Dietitians play a key role in GLP-1 medication support

Once restricted to the domain of celebrities, GLP-1 medications are now readily available and becoming increasingly common. They have rapidly changed how weight and other health conditions, like type 2 diabetes, are managed but without the right support, the rapid weight loss and side effects of these medications can cause nutritional deficiencies that have short and long-term health risks. In this article, Oxford Women’s Health Nutrition Consultants and Dietitians Sara Widdowson and Kate Collins explain how working with a dietitian can significantly improve outcomes.

GLP-1 medications have been designed to mimic the naturally-occurring hormone GLP-1, which is responsible for slowing digestion, lowering blood sugar, and telling our brains when we are full. Because they slow down the rate at which food travels through the stomach, people may notice a decrease in their appetite and “food noise” resulting in weight loss.

It is expected that people using a GLP-1 medication, will lose 15% of their body weight after one year and that most of the weight will be dropped in the first six months. We know that weight loss of 10% can help reduce the risks of metabolic syndrome, type 2 diabetes, and cardiovascular disease. Other positive “side effects” include improved cholesterol levels, and reduced visceral fat, inflammation, sleep apnoea, and joint pain.

However, GLP-1 medications can trigger gastrointestinal side effects and because they can cause people to lose interest in food, there is a risk of micronutrient deficiencies and loss of muscle mass. If not managed correctly with the support of a dietitian, people taking GLP-1 medications risk yo-yo dieting, and stopping the drugs leading to weight regain.

What are the side effects?
Sara: Side effects are common when people start taking GLP-1 medications, but they are not usually severe and occur in the first few weeks. Up to 50% of people will experience nausea and up to 20% vomiting. Other symptoms may include diarrhoea, constipation, abdominal pain, and in some cases, gallstones. The hidden psychological side effects of taking GLP-1 medications include weight cycling; the stigma associated with their use; the distress of not responding to treatment or finding symptoms are unmanageable; the fear that stopping the medication could lead to weight regain; and the loss in enjoyment of eating food.

What nutrients may be lacking in patients using GLP-1s?
Sara: Because of the unpleasant side effects, people can find it hard to meet their daily nutritional requirements when taking a GLP-1 medication. Users can miss out on adequate levels of protein, iron, calcium, magnesium, zinc, fat soluble vitamins (A and E), thiamine, B12, and vitamin C. A recent study showed people using the medication for one month were consuming lower levels of fibre, calcium, protein, and iron than recommended. A high percentage of their calories were also coming from saturated and total fat, rather than macronutrients such as carbohydrates and protein. A low protein diet can contribute to muscle mass decline. Fast weight loss, alongside reduced vitamin D and calcium intake, can also impact bone density, which is essential to maintain in older adults, particularly post-menopausal women.

Sara Widdowson 

Kate Collins

One study found that 50% of people taking GLP-1 medications discontinue the product by the 12-month mark and another 85% of people will discontinue it by two years. This can be for a variety of reasons, including the cost of the medication and difficulty managing symptoms. About two thirds of weight is regained within 12 months of stopping taking a GLP-1 medication.

How does working with a dietitian help?
Kate: GLP-1 medications do not teach people eating or nutrition skills, so working with a dietitian will result in much better outcomes. We recommend people are screened before they start taking a GLP-1 medication to record age, weight, mobility, and if they have a history of an eating disorder or previous bariatric surgery. They should then be monitored regularly to ensure they are not losing too much weight; if there are any appetite changes; and if side effects or risks arise.

Sara: We commonly hear clients tell us they notice a big reduction in food noise when they take GLP-1 medications. I suggest my clients use that pause to work on their relationship with food, behaviours, and food environment. The reduction in inflammation and joint pain can also present people with an opportunity to begin exercising again.

We encourage people starting a GLP-1 medication to:

• Eat smaller portions, more often
• Learn to eat even when they are not hungry
• Eat slowly and stop earlier
• Prioritise protein – try to eat it with every meal or snack
• Drink between meals (not with) to ensure adequate hydration
• Choosing low-fat options will help with nausea symptoms
• Be mindful of fibre intake and spread it out throughout the day, rather than eating too much in one sitting
• Resistance exercise is important for muscle and bone health.

The GLP-1 medications currently approved in New Zealand are dulaglutide (Trulicity®), liraglutide (Saxenda®, Victoza®), semaglutide (Ozempic®, Wegovy®), and tirzepatide (Mounjaro®).

Pelvic pain in adolescents

Today’s young people have more access to information about their health than ever before. Conditions like pelvic pain are regularly discussed on social media feeds and it’s impacting the way teens seek treatment and advice. In this article, Oxford Women’s Health Gynaecologist Dr Olivia Smart and Pelvic Health and Musculoskeletal Physiotherapist Niamh Clerkin talk about how they approach the diagnosis, treatment, and management of pelvic pain, specifically painful periods and endometriosis, in young people.

Olivia: The shift in how we now talk about women’s health has thankfully resulted in young people having much less whakama or shame around menstrual difficulties. They have better access to health knowledge, are more aware of other people’s experiences, and discuss issues they are having with their parents and teachers in ways that other generations wouldn’t. As a result, more teenagers are looking for early intervention to help alleviate pelvic pain. A lot of caregivers will also seek support for their young person early because they don’t want them to go through the same experiences they did. If your mother or sister has endometriosis, the risk of you having it is up to seven times higher, so family history needs to be considered when seeking support from a medical professional.

Niamh: Chronic pelvic pain is associated with a variety of issues including psychological, behavioural, sexual, physiological, and emotional issues. Research is starting to recognise that untreated pelvic pain can have many negative consequences on a person’s quality of life, and we are learning more about the link between pain, fatigue, anxiety, and depression. Women living with endometriosis and persistent pelvic pain lose an estimated 11 hours a week of work, which is similar to somebody living with untreated Crohn's disease or Rheumatoid Arthritis.

We need to educate our young people because there's so much we can do to empower them to manage their menstrual cycle, such as tracking their periods, and having pain management strategies. The good news is they are living in a world where there's so much more research and clearer diagnoses starting to happen.

Diagnosing endometriosis and pelvic pain in young people
Olivia: Endometriosis is found in adolescents and age is not a discriminator for investigation or treatment as it can significantly impair a young person’s quality of life. When you or a young person in your care speaks with a medical professional, they will be considering the stage of the condition, family history, and potential long-term implications, such as future fertility. It may be recommended that an ultrasound is performed to look at the reproductive organs.

While diagnostic investigations are underway, hormonal treatment may be offered, possibly along with pain relief, physiotherapy, and mental health support. If there is no improvement after initial treatment, a referral to a gynaecologist may be required. Menstrual suppression is a first line option to provide a break from painful periods. It allows the brain to reset and for its pathways to come back down to baseline.

The physiotherapy approach
Niamh: Experiencing a significant amount of pain during a menstrual cycle is not normal. Dysmenorrhea (painful periods) is associated with missing school or work for an average of one to three days a month, or when the pain is unmanageable with over-the-counter medication, such as paracetamol.

I find that most of the evidence around lifestyle factors that can support pelvic pain are based on exercise, but we are mindful that everyone will be at 

Dr Olivia Smart 

Niamh Clerkin

different stages of their journey, so recommendations will vary from person-to-person. For example, somebody who's missing three to five days a week of school is going to be exercising differently from somebody who trains regularly. Recent studies have found that treadmill training, stretching, and muscle relaxation techniques can help to reduce menstrual pain, as does exercise using acupressure points and heat. Yoga for only 60 minutes once a week, over a 12-week period, has also been found to be effective in women living with dysmenorrhea.

There has been positive research around the use of Transcutaneous Electrical Nerve Stimulation (TENS) machines used alongside pain medication, and some studies have shown it can reduce the amount of pain medication needed by young women. It is also important to consider bladder and bowel care. Chronic constipation or not emptying correctly will increase musculoskeletal pain, distension, and abdominal bloating.

Research has shown that non-menstrual pelvic pain symptoms can often cause people more stress because of their unpredictable nature. Other lifestyle factors that may help people navigate pelvic pain include managing sleep and stress; embracing movement and exercise as therapy and a management tool; taking care of the gut microbiome; and reducing inflammation through diet and nutrition. Physiotherapists can support you to manage your condition before and post-surgery, provide education and pain management tools, and offer musculoskeletal treatments.

The impact of social media
Olivia: Social media is often the first point of contact for teens seeking health information. TikTok, Instagram, and YouTube are major sources of reproductive health content, but they're not always helpful and can spread misinformation. Many of our teens research pelvic pain online before seeing a health professional, and while this can empower them to seek help, it can also create confusion and fear. There is also a lot of catastrophising and clickbait online that can influence how management is perceived. We must acknowledge that although social media has raised awareness and teens are recognising endometriosis symptoms earlier, it does have its downsides. It is important that young people continue to access good-quality, trusted education and medical information from their healthcare professionals and other reputable sources.

pelvicpain.org.au

Celebrating International Women’s Day

To mark International Women’s Day on 8 March, Oxford Women’s Health partnered with The Breeze to celebrate Canterbury’s inspirational women, including our own Gynaecological Endocrinologist, Dr Anna Fenton.

Other well-known local personalities interviewed on The Breeze were Dame Sue Bagshaw, Dame Sophie Pascoe, Hayley Westenra, and Leeann Watson, who shared powerful stories of strength, resilience, overcoming difficult life chapters, and the importance of self-care.

In her segment, Dr Fenton discussed the evolution and “rollercoaster” of attitudes towards HRT following the misinformation that was published in the early 2000s.

“Literally overnight, 90% of women around the world who had been taking hormone therapy stopped it. Despite our best attempts to get better 

Dr Anna Fenton

information out there as the research findings evolved,…we were just hitting a brick wall. It really took the rise of social media to make the change in our understanding about hormone therapy more apparent to the public.”

Endometriosis Awareness Month

Oxford Women’s Health was proud to sponsor Endometriosis Awareness Month, this March. An estimated 120,000 New Zealand girls, women, and those assigned female at birth, live with this inflammatory disease.

This year, Endometriosis New Zealand encouraged people to show their support by taking part in the 120 Challenge. This involved some participants running or walking 120km, skydiving 12,000ft, baking 120 cupcakes, and more. 

Endometriosis New Zealand CEO, Tanya Cooke, expressed her thanks for sponsoring the 120 Challenge this year.

"Your support means a lot to us and to everyone in our community. It’s been an incredible awareness month. We had 196 people across 27 teams take part in the 120 Challenge and, together, raised close to $70,000 to support the work of Endometriosis New Zealand." 
 

“The energy, creativity, and commitment people brought to their challenges was genuinely inspiring. 120 Challenge Awareness Month is always a powerful reminder of how important storytelling and community support are in driving change and your contribution has helped make that possible.”

Oxford Women’s Health is delighted to have contributed to such a successful initiative.

https://nzendo.org.nz/march-awareness-month/

Pharmac urged to fund female-specific testosterone

Oxford Women’s Health Gynaecological Endocrinologist, Dr Anna Fenton and other specialists recently called on Pharmac to fund a testosterone medication that is designed especially for women. Sadly, Pharmac declined the submission.

Testogel® is currently publicly funded but has been designed for men. It is often prescribed to women without appropriate follow up testing to ensure levels are correct. In a joint submission endorsed by The Australasian Menopause Society, the submitters said that evidence-based, female-specific therapies should instead be prioritised. 

An option that is researched and designed for women is AndroFeme®1, but it is unfunded, and costs anywhere from $150 to $250 for a three-month supply. Testosterone is used to treat Hypoactive Sexual Desire 
 

Dr Anna Fenton

Disorder, known as low libido, in women. In their submission, the clinicians reported adverse outcomes associated with women being given inaccurate doses of Testogel® and sustained exposure. These include acne, hair growth, voice deepening, and enlarging of the clitoris, the latter two of which may be irreversible.

Welcome to Dr Janet Whineray

We are delighted Dr Janet Whineray has joined the Oxford Women’s Health team.

Dr Whineray is a highly regarded specialist and skilled surgeon who covers most areas of gynaecology. She has had many years’ experience assisting people with conditions such as endometriosis, abnormal bleeding, vulval disorders, menopause issues, contraception, sexually transmitted infections (STIs), and pelvic pain.

She says she really enjoys her work, particularly the relationship she has with her patients. Being part of a multidisciplinary team was one of the factors that drew her to Oxford Women’s Health.  

“I already knew many members of the Oxford Women’s Health team well,” she says. “It’s always seemed a very collegial place to work with great systems and procedures. I particularly love the multidisciplinary approach. You can’t do medicine in isolation.”

A graduate of the University of Otago Medical School, Dr Whineray studied and worked in the United Kingdom and Canada, before completing her specialist training in obstetrics and gynaecology in Auckland. After three years working in private practice in Auckland, she moved to Christchurch to start a family and work with obstetrician, Dr Harry Bashford, and at Christchurch Women’s Hospital. 

Dr Janet Whineray

Her sons are now 21 and 22-years-old.

She was the Christchurch Women’s Hospital Clinical Director for two years, has also served on the Forté Health Board, and holds a governance role at Southern Cross Hospital in Christchurch.

Dr Whineray is looking forward to spending time working from our Queenstown satellite clinic at the Centre of Medical Excellence at Kawarau Park, and hopes that her visits south may allow time to squeeze in some tramping opportunities. She has recently completed the Milford and Kepler Tracks and looks forward to walking Tour du Mont Blanc later this year.

To make an appointment to see Dr Whineray, you will need a GP referral.