intensity activity, which would play in perfectly to the maintenance

space, really, where they've got all their habits in place and they're maintaining a

lower body weight. In fact, this is when exercise can really drive the bus rather than relying

on it to for the caloric burn during the process.

Yeah. And like, as you know, like exercise is such a small component of weight loss anyway.

Like we want a small bit to get things moving, but I think exactly like it's more of a maintenance

thing, ideally.

and also everyone's so different some people love it and need it for their mental health and we

definitely don't want people to stop that yeah no totally Lara um so we've talked a lot about the

habits and behaviors of women in perimenopause and just the life right makes it's a challenge

um do you have experience or thoughts around the combo of these medications along HRT like

have you got any clinical sort of pearls or anything that you want to bring to the conversation

around that I'm very supportive of HRT and I encourage patients to get it and use it when I

went through my GP training we had a different attitude towards it and now with the new sort of

topical formulations they are much safer and and they can be really life-changing and the new

evidence that you're better to be on a long-term low dose so I do a lot of talking to patients

about mood and things like that so I will encourage anyone in that

stage of life to go on HRT from a weight loss perspective some people put on a little bit of

weight because of it but I don't think that's a bad thing I think you've got to weigh up

what like your mental state versus you know weight and and sometimes a kg or two is nothing really

these are more the patients that are in maintenance phase and because mostly I talk to people about

being healthier and and wellness and that's that's what we're focusing on rather than

weight so I think that's a good thing I think that's a good thing I think that's a good thing

I think I think HRT is great yeah no nice one I um you know and it's it's interesting to look at

there's just tiny little trials out about HRT and the medications and that they are like together

they're quite a like it's useful together yeah I wouldn't so I need to yeah I don't haven't read

those papers but I can imagine they are based on the people I've spoken to but it's they can be it

can be so life-changing and I definitely encourage women to to look into it hey well I've super

appreciated chatting to you like it's so great to chat to someone who's in the trenches

in New Zealand working with people and are super favorable of the whole of the you know the

potential you know obviously the individual benefit but actually just the benefit for um

health in general is um you know it's really refreshing other than to be against something

like um GLPs which a lot of doctors still are Lara can people how do people contact the

McMurray clinic like do they just can they self-refer like what's the deal with that

is it a private health insurance situation no so sadly insurance oh some companies might but

it's just call the clinic themselves and then you just say you want to see the weight loss

doctor and clinic and we have a specific weight loss admin team that will help you book everything

and if if your GP is giving you the medication you don't want to see me that's fine our dietitians

will see you without seeing me so that's another option as well if you wanted that support but

uh we tend to

work yeah we tend to work as a team where you see me then the dietitians and or the psychologist and

then we follow up so you just um go I don't even know what the phone number is I guess you have to

just pop it into the google McMurray McMurray center in Auckland yeah but we have patients

all over New Zealand okay well that's lovely Lara thank you so much for your time I appreciate it

because it's not a um not a quiet time in life for you right now so um thank you sorry I thought

the baby was going to sleep but she's um she's all right she's going to sleep she's going to sleep

she's happy now yeah no she sounds really happy so um thanks so much Lara I really appreciate your

time oh no thank you for having me it's fun I've never done anything like this before so

it's it's an interesting fun thing to do

all right hopefully you enjoyed that and got a little bit from the New Zealand perspective of

what it's like here and some of the challenges

and how to work through those challenges with a specialist like Dr Lara Courtney and as I said

I have a link to where you can find her in the show notes all right guys let me know what you

think I'm over on Instagram threads and x at Mikki Williden Facebook at Mikki Williden

nutrition or head to my website mikkiwilliden.com scroll right down to the bottom and pop your name

in that box to jump on my email list I'd love to hear from you all right guys that's it for

me for this week see you later