00:00 Introduction to Bariatric Medicine

02:11 The Journey to Low Carb Advocacy

05:44 Transitioning to Low Carb Approaches

10:38 Understanding Patient Histories

14:49 Empowering Patients Through Education

18:58 Addressing Setbacks and Challenges

21:42 The Role of Insulin Resistance

25:26 The Role of Obesity Medications

28:37 Dietary Changes and Metabolic Health

31:25 Cultural Differences in Patient Care

34:01 Addressing Weight Loss Plateaus

37:29 Intermittent Fasting vs. Low Carb Diets

39:53 Challenges of Perimenopause and Aging

41:57 Genetics vs. Environment in Obesity

44:01 Utilizing the Defeat Diabetes Program

44:13 Final Advice for Better Health

Dr Peter Brukner (00:01.4)
Hello and welcome to our Defeat Diabetes webinar. And it's a great pleasure today. We're heading down to Hobart, Tasmania, and we're speaking to Dr. Fran Ramsay, who describes herself as a bariatric medical practitioner. Now I'm not too sure what a bariatric medical practitioner, I know a bariatric surgeon. Anyway, Fran, welcome. we always start by getting you to tell...

tell your story rather than me introduce you. think it's much better if you tell us your story from day one to being a bariatric medical practitioner. You know, welcome.

Dr Fran Ramsay (00:39.499)
Okay, thank you. Thank you, Peter. Bariatric medical practitioner is just very fancy words for weight loss, know, or weight management doctor. That's all it is. I guess I'd probably say that my journey began around about

2003, I had been working in general practice for almost a decade. I just had my second child, I was looking to return to work. And instead of going back to general practice, I was offered the role of a medical coordinator at a non-surgical, multidisciplinary weight loss clinic in Brisbane. And it was a lifestyle choice, so it wasn't something that I...

graduated and thought I'm going to do this. I didn't, was purely, I fell into it. It was a lovely low stress job, office hours, very life balance stick for me. And I really enjoyed it. I worked with a great group. They employed doctors and dietitians and exercise physiologists and psychologists. And it was the typical weight loss clinic where

We followed a calorie controlled low fat diet with exercise. And it was one of the first clinics that introduced the use of Optifast shakes and bars as part of a calorie controlled diet. But it was very carb heavy, it was 55 % carbs. But that, you know, that was the Australian dietary guidelines. So I worked there, I ended up working there for 12 years.

Dr Peter Brukner (02:14.094)
That's normal.

Dr Fran Ramsay (02:21.953)
As time went on though, I began to become a little bit concerned or disillusioned because I was noticing that people were having trouble maintaining their weight loss and they were returning for their second or third or fourth program and often they would regain more weight than they had lost initially. And I also was noticing at their

end of medical, end of program medical that their fasting glucose was often raised. And over time their ALT, which is a liver enzyme, which is a marker for fatty liver, that was also raised. And I was really confused by that. But back then, we didn't order fasting insulins and we didn't have the HOMA index test which looked for insulin resistance.

but I now know that what I was picking up on was worsening insulin resistance. So it was about five years after I had started, so was around about 2008, I was also working with some bariatric surgeons at some different clinics and I was seeing weight loss surgery patients as well as non-surgery patients and a psychologist.

Carolyn Rogers introduced me to this idea of eating low carb, which was very shocking when I first heard it. thus began a deep dive into all of that emerging science that was coming out at that time. So Professor Tim Noakes, Sarah Hallberg, Robert Lustig, Jason Fulmer, too many to name.

And the more I learned, the more my mind was blown. I mean, this was really my penny drop moment because it really explained what I was seeing in the real world with regards to why the typical weight loss patient was having trouble maintaining their weight. They were all really hungry and why their metabolic health.

Dr Fran Ramsay (04:47.631)
was deteriorating over time. So I made the decision that in my other clinics I was going to advocate low carb and that's what I did. So for seven years I simultaneously worked both sides of the nutritional debate and I wasn't doing any general practice. I was working every day. So every single patient was a bariatric patient, a metabolic patient.

either surgical or non-surgical, every single one. So that's thousands and thousands of patients over that time working two sides of the nutritional debate. I can tell you, chalk and cheese, absolutely no doubt in my mind that the low-fat, calorie-controlled diet with or without shakes leads to hunger.

difficulty maintaining weight loss, metabolic dysfunction. However, in the other group, they weren't as hungry, they were able to maintain their weight loss, they were coming off their blood pressure medications, coming off their diabetes medications, their metabolic health was improving. So I felt that I had discovered this deep, dark secret that I was then compelled to tell.

everybody he would listen about. so around about 2015 I moved into state, I moved to Hobart and I have continued to work with bariatric patients and I, yes, my goal in life is to educate as many people as I can to try and help them, you know, control their weight, get control of their weight.

but also turn their metabolic health around. And I'll tell anyone who listens. I I pity anyone who might be sat next to me at a dinner party or next to me at a wedding, because if they happen to ask me what I do for a living, I will tell them in great detail, and I'll even talk about the old food pyramid from the 1980s, and I'll talk to them about insulin resistance. And I have been nine Peter at dinner parties to get out master class videos of

Dr Fran Ramsay (07:10.757)
Dr. Peter Bruckner explaining why diets are so confusing. So watch out if you sit next to me because I'll bore you to tears with all of that.

Dr Peter Brukner (07:19.522)
like my wife, always says before we go out, now you're not going to talk about diet. And I'm not going to talk and then people ask you, well, what you know, I look at her and shrug my shoulders and she rolls her eyes away. Yeah, look, I'm curious as to as to how your colleagues, you know, say at the original clinic, you know, I mean, they obviously also following the traditional low Cal low fat sort of diet. mean, you know, you said you talked to anyone about it. So presumably you talked to them about it.

Dr Fran Ramsay (07:22.513)
You

Dr Fran Ramsay (07:30.756)
I know.

Dr Peter Brukner (07:48.622)
How did they sort of take it all on and, uh, you know, did they ever think, you know, she's got a loopy or what do they think?

Dr Fran Ramsay (07:51.473)
Mm.

Dr Fran Ramsay (07:55.441)
Well, I felt like I was really having this inner conflict because I felt I had a duty of care to these patients. So I had many, many discussions with management about their carb content and suggesting a lower carb program. But

It fell on deaf ears. The head dietician said that she would never go against the Australian dietary guidelines and the managing director, I guess, he wasn't a doctor, but the clinic was owned by a group of cardiologists and he was a brother of one of the cardiologists. And he just said, Fran, you know, we rely so much on the...

the income from selling the shakes and bars, I can't even contemplate, you know, not, you know, doing that. It's not, it's not in the business model. And it was really, it got very awkward actually. I think they were very relieved when I said, guys, I'm moving to Tasmania. They really thought, you're a little ripper.

Dr Peter Brukner (09:08.206)
They obviously didn't warn their colleagues in Tasmania because you obviously got a job there with a bariatric. So, I mean, you work with surgeons who obviously believe that bariatric surgery is the way to go. And there is a role, I think we all agree, for bariatric surgery in some cases. how do they sort of think, what do they think about your weird ideas about low carb and so

Dr Fran Ramsay (09:13.071)
Yeah.

Dr Fran Ramsay (09:33.295)
Well, it's far more accepted now. But yes, it took a bit of bravery really to go against, to swim against the stream. And I've worked with great bariatric surgeons and I think all of them are looking forward to that time in the future where no one needs bariatric surgery anymore.

They're not in it for padding their bank balance. They wanna know what's new in the world of science, what's going to work for their patients because we all know that weight loss does not mean metabolic health. So even if someone has metabolic obesity surgery and they've lost the usual amount of weight, it doesn't mean that they're metabolically healthy.

In order to be successful in the long term, there has to be a correction of diet. Otherwise, you know, they may have lost a lot of weight, but you know, they could end up with diabetes or have a heart attack. And no one wants that for their patients. So, you know, all of the surgeons that I work with are on board with low carb.

Dr Peter Brukner (10:56.664)
Hmm, no, that's fantastic. You always done a good job of educating them. I'm really interested in your sort of approach to the obese patients. So, you know, let's say I come in to see you and I'm a middle-aged person who's always struggled with my weight and I'm just slowly getting, you know, sort of more obese every year. I've tried every diet, I've tried, you know, this diet, that diet, Weight Watchers, know, shakes, all that sort of stuff.

Yeah, they all sort of worked for a little while, I, you know, I put it back, you know, and I'm just, I'm desperate, you know, and I've sort of a bit disillusioned as well, cause I've tried all those things, spent all this money and nothing's, nothing's worked, you know, I mean, what's, what's your approach to someone like, like that, you know, walk in, you know, you see, I'm obviously obese, you know, and, yeah, how would you approach that person?

Dr Fran Ramsay (11:49.554)
Well that's very typical of the patients that I see. So I would always take a full history. I talk about their weight history. Were they a normal weight kid, underweight kid, chubby kid? And then some sort of weight trajectory. So what was their weight? 18, 21, 30, 40, 50, except. So I can have an idea and then I talk about.

what have you tried and what success may have you had. So I get an idea of the sort of the up and down. And yeah, by the time people see me, they have tried everything. They've tried every diet, they've seen dieticians, they've joined the gym, they've tried shakes, they've medications and operations, maybe even two operations. So it's not through lack of effort that...

they're struggling, it's through lack of understanding. So I take my role as a supporter and an educator and I explain to them why this has happened. And this does go back to the poor dietary and dieting advice that we've all been given.

And they've probably followed all of that advice, but all of that has actually just primed them for weight regain after weight loss, and it's primed them for metabolic dysfunction. So I say, this is not your fault. this is not, you know, they carry a lot of shame and guilt unnecessarily, because when you look at the dieting, eat less, move more model,

What that's really saying is if you're overweight, you're eating too much and you're not moving enough. So it's really your fault.

Dr Fran Ramsay (13:42.81)
So they've lived with that shame and guilt. They think it's a lack of character, a lack of willpower and I explain that's not the case. This is a matter of biology. This is a matter of physiology. Let's have a look at your metabolic health. Let's do some blood work. And I look at everything from thyroid to vitamins and minerals and liver function and...

markers for diabetes. also do the fasting insulin, the HOMA index, which is a marker for insulin resistance and that's quite sensitive for carb load in their diet. I do it all. So we do the blood work. Often in that first meeting I'll take a quick diet history like what's their routine at the minute so I can sort of gauge

what their diet is like. And often it's very high carb, but they always say, I eat a really good diet. And then you ask them what they're doing and it's very carb heavy. And that's what the old food pyramid was. We were taught to have toast in the morning, breakfast cereals, low fat crackers, sandwiches, and then at dinner, side serve of pasta rice or a wholemeal bread roll. So that gives me an idea. I often will...

Peter, open up the Defeat Diabetes app and we'll look together at one of your videos which explains about diet or how did we get it so wrong. That's a real time saver for me, so thank you very much because you get across and hit home a lot quicker than I do. So that's been very useful. And I give them some reassurance that, you know,

there is a way forward, but we just need to look at your metabolic markers, we need to have a look at your diet, and let's go get the blood tests, come back, and then we'll take it from there. So then when they come back, mostly they will have a raised HOMA index, and we talk about insulin resistance. And it's like that aha moment, the penny drops and everything kind of clicks, and everything changes from there.

Dr Fran Ramsay (16:03.844)
It's about empowering that person to understand their physiology, how human metabolic health works and how there's this connection to their diet. And it's about helping them connect the dots so that they can make those meaningful changes, not just a crash diet or...

you know, this is going to be a quick rapid transformation. This is a slow, calm journey for them of stabilizing their metabolic health, getting them to understand the connection between glucose spikes, insulin spikes, and what they're eating. And a really good device for that is a continuous glucose monitor. I use them all the time. And that again helps connect the dots between

you know, what they're having for breakfast and there's this huge spike of glucose. And then we know that that will mean that there's a release of insulin from the pancreas, which will mean that that glucose will then go down lower probably than where it was. And that's about two hours after they've had breakfast. And that's when they complain of hunger, pains, food, noise, cravings. So connecting the dots between hunger, cravings and energy is all part of that

learning process. So it's a bit of a journey, but I really enjoy it. And more often than not, when people engage, it's not hard. It's actually relatively easy. And what happens is they gain back that control. They're not at the mercy of hunger or cravings or food noise anymore. They know how to calm things down. And in that process, they lose weight.

It's not, it's not, you know, it always happens that they will lose weight.

Dr Peter Brukner (18:11.192)
Yeah, I think, you know, one of the big things is you give people hope, don't you? Because, know, up until then, they've really, they've pretty much given up, haven't they? you know, you're the last, I'm sure that many of them come to you and say, you know, you're my last resort, you know, please help me. And yeah, hope is a really important thing.

Dr Fran Ramsay (18:15.41)
Hmm.

Dr Fran Ramsay (18:19.187)
absolutely.

Dr Fran Ramsay (18:29.844)
yeah, I often have people have a little weep actually because they're so relieved that it's not their fault that they don't have to feel shame and guilt anymore and yeah there is hope and there's a way forward and it's relatively easy and I do this every day of the week.

Dr Peter Brukner (18:47.042)
Yeah, no, well done. It's remarkable. Okay, so how I mean, you know, how often do you see your sort of your patients, you know, you obviously see them initially, then, you know, a week or two later, when they've had their bloods done, and you have to do review and so on. What's the process from then on?

Dr Fran Ramsay (19:08.626)
I see them as often as they would like to be seen. So for some people, making a follow-up appointment and knowing they're coming back is a way of being accountable and they find that that's very helpful. For some people, I might only see them once or twice a year for their annual bloods. I always do annual metabolic markers, but they're often doing really well.

I say to people to have, when they're in maintenance mode, they'll often maintain their weight between a two to three kilo range, but if they're weighing themselves once a week at home and their weight is creeping up,

pick up the phone, don't press the panic button, press the help button, come back and see me. It might be time to check their metabolic markers or it might be time to get another CDM, continuous glucose monitor, or just to have a chat and just see what's going on, what's happened in their life. If sugars and carbs come back in or what's going on, just two minds are better than one to try and work out what's going on. And we can often work out what's going on.

patients I will see them quite close together for a period of time and then once they're steady and stable we'll stretch it out and stretch it out again but you know often I do encourage them to come back some of my patients I've been seeing in Hobart or lots of my patients I've been seeing for 10 years now and they still come back and it's good to do those metabolic markers and make sure that they're doing well.

Dr Peter Brukner (20:53.016)
Okay, I've seen you, I've been inspired, I've lost weight, but you know, I had a death in the family, I lost my job, my kids are off the rails, whatever. And I've gone off the diet, I've failed. I put the weight back on, I'm feeling guilty, miserable, terrible, I'm a failure in life, I can't do anything right. Watch your approach to horrible me.

Dr Fran Ramsay (21:22.98)
Yeah, well, you're not horrible, you know that. And sometimes people don't come back because they say, I'm embarrassed. may not see them. And by the time I see them again, they have regained a lot of weight. And they say, I didn't want to come back because I was so embarrassed. think, don't be embarrassed. That's just a wasted energy. I don't think poorly of anybody. I'm just here to help. So let's just put out.

detective hat on and let's just have a look at what's happening. If there's been, you know, the sugars and carbs have come back into their diet, often what I'll suggest is let's up the fats and proteins because that often cuts dead the sugar cravings. And we know that, we know that the highly processed foods, the...

the starchy carbs, the sugars, they activate the reward pathways in your brain. And the real foods like salmon and egg and pork chops, they just don't. I say, just up your fats and proteins, let's go and do your metabolic markers, let's check for insulin resistance. let's press the reset button. And a period of abstinence off those foods that they're

their craving does help. yeah, we just, know, every person is a different, you know, set of circumstances and you mentioned, you know, a lot's happened. you know, stress, stress plays a big role in your cortisol, your sleep patterns, which can all affect, you know, your weight in the long term. So,

Is there needing a bit of support there? Do they have a good GP? Do they need to see a psychologist? What's going on in that space? Can we add some extra support in? And we can get people back on track relatively easily, as long as they come back and have a chat.

Dr Peter Brukner (23:33.038)
Yeah. You mentioned support. do you, I mean, obviously family support is, or, you know, whoever you're living with, it's very, really important to have their support. I mean, do you sometimes see their partners or family members as well, or how do you, what's your approach to sort of the family?

Dr Fran Ramsay (23:48.946)
Oh yeah, I see. see. Yes, I see spouses and I see children and yeah, yeah, it's lovely and it's lovely to see. I mean, sometimes I don't see them, but I hear, oh, my husband's also lost seven kilos or, you know, that sort of thing. So I say to them, you know, this is not just for you. This is for everyone in the family. Spread the word, you know. So yeah, yeah, it's environment, food, food environment.

it plays a big role in metabolic health.

Dr Peter Brukner (24:24.398)
Insulin resistance, you've mentioned that a few times and it's obviously very important. I I think it's something that is quite hard to explain to people. I'd love to know your sort of explanation. Well, firstly, maybe tell us a little bit about the HOMA-IR test because I know you're in that sort of insulin test, which we both believe are really important. And I know you do that on all your patients.

Yeah, I mean, how would you again explain to a patient, you know, what the significance of an abnormal homo-IR might be and what does insulin resistance mean?

Dr Fran Ramsay (25:02.234)
Okay, so when I do the metabolic markers, I order fasting insulin, fasting glucose, and the Homer index test is a calculation of those two numbers. So it's fasting insulin times fasting glucose divided by 22.5. Now don't ask me why, I don't know. I don't really need to know. But yeah, that's right.

Dr Peter Brukner (25:28.354)
much clever people at us have worked that out.

Dr Fran Ramsay (25:31.686)
But if it, normal is less than two. If it is above two, then it's possible that you have insulin resistance and then it's graded up. If it's higher than three to four, it's probable and then it's diabetes and so forth. So I say to people, doing this blood test is a good indicator of your metabolic health. And...

If it comes back positive for insulin resistance, that's a good opportunity to educate them that this marker has been connected to people who are high risk for diabetes, heart disease, stroke, and some cancers. And it is a good indicator of your carb load in your diet.

So every time your blood sugar spikes, and the only way that can happen is through what you digest, then your body's not designed for you to be walking around with a high blood sugar. It very quickly wants that blood sugar reduced. So it sends a message to your pancreas to secrete insulin, and insulin will get the blood, the sugar from the blood into your body cells.

But insulin is your main hunger hormone and your main fat storage hormone. And so if you've got higher levels of circulating insulin, your body just doesn't seem to, it loses its sensitivity to insulin. So it isn't able to do that job very well. And so slowly your blood sugar will start to rise and then.

you know, you're looking at diabetes. And also as we age, our pancreas ages and it slowly sort of gives up the ghost if it's having to work very, very hard all the time. So what someone may have been able to have in their diet when they were younger, they can no longer have in their diet because their tolerance to carbs.

Dr Fran Ramsay (27:46.298)
markedly reduces. So it's an indicator that they're having too many sugars and carbs and it's affecting their metabolic health and if we don't turn it around then I'm very concerned that they may end up with a chronic disease. Your video is much better explaining that than me to be honest.

Dr Peter Brukner (28:06.566)
No, No,

Obviously, presume, well, firstly, do you use those drugs? When do you use them and how do you use them? I guess they're the sort of queries I would have.

Dr Fran Ramsay (28:49.018)
Well, I mean there's been a lot of obesity medications over the years and each time a new one gets released there's high hopes that this is the magic bullet that everyone's hoping for. But unfortunately there is no magic bullet. I look at semaglutide, ozimpic, wig ovie as a useful tool but it's not a standalone solution and I've been prescribing it.

for a couple of years, so I've got experience with it. And the way I look at it is if it makes a patient who's struggling ring up to make an appointment to come in to see me to have a discussion, then that's a great opportunity for me.

to get them on board with regards to understanding their metabolic health, assessing their metabolic health, going down the education route to helping them improve their diet and get that diet correction. So it's a good opportunity. With regards to starting...

the GLP ones, I have to do a workup beforehand. I just can't write a script. I've got a duty of care to these people. I need to understand what's happening here. that in itself is the first step and then they'll come back and we'll talk about their metabolic health. And I'll often say, in order to get the most out of this medication, you really need to correct your diet.

you really do need to increase your proteins in particular because there is a risk that perhaps you might lose weight but it's not gonna be fat weight, it might be muscle weight. So let's bulletproof you and let's increase your proteins and your natural fats.

Dr Fran Ramsay (30:46.738)
Let's actually order a continuous glucose monitor first so we know what's happening in your body, we know what foods are agreeing with you and not and get an idea as to your own glucose and insulin spikes. Once you've kind of done all that, often they've lost five to seven kilos over those weeks where I'm doing all of that and then often they'll say actually I don't want the script after I'm quite happy keep going.

But that, mean, I have prescribed it and I do know that if people don't make the dietary corrections and they keep eating the high carb starchy foods, they may initially lose a modest amount of weight, say five kilos, but then it stops and they get really disheartened with it and they say, stop working.

The drugs don't override what's happening with regards to your physiology if you continue to eat high carb foods. And they certainly don't fix the underlying metabolic dysfunction. So they're not the magic bullet, but they can be a useful tool to help motivate people to make those long-term behavioural changes.

Dr Peter Brukner (32:08.728)
So you don't feel like can really be effective without a change of diet in your experience.

Dr Fran Ramsay (32:16.144)
I've never seen it. I've not seen it. I've seen some people lose a fair bit of weight, but when they come and see me and so forth, some people don't eat very much at all. If they get a prescription and they're not getting the necessary sort of dietary recommendations and they don't know, they may not know.

Dr Peter Brukner (32:17.826)
Really.

Dr Fran Ramsay (32:45.446)
what they need to do. Some people actually, because you get such a decreased appetite, they actually aren't eating a lot. And I really worry about their nutrition and nutritional deficiencies will catch up with them. I mean, you can't run a car on water, like you need to put petrol, you know. So they're not magic. You can't...

go onto them and have your appetite suppressed and eat, you know, poor, poor food, like small amounts of poor food and not think that that's not that that will catch up with them. Eventually.

Dr Peter Brukner (33:26.762)
our colleague Zoe Harkum who's been on this webinar before, mean, she's quite convinced that within two or three years they'll be banned. I mean, she says that history shows, as you mentioned, every anti-obesity drug has come onto the market, big fanfare, you this is the world's greatest drug, solution. And within a fairly short period of time, it's shown to be not effective or significant side effects and so on. And certainly, you know, every second day in the...

news now is something about, you know, last week was pancreatitis, this week it's psychological suicidal tendencies. You know, I mean, they're probably relatively rare side effects, but they seems to be sort of, you know, accumulating. And so I don't know, do think they'll be banned? Do you agree with Zoe or are you all the same?

Dr Fran Ramsay (34:14.032)
Yeah, well I'm not sure about that but you certainly need more studies and longer studies and I'm particularly worried about the use in children. I think you know that that does concern me.

Dr Peter Brukner (34:30.318)
And this whole business of osteoporosis and sarcopenia, so reduced bone mass and then reduced muscle mass, which is a huge issue in older people. That's why we're encouraged to do a resistance exercise and make sure we don't, we minimize that muscle loss that we're having anyway as you get older. Speaking as an old person, I can say that. that this is only going to exacerbate that and cause a real problem, as you say.

Dr Fran Ramsay (34:39.602)
Mmm.

Dr Fran Ramsay (34:46.352)
Mmm.

Dr Peter Brukner (34:56.558)
increasing the diet, the protein component of the diet can maybe mitigate some of that. it's a real, I think it's a real concern. think we're to have an epidemic. I mean, we already do, but it's just going to get worse and negative effect on the the older generation.

Dr Fran Ramsay (35:05.765)
and

Dr Fran Ramsay (35:09.284)
Yeah.

Dr Fran Ramsay (35:12.922)
Yeah, yeah, no, I'm concerned too.

Dr Peter Brukner (35:16.494)
Yeah. Let's talk about the you know, you said you moved to to Hobart 10 years ago. So I mean, is there a different, you know, clientele? mean, Brisbane people different from Hobart people? mean, you know, what did you know? mean, did you notice any other than, you know, wearing a lot more clothes, keep warm. I mean, you know, what was there any is there any difference do you think in the sort of the culture and the

Dr Fran Ramsay (35:33.849)
Bye.

Dr Peter Brukner (35:44.622)
the type of patients you see.

Dr Fran Ramsay (35:48.646)
Well, mean, there are differences. I do work in sort of probably different socioeconomic areas. But on the whole, metabolic dysfunction, of which obesity is part of, doesn't discriminate really. I mean, I see people from all walks of life, of all ages, of all levels of education.

So it's kind of endemic and it's penetrated into every single sort of household in Australia, I think, with regards to just poor nutritional literacy, not their fault because it's all just based on what we were told to do, but it's a jolly big job trying to educate people just to make those small changes, which over time will...

mean a lot with regards to their weight and their metabolic health. I guess if I was able to try and turn the tide and make a big impact, I could wave a magic wand and swap out

the typical Australian breakfast, which is usually sourdough or wheat bakes or rolled oats or fruit smoothie, juice. For a nutrient dense real food breakfast, I think that would make a huge impact on the health of

everybody and you know set up that modeling of behavior for that next generation to start the day with eggs, Greek yogurt, leftover you know from last night's dinner or low carb bread with butter and avocado. I mean that would just start the day with just such a calm you know no rise in insulin not setting off the hunger pains that ferocious appetite.

Dr Fran Ramsay (38:08.058)
send children off to school, not hyped up on a sugary breakfast, you know, it would be calmer in the classroom. it's really a problem that doesn't discriminate. It's penetrated into everyone's house.

Dr Peter Brukner (38:29.038)
Yeah, yeah. Okay. We've got a few questions from members of the audience. I might just run through some of them, Fran, if that's okay. Gabrielle talks about how to get back into weight loss. So she already lost 16 kilograms, but sort of leveled out a bit and doesn't seem to be able to take that next step. And that's quite a common, I'm sure you see that quite a lot.

Dr Fran Ramsay (38:39.13)
Yeah, sure.

Dr Peter Brukner (38:57.774)
you know, that people sort of plateau that, uh, at after, know, whatever, six months, 12 months, whatever, you know, and they, they're, they're all excited. They're steadily losing weight. And then at some stage they'll just sort of, uh, you know, level out a bit. and, uh, despite, know, seemingly they would say still doing the same thing, although that may not be the case. Um, what's your approach to, to someone like Abriel?

Dr Fran Ramsay (39:20.946)
Okay, well there's probably a few unknowns that I don't know how to fill the gaps there. So with regards to the first thing is realistic goal setting. I'd want to ask Gabrielle what was her heaviest lifetime non-pregnant weight?

and then work out what percentage of weight loss was she wanting to aim for because I know there's something magical about maintaining a 20 % drop in weight regardless of whether your heaviest weight was 300 kilos or 100 kilos. I'm not saying that people can't lose more than that and I've certainly seen people lose much, much more than that but that just seems from the 10 year studies to be where most people will maintain and that's a fabulous result. We know that just maintaining five to 10 %

can be enough to change your metabolic markers. it's about setting some realistic goals there and also making sure that someone's not aiming to get too low in their weight because there's health risks with getting too low in their weight or underweight. I'd also just want to probably with Gabrielle make sure that her metabolic markers have been looked at, what's her HOMA index indicate.

with regards to insulin resistance, you know, what is her diet like, how many grams of carbs is she having in a day. But if we've sorted through that and everything's okay and the right number of carbs that we think and we've hit a plateau, which always does happen, weight's never a straight line, it's always down and then maybe plateau and maybe up and then back down again, that's normal.

Dr Peter Brukner (40:50.382)
BOOM!

Dr Fran Ramsay (41:08.786)
I might talk to Gabrielle about maybe adding in something like intermittent fasting one or two times a week, know, fasting overnight for 16 to 18 hours.

that can sometimes spark a little bit more. I might talk to her about some resistance training. Is she over-exercising? I do find that if someone's doing high-intensity exercise and that's where they're getting huffed and puffed, they can't talk, they can't sing while they're exercising, then we need to tone it down a little bit because that high-intensity exercise might actually be making them too hungry or slowing down their metabolic rate. So it's just a

about again putting your detectors head on and just having a look at different parameters. What's the sleep like? What are your stress levels like? All of those things are really important. And also not focusing so much on scales, you know, how your clothes are fitting, your sense of fitness and wellbeing. They're all really important as well. Sometimes we can get really super focused on the scales and that can do your head in as well.

Dr Peter Brukner (42:17.486)
Great, now you mentioned intermittent fasting. So that is a nice segue into Maz's question, which is, what's better for reversing insulin resistance, low carb or intermittent fasting? I think I know what you're gonna say, but let's.

Dr Fran Ramsay (42:34.192)
Well, I don't think there's a head-to-head study that compares it both, but I guess I would always say let's do the low carb first. Let's get that on board and let's make sure that you're eating to keep your insulin nice and level and that keeps your hunger levels regulated, your energy levels are good. And once we've got that settled,

then bringing in intermittent fasting is a good strategy as well. So low carb reduces the amount of insulin that is released and insulin and intermittent fasting reduces how often it's released.

If you wanted to do a 16 to 18 hour fast and do that a few times a week, that's fine by me. Happy for you to do that, because that often will just bring that insulin down to that next level. However, if you fast for too long, if you fast for 22 hours, then you'll lose all of the benefit of that. And if you then fast, but then have lots of carbs in...

in the other hours of that day, well that's of no benefit either. I think it works better as a combined strategy.

Dr Peter Brukner (44:00.088)
Yeah. Well, you do hear people saying, you know, they do a two or three day fast, a reset or, you know, a cleansing fast or whatever. mean, what would be your approach to someone who asked you, you know, should I try a two or three day fast?

Dr Fran Ramsay (44:17.604)
I wouldn't recommend it. To me that sounds like a bit of a crash diet. There's not a lot of science to support that. I've never advocated it. It's never come across as something that I should be advocating to my patients. I don't think that's a good idea.

Dr Peter Brukner (44:40.206)
Okay. Now, I've got a question about the challenges in around perimenopause or women, you know, I think we just obviously have a lot of a lot of issues with with weight and insulin resistance on any particular approaches or issues to that group of people or is it just the general sort of principles you've talked about?

Dr Fran Ramsay (45:08.09)
I'm starting to sound like a bit of a broken record, perimenopause is the perfect storm really to be honest because it happens at a time where we're naturally aging as well. Our pancreas is aging. So our natural...

tolerance for carbohydrates is starting to go down. And interestingly, men around that age group between 45 and 65, men also get an increased central obesity around about that age and worsening insulin resistance around that time. So that's happening in the background. Then you combine the reduced insulin and the fluctuating levels of progesterone and inability to sleep very well and the extra stress that that causes and the loss of...

muscle bulk around that age, though it is the perfect storm. So it is a difficult time, you know, just a few minor adjustments and it can make, you know, all the difference. So again, I suggest let's increase the fats and proteins. Let's make sure we've got protein with every meal. Let's start the day with, you know, quite a protein.

based meal, so maybe some salmon or last night's leftovers, that sort of thing. Let's making sure that we're adding in resistance training, that's really important in that age group.

So it is, you know, and it's again checking the metabolic markers and honing those, the diet with the use of a continuous glucose monitor to make sure that that woman knows what foods are spiking glucose and insulin so that she can eat accordingly. So you can get, you know, that change in body shape, that central obesity, but menopause is not actually responsible for

Dr Fran Ramsay (47:04.718)
an ongoing weight gain. It's more just general aging and that starts around at that time.

Dr Peter Brukner (47:13.422)
Right. Question from Jill, is obesity really a genetic issue or is it just that because it does seem to run in families, is it just because families have similar eating patterns or is there actually some genetics involved as well?

Dr Fran Ramsay (47:29.154)
Okay, obesity is not someone's destiny. It is more related to the environment. So if you look at adoption studies, the weight of that adopted person will more closely correlate with their adoptive

families and their biological families. So there are certain genetic conditions that can make you more vulnerable like polycystic Ivarian syndrome which can increase your risk for insulin resistance but it's really that food environment, lifestyle behaviours that set someone up for a problem with weight and I see that every day that

Someone can change their biology by changing their diet regardless of what's happening with the rest of the family members. And it's the same with diabetes. You can have a family history of diabetes but you can also reverse that diabetes regardless of what's happening with the other family members. So it's more environmental than genetic.

Dr Peter Brukner (48:47.982)
And you mentioned to me many times previously that you're a big user of Defeat Diabetes, of our program. How do you use the Defeat Diabetes program in your practice?

Dr Fran Ramsay (49:00.946)
Well, I encourage all of my patients to join and I do as I mentioned before I do watch some of the videos with them during a consultation. I do find that they're more likely to to do that and engage if I do that with them rather than saying can you please go away and here's a list of videos I want you to watch and

people will come back and they'll thank me and they'll I've joined the program. I've looked at the recipes and yeah, it's been a very helpful resource for me, Peter, because yeah, it's been quite lonely out here. So it's nice to have people I can say, look, I'm not just saying this. I'm not making it up. There's a lot of science and a lot of other people think this is case as well. So yeah.

Dr Peter Brukner (49:45.208)
Yeah, I understand that.

Dr Peter Brukner (49:56.576)
Yeah, that's great. All right, we're nearly out of time. Just one last comment. mean, if you had to give one piece of advice to people generally in the population, what would that be in a sentence or two?

Dr Fran Ramsay (50:14.298)
Okay, one piece of advice.

Dr Peter Brukner (50:15.278)
Question that, just...

Dr Peter Brukner (50:20.27)
The importance of breakfast. Okay, we'll take that one on that.

Dr Fran Ramsay (50:23.108)
Yeah, think that is what I think would make a big difference to the health trajectory of Australians is to get education out there with regards to improving breakfast. I would encourage everyone probably to talk to their doctor about getting their metabolic markers checked with regards to fasting glucose, fasting insulin and the Homer index.

and if they're confused and they don't understand then I would suggest that they get onto the Defeat Diabetes program and have a look at the videos and the master classes and encourage their GP to become a HCP partner which gives them access to all of the resources. The more people that can be educated and have that

penny drop moment and then spread the word, then the healthier we will be as a population.

Dr Peter Brukner (51:29.58)
that's certainly what you're doing and making a fantastic contribution to the people of Tasmania. You're very lucky, I think, that you moved down there and you're having a massive influence on so many people there. So, Fran, keep up the good work. Thanks for joining us today. It's been a real pleasure and I'm sure our viewers have really, our listeners have really enjoyed your insights into obesity management. So, Fran, thank you very much. Great.

Dr Fran Ramsay (51:54.14)
Thank you. Thank you for asking me,

Dr Peter Brukner (51:58.424)
We'll see you next time, everyone.