Ozempic, Weight Loss, and the Metabolic Truth No One Is Talking About | Ashley Koff

25:08What would you recommend is the most ideal breakfast? Yeah. And I don't believe in superlatives, whether it's ideal or average. What I would say is lean into you personally. And this is going to be different every single day. you may wake up and your digestion may not be woken up, right? You're like, maybe you had to get up too early, or maybe it's a certain time of the month, or maybe you're really stressed out about something. And at that time period, liquid nutrition may actually be easier for you. So your body doesn't have to do all the digestive work. So sometimes I lean into, you know, something that's where maybe a smoothie or even some concoction with your coffee where you're like, okay, I got in some nutrients and we'll talk about what those are in a moment, but I was able to get that in.

25:49And then I might chew a little bit later. or do that kind of thing, and it's absorbed. I think the other side is it's really important that your food at every point in the day is delicious to you. I actually give people an exercise of, I call it the delicious to me scale. On a scale of one to 10, with one being not delicious and 10 being absolutely delicious, is it a seven or greater? When our food isn't delicious to us or our beverages, we go looking for something else or we overeat or we walk away unsatisfied, which leaves us with this lingeringness of like, when am I going to have something next on that part?

26:21So for example, sometimes what is the most delicious to me is something savory and something like from the evening, you know, or I walk by somewhere and I'm like, oh my gosh, yes, I would love to have like salmon and lentils for breakfast, you know, or whatever. And that might not be delicious to anyone else ever, but you know, I might lean into that part. And then from a nutrition standpoint, we definitely want to lean into, for most of us, a balance of nutrients. So some carbohydrate, protein, and fats. And I know plenty of people will say to me, don't get in a carbohydrate. You know, you don't need carbohydrate.

26:54Most of those people are also confusing stimulation with energy and really thinking about, you know, oh, I can get quote-unquote energy, but their coffee is giving them more of a stimulant. But the other thing is carbohydrate is a delivery mechanism for a lot of important vitamins and minerals and also for fiber. So we need to get that in somewhere. Then proteins and fats. And I look at somewhere in the neighborhood of maybe 15 to 30 grams carbs, 15 to 30 grams of protein. We'll talk about that in a second. I like more than five grams of fiber for most of us, again, depending on your digestion.

27:27And that sort of nutrient balance gives us a good amount of energy at a pace that's going to unfold energy for the body over the next three hours. Where the issue is, you know, I think where people struggle in that part is, you know, the messaging out there, like everyone needs to get in 30 grams of protein, or another messaging would be start the morning with a protein food. There's, or start the morning with protein. There's no food in nature that is just a protein. So you're going to get carbohydrates in if you have any sort of plant protein. If you, well, maybe, yeah, you get a little bit from hemp seeds, but you're going to get in other places, you might get proteins and fats, or you might get a food that is carbohydrate, protein, and fat.

28:07So we need to start to look at the foods and the nutrients and sort of blend those together. So for the person who loves a bagel and it's actually a delicious bagel, I would rather that it wasn't enriched flour as an example, but it was actually like a good flour. Maybe it's even a sourdough. Maybe that's a little better on their digestion, but maybe they take half of it instead of the whole bagel. Maybe they like cream cheese. Great. Maybe they don't like cream cheese. And somebody was telling me the other day they put cottage cheese on their bagel. Somebody else put mustard on their bagel. You do whatever on that part.

28:39Maybe you want salmon. Maybe you want peanut butter. I mean, a lot of options on that piece. But if the bagel is the vehicle there that actually fuels you better and you enjoy it and it's delicious, if we then see from your blood sugar, your digestion, all these other things, that that's working better for you, great. If we take in too much carbohydrate, if we have the bagel and then we have an oat milk latte, suddenly now we're forgetting that what's in our beverages is also going to matter. So the one thing about your breakfast is you really need to look at your total nutrition. You need to look at, are your supplements, you know, if you're having gummy supplements, are they giving us carbs, you know, like proteins, fats, like any of those things.

29:16So how you design it is very much a Burger King ad. Have it your way, but, you know, try to have it have that nutrition and try to have it be delicious. Talk to us about nutrients in coffee. Yeah. So there's two things probably to consider there. First of all, I think we should talk about the quality of coffee. Like there are, you know, your coffee can be an example of where you're washing your floor with dirty shoes. So if the coffee is dirty to you, you're going to be bringing in toxins and that's just not better, you know, so a cleaner coffee and a little bit better on that part. I think many people actually do well with having something in their coffee because it's less irritating because it's that coffee can be very acidic and, you know, irritating to the digestive system.

29:53So within there, I'm a big fan of flavor. So depending on what you like from a flavor standpoint, I would lean into that. There are some nutrients though, where the coffee is going to interfere with the ability to absorb those nutrients. And so I would say whether it's nutrients in your coffee or it's things that you're having at the same time. As an example, my understanding is that creatine is not that heat stable. So don't necessarily have your creatine in your coffee. That's disgusting. Don't do that. And I'm also like, don't do that. But I have people who like collagen in their coffee. But, you know, but like anything that's like you can tell immediately if it's like super clumpy and disassociated, like that's not going to be better.

30:31I have collagen in my coffee. Yeah. It totally blends in. And it blends in. And apparently, like, you know, when you look at it and they show it. Yeah, creatine. I know. Yeah. And, you know, the heat, I think, is a little bit there. Yeah. So I think, you know, in that way, I mean, there's a part of like the crazy world. You know, people will ask me like, you know, is it better for you to have broccoli cooked or raw? And I'm like, well, it's kind of better to just have broccoli. But if raw broccoli makes you really gassy or bloated or you don't like the taste of it, cook it. Yes, you might see some nutrients lost, but you also might see some nutrients gained.

31:04I think we're just in this society where we're so like right versus wrong, you know, like all this stuff. And nutrition is extremely nuanced and needs to be personalized. Yeah, well, that's what every influencer that asserts they are a nutrition expert but isn't factually a nutrition expert tries to do is everything's very black and white. I mean, you even see now I'm like, I can't believe I've lived long enough to see people pushing, eating raw chicken on the internet. And I, oh, you haven't seen this. Oh my goodness. I feel like we need to like pull a reaction video. Like my jaw is on the floor.

31:41Yeah. That's a thing. Seriously eating just raw chicken, eating raw meat. And I'm like, wow, why are we not teaching microbiology in elementary school? because seriously, this is not going to bode well. But, you know, in this conversation, you had brought up pit stops. And I think it's a very interesting thing that we just kind of like glazed over really quick. Can we go a little bit deeper into like the dietitians approach to pit stops during your day? Good sleep is everything. That's why Ali's Science Back Support is made with a blend of melatonin and L-theanine for both kiddos and grownups.

32:18So when your mind won't switch off, you've got something that can help. Erasing thoughts and restless nights won't stand a chance. Find Oli Sleep Solutions for the whole family at Oli.com. That's O-L-L-Y dot com. And I think I could say, like, it's this dietician. I have a lot of dieticians that don't agree with me. I'm fine with that. Like, you know, I think many times they come around to the conversation. But one of the issues that we have is every word is, like, so loaded. So the marketer in me was like, uh-oh. I had people that, you know, they felt meals would be something and snacks would be another, you know, snacks are fun.

32:55Snacks are grab this. Snacks might be okay to be incomplete. Snacks could be a little bit naughty. A meal has to be this. And I share in my book that one of the women came in and she was like, you know, Ashley, I mean, I never have lunch and I know that's such an issue for me and why I'm overeating on dinner. And then I asked her to give me her food journal for a couple of days. And I said, you know, Laura, I think that you've been having four lunches a day because basically what was happening by not actually stopping to have lunch, she's like, oh, I usually grab something from the break room or I might snack on something when we're at a meeting or if I run to the coffee shop or whatever.

33:29And I went through and I was like, in the four hours between 11 and 3 p.m., you have had four pit stops in there. So I realized that meal and snack were no longer helpful terms. They have just too many things. And if we think about the body as an operating system, one of the operating systems that I think we're all aware of is a car. Yes, it's changed considerably. But when you think about a car and specifically a race car, we can lean into that idea of pit stopping. You don't put too much into a race car. You don't put like three or four extra tanks of gas in there and then have it run around.

34:01That would be really dangerous. You also want to have it as light and nimble as you can go. And so you put the exact right amount in, same with air in the tires, same with oil in the engine. It goes its three laps and it comes back and it's like, let's do it again, right? Well, our body really likes that. It likes that because it wants to use, it wants to get in, go through the process of getting what it gets, and then be able to use it. And anything that it can't use when it gets too much at one time, or maybe it has to figure out, like, can I use this? Can I not use it? That's sort of where it tucks it over into the fat side and into the fat storage.

34:35Or if it's something that, you know, alters or disrupts the function of the body, it's going to be more problematic. So pit stopping to me became a nutrition recommendation. I was like, hey, I kind of don't care what you call it. From the morning you wake up, you know, maybe about like, you know, within about two hours, I'd like you to have your first pit stop. And then we usually have pit stops, three-ish hours, better not perfect. You know, life doesn't happen in three-hour increments, but about three-ish hours until ideally, you know, maybe around two to three hours before you're going to go to bed, you know, on that part.

35:05And then it became, as I started to work with people who were also hearing other messages that were unhelpful. And I was responding to them where somebody said, oh, I exercised for 30 minutes today. I'm super, I was happy for them. But then they sat the rest of the day. And it was just like, and this is not somebody who is like not successful, lazy, like anything else. I don't think people are in that way. This was somebody who literally just went to work the rest of the time. They drove, they went to work, then they got an airplane, whatever. And I said, you literally got in 30 minutes, but the rest of the day was, you know, not activity.

35:36I realized you've got a pit stop for movement about every three hours, right? Then I turned around and I was like, you know what, we're on all these devices. You know, we're kind of like our eyes are doing all this other stuff. I heard my, you know, brilliant colleagues talk about how our eyes need rest and we need to, I was like, we got a pit stop for our eyes. And then we're on the hydration side. So I basically came to realize that, you know, about every three hours in a day, if we pit stop to check in with our bodies and figure out, you know, how do I nourish that body? and that's a process of movement and nutrition and, you know, other lifestyle choices, that's a really good way to think about and to have a day unfold where I now have leaned into what my body's needs might be.

36:15Okay, I want to talk, I got a question for you about the pit stop, but I got to ask you first, where do you come from in the world that you're talking NASCAR or Formula One? Yeah, so I mean, there are so many where's do I come from on that part. So I come from... No, but I'm like, are you from Kentucky or something? Well, I grew up in Ohio, so I'm pretty close, you know, so we've got that part. But when I was selling sugared cereals, we had Smart Start, which was the Kellogg cereal that I was working on. And we did an integration, you know, with NASCAR at that time period. And so I shot a bunch of quick commercials down at NASCAR.

36:48This was somewhere like 1995, you know, and I was like, oh, my gosh, this is another world, you know, on that part. Because the funny part is I legit don't know anything about cars. I'm the one that drove my car to, you know, with a$50 bill and that my mom had given me to go to a dance party. And I was driving other kids in there to the then the check windshield wiper fluid light came on and I drove to the gas station and crying. Ask the guy, is there any way I know you guys probably don't do this, but is there any way you could fix my car in the windshield wiper situation right now so I can safely drive the kids?

37:21And he was like brought over the container. He's like, I'm going to put it in for you. And he gave me forty seven dollars worth of change. you know, like that kind of thing. So I don't know anything about a car. I've, you know, learned a little bit, but you know, you turn around and you say, you know, you lean into it. And one of my favorite things, and you're asking on that is I've done four reality TV shows and one of the reality TV shows. Yeah, totally, totally. So I did shedding for the wedding. And then when I was doing this other reality TV show, one of the things they had us do on it, or you mark, I know I love that when you ask that question, and somebody asked, they were like, wait, were you like one of the hosts?

37:54Or were you want to on that? And I was on the diet on air dietician. So my practice was in Los Angeles. So, you know, I did a lot of those. And so we went around the country and a lot of the work that I did was in the South. And you know, what came into real handy was knowing about NASCAR, you know, so we went into the grocery store, we had these conversations, you know, like I knew on that part. And so it's fun to, you know, and I've lived all over, you know, and kind of lean into, but, you know, that's one of the other things about having something land and empower someone is you come in and you realize, you know, it is not about us all doing it the same way, but also it's not about all of us being told to do it in the same manner.

38:33And that's one of the reasons I love just, you know, podcasts and things like what you're doing, which is hearing from so many different voices, like hopefully somebody hears something maybe in a different way today, you know, that helps them on that part. Okay. So every three hours, We're doing the pit stop. Yeah, three-ish. Yeah, yeah. Who's on the crew? Yeah. What's on the punch list that's got to be maintained, that's got to be looked at? Yeah, yeah. So I think the underlying one is if you're having digestive issues at any point in the day, that's a good thing to lean into. You might not be able to fix it, but you may be able to sort of lean into making a different choice to optimize it.

39:06You know, and an example of that is like, let's say that you were kind of like gassy or, you know, maybe you had like some looser stools based on whatever. that might not be the time that you then go to lunch, like at your midday pit stop, as an example, and have something, you know, and have another coffee or have something that could be like a little bit more like harder on your digestive system. It might be where you don't even have like a raw salad. That might be where you have cooked vegetables, right? So checking in on your digestive system is great. The other one is water and hydration.

39:35So there we have to recognize that drinking half your body weight in water is just like not the hydration recommendation or drinking more water or making hydration at all about just water. It's about our water. It's about our electrolytes. But one of the pit stops is, let me pause for a second. And when was the last time I peed? So if I'm peeing all day, then I actually know I'm a hose. It means whatever's come in is coming out, like it's not getting absorbed. If I haven't peed at all, that's going to give me a good indication. And I should probably go ahead and have some water, but I might also need some electrolytes.

40:08I can get electrolytes from food. I can get electrolytes from a supplement. It depends on that part, but I need to make sure that I'm absorbing water. Do I have dry mouth? You know, do I notice, am I more fatigued? Do I notice that, you know, as I said, I haven't peed? That's going to help me, you know, from hydration. I have a fun little, are you a hose or a sponge quiz that I have people do where you drink eight to 10 ounces of water and see how long it is until you have to pee. And that'll help us like sort of gauge your hydration and work on that. And then you may need help with this and you may need somebody like, you know, a coach or somebody to help you with that part, or it may be something you can check in on your own.

40:43But I do these stress check-ins, and I ask people to, and this started off as a process I did for myself. When I'm stressed, my shoulders just start to go up like this. I talk faster. I talk from here. I don't talk from my belly. My digestion might feel a certain way. So what I started to realize is there are cues that our body can tell us that we've been in a stressed out state for too long. If we go all the way back to that blood sugar conversation, we're going to understand that that's going to be less optimal for us. And if we understand that elevated stress actually impairs digestion, it turns attention away from digestion.

41:16If we're eating, we're actually not going to be able to break it down and digest it. So one of the things I want us to do is to actually stop and breathe or laugh or punch something, hopefully like an okay thing to punch, or go outside. Hopefully. Yeah. Wait a minute. Don't punch a person. Don't commit a crime. No, no. Yeah, Exactly. You know, pet a dog, like do, you know, whatever, like lean into like, how can I actually bring my stress down? And that one, you know, is going to be important. And I actually, in my book, walk through all of these different ways to, first of all, understand your body signals and then ways to decode them and things to experiment with.

41:53You know, if you're on the toilet and you're having trouble moving your bowels, which is a stressful situation, what works for you there is maybe going to be different than if you're in a meeting or if you're somewhere else and you're trying to change your stress. So what we want to do is we want to really develop a toolkit of what are those things we can do in that pit stop. Yeah. I want to shift the conversation and ask you, as a dietician, what is your perspective on GLP-1s? Thank you. Yeah. First of all, I'm thrilled about them. They are teaching us all how the body works, I hope, right? And there's also, because they're there, pharma is investing in a lot of research that is showing us we have receptor sites for AGLP1 hormone in our blood vessels, in the endothelial tissue there.

42:38So we now are understanding that it's not just about the brain or it's not just about the pancreas and it's about this ecosystem. Where I'm also excited about it is that this is a tool that for someone where there's suboptimal function of their own weight health hormones, we can do this biosimilar hormone replacement therapy and we can either do it as like putting on training wheels so they can feel comfortable starting to ride the bike or we can come in and we can work on some other stuff and then use it you know just kind of depends and we can also for a lot of perimenopausal and menopausal women and men who are having shifting hormones we can help use it to offset some of the and to help us like balance our sex hormones too and you know really create a stronger foundation.

43:23Where I'm really concerned, I would say confused if I wasn't 52 and didn't have the degree of cynicism that I have about things, but I don't understand why dieticians and, you know, nutrition, why, you know, social work, therapists, coaches, why that isn't what's required for someone who is using this and how we've made it accessible. Because when you are using one, the dissimilarities, remember I said they're biosimilar hormones, they're not bioidentical. The dissimilarity means you're going from something in your own body that in optimal functioning is on for two to five minutes to something that's on for 24 hours, seven days a week.

44:03So think about your electric bill if you had a light that went on and off for two to five minutes, maybe six times a day. So 30 minutes, like you're paying for 30 minutes of electricity. Now say that you left it on for a week while you went on vacation accidentally. You come back and you're like, oh, I had a lot of hours that this was on. There are very significant functional shifts that are occurring in the body when that stays on. Those that affect our rest and digest, as we were just talking about. Those that affect fatigue. Definitely those that affect our digestive system. And because we're coming to these with suboptimal function, that's why we're seeking them out, they're also exacerbating whatever is already suboptimal or even dysfunctional underneath there.

44:45So as a dietician, it's a buyer beware. I like to use the term pros and considerations. By the way, like every single medication, let's not say that these are different. If you're going on a statin, if you're using a proton pump inhibitor, if you're using an SSRI, all of these are, I want to understand how they're working. And if I'm using them for any benefit, I also want to understand how else they're impacting my ecosystem. And then I want to partner with somebody who can help me do that optimization at every step, right? So if I'm shrinking fat cells, yay, like if I'm excited about that, if I'm losing my excess weight, or maybe I'm also taking fat and shrinking fat cells from the liver, which is really exciting, right?

45:28I'm getting rid of something that is a sign that my body suboptimally functioning. I'm releasing toxins into my body that have to be eliminated. Well, if my digestion is shut down, then I might actually see weight loss on the scale, but I am not seeing a lot of problems that are incurring inside my body. So as a dietitian, pros and considerations. As a dietitian, I wish I was like, you know, if you're scripting and if you're a physician scripting this, you have to ensure that your patient has access to this kind of care, in my opinion. Yeah. What do you think the biggest mistake that's happening right now in prescribing GLP-1s that we're going to come to regret in the next decade or so?

46:07It's probably twofold. I think that the I hate them when I'm asked for one, because I think these two are interrelated. You can have two. OK, all right. I know I always feel like and they're like, and could you vary? And I'm like, all right, I'm picking two. I think that, you know, I just said one. I think that not having a plan to optimize overall function is such a problem at every phase, because if you decide you want to come off of it, if you have to come off of it, if access, finances, or even desire, you've achieved, you know, some weight or et cetera, and you want to come off of it, if you haven't fixed anything underneath, you're going to just go back to a system that was suboptimally functioning.

46:46And so, of course, you're going to go back to, you know, problems or gain weight or, you know, do whatever on that part. I think the other one is our dosing strategies are ridiculous. And they're being driven by pharma. So that's the same thing, or the research, that's the same thing as an insurance company telling us how to, what somebody should be doing. You know, the practitioner, being a doctor, it's an art. You know, being a dietician, it's an art. We're curious about you. Even when I come up with recommendations, even when you come up with a prescription and a plan for someone, that's just an experiment to see how it works in your body.

47:20And so then if somebody is dealing with crippling fatigue. I had somebody the other day who came in and they had gone from having an espresso shot in the morning as a coffee to having four shots of espresso because they're so fatigued on their dose and they had not been going back to the doctor and they had just been increasing their dose. I was like, uh-uh, we're going back to that lower dose. That fatigue is hugely problematic because what it's telling me is during your body's recovery time, we're not getting enough recovery in there, right? Study and play. Come together on a Windows 11 PC. And for a limited time, college students get the best of both worlds.

47:59Get the Unreal College Deal. Everything you need to study and play with select Windows 11 PCs. Eligible students get a year of Microsoft 365 Premium and a year of Xbox Game Pass Ultimate with a custom color Xbox wireless controller. Learn more at windows.com slash student offer. While supplies last, ends June 30th. terms at aka.ms slash college pc. I can't have you achieve a weight goal and end up with a disease of I had suboptimal recovery time and we know what those diseases are you know that can be cognitive decline that can be you know actually during the day functioning less well and injuring yourself that can be that the body is suboptimally resourced and as a result disease you know sets in so I think this is really important for us to look at that.

48:44Yeah and when we're talking about dosing for people listening. There's a standardization in the protocol, which is, you know, depending on which one it is, you start at this dose, you typically increase every 30 days or every four weeks. The pen runs out in about four weeks. And it's just continuing to increase, to increase, to increase. And this is something that many people, I would say, who are responsibly prescribing GLP-1s have echoed in that the best dose is the one working for the patient. Why should we just go up? Because they've told us that like Ozympic is best when achieved at 2.5 milligrams, but at 0.5, you started having side effects and at 0.25, you felt great.

49:28You were reducing appetite. You were seeing changes. We don't have to go up in that way. What do you think is dangerous about prescribing these medications without ever counseling someone about nutrition and lifestyle factors that play a role, not just in body composition, but overall health. You alluded to the GLP-1 studies on cardiovascular outcomes. Super exciting. Amazing. I absolutely love those. However, it's very problematic to think that like, oh, we just use the GLP-1 to prevent neurological disease. We just use the GLP-1 to prevent cardiovascular outcomes. And we're leaving the things that empower patients most off the table in that conversation.

50:13I love that. So that was like, oh, everybody had a really sad GLP-1 day on social media that the day that the results came out and it showed that a GLP-1 agonist didn't reverse Alzheimer's. And by the way, I am the first to want to reverse Alzheimer's and to prevent it. And I'm being extremely sarcastic there. But are you kidding me? If you think that one medication and taking a medication can go in and be the entire solution to reversing that disease, which we know is multifactorial, and we also are understanding so much more, I love, like Lisa Moscone's work, David Perlmutter, like so many others, where we're understanding plaque and we're understanding what crosses the blood-brain barrier, we're understanding glial cells and we're understanding glymphatic and like all these things that there are much better experts to talk about than me on this part.

51:01And, you know, when you look at that and you're saying like, oh, bummer, this medication. But what's interesting is then everybody said, well, okay, it doesn't do that. Let's not think about that. Are you kidding? It is so great for an Alzheimer's patient to be able to better regulate blood sugar. And maybe this is actually something, especially as the disease progresses, that is going to be harder from the standpoint of their nutrition choices and what they're able to do. And so maybe using this medication will help us, you know, with them. Maybe it will be harmful because at a higher dose, they actually, or even at a low dose, they don't feel hungry.

51:34So they're not remembering to eat. And so they go under, you know, they actually don't take in nutrition. So I think this concept of just thinking of a medication as a panacea, we would both say, I think is just hugely problematic in there. Why isn't diet and exercise in there? Well, what's really interesting to me is in the world of weight, diet and exercise is so in there. And it's also in there in the myth of the non-compliant patient. For 20 years of my life, I was told by society, and if there had been influencers back then, I would have, you know, I think even been more unhealthy or social media, you know, certainly in that space.

52:06Oh, but we had Cosmo. Yeah, exactly. We had Blubber, right? Like we had, you know, we had the, you know, we had the books and, you know, Judy Blume and stuff, and I loved them. But what, you know, I think one of those, the issue, yeah, so it's the amount of influence right on that part. You know, I think the issue there is that, number one, there's a myth of the noncompliant patient, that somebody is just not trying with diet and exercise. So one of the reasons that conversations about nutrition, diet and exercise, don't come into the conversation when the medications are scripted, and I just heard this in the elevator, is, yeah, but all my patients really want is they just want the prescription.

52:41They don't really want to do the diet and exercise. They're so lazy. And I didn't interject myself in that conversation in the elevator because I kind of learned. Everyone on YouTube just saw my eyes, one of its biggest stoppers. Oh my God. Like you've got better self-control than I would. Yeah, I didn't. You know, I've learned because I really actually just wanted to be here on time and preserve my energy. But I was like, you know, okay, like my job right now. Yeah. Yeah. I'm like, you know, well, with you, I'm like, I'm going to reach thousands and thousands. And maybe right now my moment isn't to help this one doctor, but let me be clear if I see him again.

53:12But I think, you know, in that part, it's not that people don't want that. It's that we've failed so much and we failed because we've had the wrong messages with diet and exercise. We've had, you know, really dumb amounts RDAs told us of like what we're supposed to have or we've had impersonalized recommendations or, you know, all these different things. And so one of the reasons that there's two reasons that I'm told that and I'm told point blank why I'm not included right in this space. I would have loved if they could have accessed you, Ashley. But after they paid for me and they paid for the medication, they're just not willing to pay the price for you.

53:48And I'm like, okay, they're going to pay the price for me regardless across the board. So I think when you're in that space, we have to recognize that we have to budget better around this. That maybe as a physician, I have plenty of physicians who just say, like, I actually don't even need to be part of this. Once we know that's the plan for the patient, I would much rather them pay and work with you and then come back and see me. Or I'm often talking to the physician and saying, like, hey, should we adjust dose or whatever? So I think that's really important. I think the second part is that when physicians have historically tried to get into the diet and exercise conversation, they've used very quick things like, oh, well, you need one gram per pound of protein.

54:29It's not like in terms of amount of protein. That's not very actionable. or you know what, you should have protein at the start of your, like whatever it is. And instead, what somebody really needs help with is how do I actually do this, right? It's not so much a knowledge acquisition. It's a how can I look at my life today and all the things that I'm being told to do and how can I actually do something and see that it works? So I think that how we need to shift this is really looking at how do we make diet and exercise. Maybe we just don't call it diet and exercise, But how do we look at optimally resourcing the body and optimizing function, which is the job of nutrition and not even call it exercise, movement, you know, in that regard?

55:09How do we do that so that we can optimize your outcome, you know, with your GLP-1? And I think we also have to recognize the systemic issue that exists. A patient shouldn't have to pay out of pocket and pay for an insurer. And that's a big problematic. So a big problem here is that, you know, the United States Preventative Task Force at any point could have incorporated nutrition and dieticians. The American Medical Association at any point could have encouraged this collaboration. Medical schools at any point could have given at least like some lip service at minimum to nutrition. And this is the thing we see a lot of people say, oh, well, doctors don't understand nutrition.

55:54So like they're no good. doctors understand a lot. What doctors don't understand is that they need to be referring and collaborating. And why so many patients spiral struggle don't have success is because doctors aren't necessarily taught the value of a healthcare team and how to integrate this. And what is sad and who suffers the most is the patient. The patient should not have to pay out of pocket when they're already paying a deductible. They're already paying for an insurer and they shouldn't have to argue with their doctor to try to get a referral. And so I bring this up, you know, when this was like 20 years ago when I was getting my nutrition degree and I was concurrently studying didactics and nutrition science.

56:37And I was like, why the hell would I become a dietitian when dietitian after dietitian would just tell stories about how abusive physicians were to them? And I was like, screw it. I'll be the big D, little R in front of my name. And then I will make sure that patients are understanding nutrition and working with nutrition experts like yourself. And so I think, you know, there's a big systemic change that has to happen. And then we are in a really dangerous place with GLP-1s. I think they're a fantastic tool. I've done episodes on them. I think they have a time and a place where you're seeing too many turnstile clinics, pumping patients through, not doing any body analysis, not doing a DEXA, not making sure that this person is well qualified and well supported not to have disease outcomes because the only focus is where we started this podcast, that number on the scale.

57:31So I want you to talk to us about in your book, you're shifting the paradigm away from weight loss into weight healthy. And what does that look like for people? Yeah. And thank you so much for bringing up the clinics because you're talking about the turnstile where they're just working, but there are plenty of places where you can buy these medications and you're literally never seeing a physician. And I also have people who then aren't actually telling their practitioner. And one of the things we have to look at is - Super shameful though. It's so shameful. Because practitioners will say, oh, you're taking the easy way out.

58:00Oh, you're so lazy, you're not going to try. Super judgy. People who have been trying to lose weight have been trying harder than anyone else. And then they're met with weight stigma and judgment by providers. Yeah. And so we come in there and it's like not only on that side, like the risk associated when a practitioner treats a patient like that is as you actually are losing weight, we need to adjust all your other medications. So I had someone who was on the absolute wrong dose of their SSRI and it was not getting adjusted because they were embarrassed to go back to the prescriber and actually have the prescriber see that because the prescriber had said, I don't think you should be on an agonist.

58:41And then they went on that part. I also have people where weight isn't the reason that they're going on a GLP-1 agonist external weight. It might be visceral fat. It might be blood sugar, you know, and any of these others. And they've been sort of their doctor has said, you know, you don't need a weight medication, right? And so there's that part. So the reason I feel like we have to shift the focus to weight healthy is super foundational. This is the way the body works. So I took the opposite approach of you. It's funny because I'm raised by a physician and I grew up in the world of doctors. And as my five-year-old nephew says, like, you're a backwards doctor now, like as an RT, you know, on that part.

59:15And I was like, by choice. You know, I think sometimes doctors, I've had that experience where doctors and other dietitians have told me they felt this way that like in some way or treating me as like in a service of theirs, like, oh, my dietitian who's going to go tell us now that I've come up with the plan is going to go like tell someone what to eat. and go do that. I'm like, no, no. I'm a specialist in nutrition. I'm a specialist in optimally resourcing the body. And there's this whole dynamic of being afraid to, of the dietician being afraid. Dietitians would always tell me that doctors don't read the soap notes.

59:48This is why you became a doctor on that part. And I turn around and I go, oh, they're going to listen to me, right? And I think it's because I was like, dad, you're going to listen if I have something to say, that kind of thing. So we really need to change society in that part. But we also, the reason we have to embrace a weight health approach is that is what our physiology actually is. So there is no weight over here and health over here. They're not in these two separate places. There's no like, oh, I'm going to work on your heart health. And yeah, if you lost weight, it would help. But this is how I work on your heart health.

1:00:20No, every aspect of your heart health right now is woven into your weight composition and vice versa. So weight composition is a key performance indicator for your overall health, you actually can't pull those apart. Every choice that we make, whether it's what we eat, whether it's what we do, what we take, what we don't take, you know, any of these things is going to have a direct impact as hopefully intended, but it's also going to have other ecosystem impacts. So we cannot say, come to me, I'm going to put you on a statin or on Repatha, and I'm going to help lower your cholesterol, and I'm going to do all these other things over here and not have a conversation about the weight composition side of it because it's going to affect it.

1:01:03So I think that to me, it's not a choice about weight health. This has been my work for 20 years. Ever since I learned about an incretin hormone in 2004, I was like, wait, incretin, that's a GLP-1 or a GIP hormone. These are weight health hormones, right? And so now we need to have that conversation about how a weight health, the body is a weight health ecosystem. How does it work and how do we optimize it? And what does that mean to be a weight health ecosystem? Yeah, it means that our weight is a key performance indicator for everyone. So if you have bone loss, if you have a little bit of bone loss or you have a lot of bone loss, that is a weight health conversation.

1:01:41I don't think many people know that GLP-1 and GIP, two of your weight health hormones, actually impact bone formation. So when we look at bone, and by the way, that which is also impacted based on your digestive health. So it's all, you know, it's in there, right? When we understand that part of what is increasing your risk for a stroke or for cardiovascular incidents is plaque or any issues in the lining of the endothelial tissue, and now we know there's a GLP-1 receptor site there, we know that we can't have any cardiovascular plan without understanding how our weight health hormones are working.

1:02:17Yeah. Yeah. And, you know, I want to ask you, because you've alluded to digestion many times in this episode, and you've given us some symptoms and signs that people should look for. But what should people really understand, especially in the context of GLP-1s and digestion, about getting optimal nutrients? Because our food, I think so often, the big problem, one, I think like way back in the day, food pyramid, problematic. Macros, problematic. RDA, the worst. And so we've got all of these super confusing and also arbitrary ways, like food groups. We kind of made that up, right? But it's all been a framework to try to help people understand this.

1:03:01And I think the biggest thing for people to understand, especially as I've been hearing from you, is that it's about what you absorb. It's not always what you eat, it's what you absorb. And your gut function is going to be so significant in that. So I'm just curious, you know, in the context of the conversation we've been having, what do you think people should know about gut health, digestion, and getting optimal nutrition? Yeah, it is. I mean, it's the crust of your pizza. We have to start there. We have to think about you cannot start in and say, like, I'm going to eat a food because it's healthy and just give myself credit for that.

1:03:33Or choose a food that's healthy, that's not delicious, you know, et cetera. Or maybe consume something that your body isn't able to break down. So when we look at digestion, digestion, first of all, starts in the mouth and it's going to go all the way through to our exit strategies. Like, so, you know, you're looking at the rectum, the anus, et cetera, on that part. So oral microbiome, I think one of the things that was the worst for my digestion was when I did Invisalign. I suddenly had like this, you know, thing in my mouth for two years. And by the way, I love my Invisalign. I'm great. I'm like, I'm happy, you know, that I have more space in my mouth because that was also an issue for my digestion.

1:04:06But when we're doing anything in the oral, understanding what's going on in our mouth, we have to look at that's impacting it. And on our tongue, we have receptor sites for GLP-1. So we actually have to recognize that if our tongue is coated or our tongue is cracked or, you know, our mouth is irritated like any of these things or we're maybe sleeping and breathing through our mouth and we're drying our mouth out, that's going to have implications on our overall health, right? So when we look at that, we have things to pay attention to, signals to decode. One of the others is we focus a lot on absorption, and that's very important.

1:04:39And that's about the body's ability to understand that the lining of the digestive tract isn't like just a hard tube and everything that we want to pay attention to is what goes on inside the tube. The tube is actually very metabolically active and very important. And so in there, if there is damage to the tube, so if there's leakiness, if there's tears, but also if we're not creating, if we don't have like, we'll think about like acromantia. If we don't have enough acromantia in there, then that acromantia isn't chewing up the mucin, and that means that our mucosal layer isn't getting turned over appropriately, and that's going to have impact on the health.

1:05:17But we also have to break down whatever we take in and actually have it be able to get into a form where it can be absorbed. So I've talked about motility, things moving. I've talked about absorption. But another aspect of digestion is breaking down. Well, one of the things that's going to happen when we're on an agonist is when we delay gastric emptying, we're impairing some of the function, whether it's acids or enzymes, of how things are broken down. That might mean that we need to lean into chewing more often. It might mean that we need to lean into liquid nutrition. It might mean that we need digestive enzymes.

1:05:53It might mean there are a variety of different things, and I go through all these different tools. You know, the value of a fork and knife. Maybe we need to cut our, you know, if I'm having a steak, which seems like everybody's, I didn't know the raw chicken, but maybe I need to cut up my food a little bit more, you know, and definitely do the chewing so that I can break it down so that it can be in a form where it can be absorbed. So, you know, again, oversimplification is, oh, your digestion isn't great, take a probiotic. Or, you know, oh, you're constipated, eat more fiber or take magnesium.

1:06:24And so, you know, for me, and this was my third book now, but this is the only one on weight health. But my first two books and, you know, definitely work that I've done in the practitioner education space has really focused on helping transform an understanding of what digestion actually is. And it's complex. And there are all these different places where the problem could be occurring. You could have good motility, but you might have impaired breakdown or impaired absorption. And that's where we need to lean into. So it's worth doing that exploration. I also think, and this brings us back to that really annoying issue of insurance doesn't cover, you know, necessarily my services for anyone who is trying to do this preventatively or who isn't, you know, already have diabetes or doesn't have, say, kidney disease.

1:07:10But I do think that seeing a qualified dietitian, I recognize that not everybody practices the same way, but a qualified dietitian, nutritionist, a doctor who's gone through nutrition training, whoever it is, you know, who can really lean into helping you assess and then personalize your digestion is going to be, you know, the optimization. Buyer beware because there are also, and we see commercials for them all the time, you know, testing that's sold direct to consumer that says, you know, like, well, take our gut test and we'll show you, you know, like the commercial was, I think I used to eat almonds and then I did the test and, you know, and I had this horrible digestion and the test told me that I was allergic to almonds and now I don't eat almonds and my digestion is better.

1:07:53That's not the way that it works. And, you know, if you then go over and eat cashews, you're going to take that test in three months and suddenly it's going to be cashews because an irritated or suboptimally functioning digestive system is not going to like what it gets. And that's, you know, when I see testing used improperly, it's test that if you test this, it's going to tell me more or less of, you know, it can give me a personalized nutrition plan and it can't on that part. Yeah. Something that has been a very striking theme being at the conference this weekend is how many testing companies have a direct pipeline into a supplement recommendation.

1:08:29And I am, I mean, I own a supplement company. I'm not anti-supplements. I think there's a lot of great ways to leverage supplements, but it really gave me pause how often I was being presented with, oh, we do this testing. And then once you get the test results, we tell you what your supplement plan should be. And I'm like, but at what point are you talking about the nutrition plan or the lifestyle plan? And how can one test tell you exact supplements someone needs when maybe you're not considering that, you know, okay, they're low in carotenoids, so maybe they need antioxidants. However, if they're low in that, like what else is happening in their life?

1:09:07Maybe they're not absorbing what they're taking in. Exactly. It's also made me very skeptical of a lot of testing. I'm like, I don't think that's actually ethical because you're making that test really economical on the front side to make your profit on the supplement. And this is something where, again, I'm like, this is tricky. This is marketers stepping into the health space but not having the ethics of the health space. In your book, you go through a lot of the things that we've discussed today. The pit stops. You give protocols. You help people actually navigate all of this. What is a realistic timeline when you start employing these things to start feeling better?

1:09:45Maybe you're not going to 180 everything, but to just start feeling better. Well, I've talked to some people now who have had advanced reads of the book, and they're like, oh my gosh, Ashley, I was laughing so hard at the first story that you were telling or something, or oh my gosh, I had such a wake-up call. And the first maybe 30 pages are patient stories and my story. But if you're laughing, you're actually feeling better. If you are learning something that helps you unlearn other things, you're feeling better. Chapter four is shit to unlearn. When you unlearn things, you unburden yourself from a lot of feeling like I failed at doing this and you're like, oh my gosh, no wonder why.

1:10:23So I think people feel hopeful and empowered, you know, right off the bat. What's the biggest thing people have to unlearn? You know, I feel like the total scale number is probably like this does because we're talking about weight health, just because that word weight is there. I would say the biggest thing is to learn that we are not weight or health, you know, that we are weight health, but I think that the scale actually doesn't tell us anything is really powerful. That said, I think everybody has their own thing to unlearn, you know, that thing that might be blocking or has been, you know, a big one for them.

1:10:58And then we go into doing some assessments really quickly, some experiments that, you know, some things to lean into. And so you pretty quickly learn that you're going to be able to decode signals. Like I want, literally, I'm like, I'm in here. I'm like, I want you to see this signal and start to think about, you know, what does it mean? I did put in here, this is my only nod, you know, the publishers tell you what they want, what they don't want. And I was like, I'm not doing a diet, but I understand the desire for a 30-day. And I was like, I am not going to tell somebody they're going to be weight healthy in 30 days.

1:11:29Like, I'm not selling you a bridge. I'm not selling you a test and a supplement, like, you know, on that part. What I did want everyone to know is that in 30 days and literally sometimes within one, two, and three days, you can employ, you can make a SMART goal based on something that's going on in your body that you decode a signal and you can learn something about your body. And in that time period of doing an experiment, you may actually identify what is better for your body right now and learn something that's going to help the body. So I've had, you know, some people, like I have one woman whose story I share in there, 42-year-old perimenopausal woman did not want to go on an agonist, came in to see me, and she said within the first month, I lost five pounds, but I looked like I'd lost 15, and I actually stopped using back pain medication every day, and I start, you know, and my back was feeling better.

1:12:20That's huge life-changing, and that's one month. I had somebody else who came in who was on an agonist who came to me to stop. She had lost 60 pounds, and we did her weight health hormone assessment, which everybody gets in here. And we went through the five areas of it. And she was ready to go off of her agonist. She just thought, like, I'm coming to you and you're going to tell me, like, here's how you go off. I want a prescription, you know, how you go off. And I go, oh my gosh, you can't go off of this. You are going to regain every ounce and then some, and it's all going to be from fat and you're going to be miserable.

1:12:51Your muscle, you lost muscle, you lost bone, you're dehydrated, your digestion isn't working. So what we did is we actually did 30 days of a digestive tune-up there, and that allowed us to then get to a place where we could start doing the weaning process. So 30 days is a time period that you can do a lot in. I think that what I also want people to lean into, and this is something at the end of my book, but it's a theme throughout the book, that I don't think is anywhere in most books today, in most programs, is the concept and the need for reassessment. You know, when we make SMART goals, and that's an acronym, and the T stands for time bound, we actually have to come back and reassess and learn from what the body is actually telling us.

1:13:34So at the end of those 30 days, I want to actually reflect back and say like, hey, what's happened here and what can we learn from? And that's going to help inform where we're going. So one of the things I have in the book is what should you be assessing on a daily basis? What should you be assessing maybe on a weekly or every couple of weeks? What's on a monthly basis, a quarterly basis, maybe on a yearly basis, although most things I don't think you want to wait a year. You know, I think a quarterly is really good. Yeah. Well, thank you so much for sitting down to talk with me today. I've appreciated everything that you have shared.

1:14:06I hope people will grab the book. We'll definitely link it in the show notes. Thanks. Yeah, I love it. And I love the diversity of conversations that you have. And it was one of the reasons I was so looking forward to this because I do get to have a conversation with somebody who understands nuance and understands especially the nuance in nutrition. So that's so valuable. And I think it's just such a great resource you provide for people. Well, thanks. I appreciate you skipping the verbal brawl in the elevator to come chat with us. I'm a much happier person for it. So I think that's great. Yeah.

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