Dr. Jen Ashton on Unimaginable Loss, Mental Health, and Post-Traumatic Growth

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33:41So if you are focused on aging well from the inside out, it's time also to think about your skin. It should get the same level of care. Go to oneskin.co for 15 % off. Use the code Dr. Lion. It is amazing and it will not break the bank. And how about now? Because now, so as physicians, and I think as medical educators, there was a lot. So 20 years ago, there was less information. We were not Googling. We were waiting for these papers to come out and then we would go and we would get the medical journal and learn. And now we're almost at the opposite end of the spectrum. So true. And for someone who has been there from the very beginning to where we are now.

34:26If someone is listening to this and they're like, okay, well, I love nutrition and I love physical fitness and I don't even know how to distill the information. What would you say if we start with nutrition? Oh God. Well, first I would say credentials matter, right? I'll tell you a funny story that I think illustrates this really well. And it kind of brings together all of these issues that you're asking about, which are so important. There was a book written by an economist professor from the University of Chicago, I'm sure you have it. It came out maybe 10 years ago when her book, it was about pregnancy and all of the myths, you know, exist in obstetrics and midwifery and that pregnant women have to kind of navigate.

35:10The author, as I said, was a full professor of economics from the University of Chicago, not an unintelligent or uneducated woman. I did a segment on Good Morning America about the book coming out of a tape piece, and I did the segment with George Stephanopoulos. And in this book, the author says, you know, I've evaluated the data. I can look at data. I'm an economist. I know how to look at numbers. And, for example, there's no reason why pregnant women shouldn't be able to have safely three to five alcoholic beverages a week. Okay. As a board-certified OBGYN and as a doctor who's board-certified in obesity medicine and has a degree in nutrition, I really believe in the motto, stay in your lane.

35:55So I did this segment with George about her book, and I did it the same way I've done every single television segment in my life, balanced. People will never know really how I feel about something unless the anchor or host asks me to share my opinion. So when we came out of the piece and we went into commercial, I said, you know, George, I can read English. I think I'm going to write a book about the Constitution. I know I'm not a constitutional attorney, but what the heck? Now, today, and that was 10 years ago. Today, you have people who, because they can read, think that they're in a position to make black or white edicts about all kinds of things.

36:39Nutrition being probably near top of the list because we all eat. And while I will say that having a master's in nutrition does not certainly mean I or anyone else knows at all about nutrition, because quite frankly, the level of sophistication of nutritional science is pretty poor compared to like medical science. It's better than nothing. And I think that, you know, that is a perfect analogy for where we are with all kinds of things in wellness and fitness and nutrition. People think because they can read or because they try something themselves, which in medicine and science we call an N of one, that that is written in stone.

37:20And I always say, whether it's nutrition, food science, women's health, obesity medicine, weight management, menopause, you name it, I don't care. The same principle applies. In my medical, professional, scientific opinion, it is not only wise but essential for us to have a humility as individuals and scientists and doctors and public figure, whatever you want to call us, to recognize that we do not know it all. And things can be learned tomorrow that we swore today were, we know this hard and fast. We have a long historic precedent in medicine of being proven wrong. Like the Women's Health Initiative.

38:06Yes. Which, by the way, you were in residency when this came out. Can you touch on that? And have you, obviously I'm sure that you've been staying up to date with the FDA. Touch on that as being someone who was there when it happened. So first of all, I'm the daughter of a registered nurse and the niece of an OBGYN, my mother and my aunt. They both, when I was a resident and WHI came out in 2002 with the so-called shot heard around the world, both my mother and my aunt were on hormone replacement therapy, big believers in it, feeling amazing, et cetera, et cetera. When that headline came out, I was not taking care of my own patients in menopause because I was a junior resident.

38:50But it was a topic of grand rounds. Obviously, most people know that literally, like a light switch, the prescriptions to patients were discontinued. Women were taken off. Like, immediate. Due to not only the media misinterpreting the data, but the study authors misrepresenting flawed data. So it was, you know, I have a saying in medicine that I think is so true, and I don't know if you've heard it. It's often not the first mistake that kills a patient. It's the second, third, fourth, and fifth. It's usually like a lot of things have to go wrong. Same thing with this. This was flawed methodology.

39:30This was a flawed press release that the authors didn't even approve. It was flawed media coverage. It was flawed interpretation by practicing physicians. That's actually the surprising part. Yeah. I mean, but again, it was a series of errors that led to 20 years of women largely not getting the management options and treatment options and counseling that they should have gotten. So, you know, fast forward now to the last couple of years, and I actually see a somewhat precarious situation that we're in right now. because the pendulum, we have such a problem with moderation in life in this country, such a massive problem.

40:16And so we tend to do things at the extremes of a spectrum. And menopause care right now is no different, just like obesity care is no different. It's at an extreme. And the reality is that the sweet spot exists in a much more nuanced, moderate position. And hormone replacement therapy is no different. You know, you said that we're in this kind of precarious situation. Where do you think we're going wrong right now with menopause therapy? Oh, I love that question. If you listen every week and feel like we are in this together, which I believe that we are, learning, growing, and building strength, then I've created a way for us to get connected even more closely.

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41:35Where do I think we're going wrong with menopause before we get to menopause therapy? And where I think we're going wrong with menopause is, and this is not something that's discussed, so I'm so glad you're asking this question. It's a brilliant question. We have over swung our response to this stage in a woman's life to such an extreme hyperbolic degree that I think there's a real risk in putting out a message that women are passive victims once again, that we have been pushed into a corner. We're adults. So if we're put into a corner, we have some responsibility in that. You can choose not to go into the corner or you can be led like sheep.

42:29I don't believe that women are easily led like sheep to be put in a corner nor do I believe that women are so passive that we need to be presented with everything on a silver platter for it to be able to be utilized by us. And let me give you some pretty hard and fast examples of why I think that's not true. Puberty. What did we know about puberty? Did anyone, did you ever take a class or read a book about how to insert a tampon? Actually, no. No one barely told us what a period was, right? Because who, unfortunately, don't even get me started on how we teach kids health and puberty, right? But it's, for me, it was taught by a gym teacher who I'm quite sure did not want to be teaching that class to begin with, right?

43:20So we didn't learn anything about puberty. Somehow I figured out how to insert a tampon and I learned about puberty just as my children did, just as your children will, hopefully better. It's just as millions and millions of women have done forever. Pregnancy. How much did you know about being pregnant before you were pregnant? I mean, a little. And I still didn't even know what was happening while I was pregnant. Correct. Okay. I didn't know. I was a medical student. Did I know, was I an expert on pregnancy until I peed on a stick and saw two dots and was like, oh my God, I'm pregnant. Like, no.

43:57And then, oh my God, I'm pregnant again. Yeah. Okay. I learned about it. When I went into menopause at 52, Gabrielle, as a board certified OBGYN, I didn't even recognize my plethora of menopausal symptoms until my one of my best friends who's a cardiologist said, why don't you go on hormones? And I was like, oh my god, you're right. Okay, so I bring up those three stages because I think they powerfully illustrate the fact that the narrative that we're hearing about menopause, like we haven't told you women have been kept in the dark, you know, is just, I think it's actually insulting to women.

44:43I think it's disrespectful, insulting, and demeaning. And I don't think we're that meek and passive and timid. And I think ultimately it paints women as victims. I think it's well-intentioned and poorly executed. And I think instead we need to say, yeah, look, has menopause not been taught well to doctors and in medical school and covered in the popular press? Of course that's true. Has it not been legislated well? Of course. Has it not been researched? Of course. But that's very different than pointing this finger of blame, because I will tell you one of my favorite sayings, and feel free to use this with your children, it might come in handy.

45:30Is no. Oh, well, aside from that, that's a capital N-O. Is I think we should be careful when we point a finger of blame of no one ever told us about menopause because as the saying goes, when you point a finger at someone else, there's three pointing right back at you. I don't believe in blaming anyone for what it is what it is. It was what it was. Let's focus on today and what's ahead of us before we paint the, you know, menopause out to be a horrible thing that has victimized women. I just think that's so negative. And I am a glasses half full type of person. Clearly you are. How do you see a positive way of thinking about it?

46:14So let's say, because there's lots of information out there on hormones, hormone replacement, what we know, what we don't know this resurgence they just took the black black box warning off which is amazing which is amazing how do you see it done well now from a practicing from yeah just like a practicing perspective i think that the key and the way it's being done now well is when it's holistic and i don't mean holistic like i'm going to swing a crystal over your head please don't and chant But I do have a lot. And I love a good crystal. I mean a holistic way that says what we're actually supposed to do as credible and credentialed physicians, which is talk about all options, including no treatment as an option.

47:06And those options now, fortunately for women, are more numerous and more effective than ever. And it's not one size fits all. It's not robotic. It's not cookie cutter. women should not feel whether you're talking about menopause or obesity management no one should feel that it's either a glp1 or nothing it's that's one option for menopause hormone replacement therapy is one option there are a zillion options that are fda approved off-label behavioral you name it for both of those conditions but we have such a hard time in our world of being tempered and nuanced and we just want like an easy quick fix that conveniently fits in one box and I just don't believe that that the overall health of an individual an organism as complicated and complex as human beings are fits neatly into one box yes because that would be really foolish yeah it would be really foolish and people are very multi-dimensional yeah in your professional opinion do you feel that hormones are relatively safe yes i'll just yes i do and i will say you know i can talk about treating you know again because i joined my aunt's practice right out of residency so my aunt was a real she was one of the first women ob-gyns in her area new jersey and she had an incredible reputation and a very busy practice.

48:37And I was the fourth doctor to join her practice right when I finished residency. I really just wanted to take care of real people, real women. I had grown up the daughter of a cardiologist, so I saw my father have those special relationships with his patients, and I really wanted that. And my aunt and her partner had always prescribed hormone replacement therapy to patients. And how was that done? Is it the same that what we're seeing now? Patch? There were patches. There were patches. The knowledge of having to balance estrogen with progesterone was obviously known then. Mostly it was in pill form.

49:19You know, pellets and creams were not really a thing in 2004 when I joined her practice. and bioidenticals, even though that's a marketing term, as you know, not a medical term, were a thing. But my aunt and her partner were very pro-hormone replacement therapy. However, interestingly for me, I was really interested in adolescent gynecology. So while I did a lot of the obstetrics in our group, I was really interested in taking care of teenage girls. So 50%, half of my practice were girls and young college-age women under the age of 21. So obviously I didn't have a strongly perimenopausal or menopausal practice until I had been in practice for 18 years.

50:04And those college-age women who were coming to me as their first gynecologist then started to go into perimenopause. And as my patient population got older with me, I obviously started to see a lot more menopausal symptoms. How did you manage that at the time? Because prior to that, it's difficult when you have a practicing physician, so your aunt and then the other partners who had already been prescribing hormones and then seeing the benefit. Yeah. Having them pull off of that and then your patients going through perimenopause. It actually was not a difficult thing for me because I put it into the category that I practice, used to practice and still do in terms of, you know, the medical information that I produce in a form of content for people and for Agenda, which is my women's health company, is what are the risks, what are the benefits, what are the options?

51:04And so when I would talk to a woman in perimenopause or menopause, I would say there's three tiers of options. There's hormone replacement therapy. There's non-hormonal prescription medication, because we've been using off-label prescription medication to treat menopausal symptoms. For example, which ones are you referring to? Effexor is the brand name of a drug that's an antidepressant in higher doses and in lower doses, very effective for treating vasomotor symptoms. And we had been doing that for decades. It's not a new thing. And then I would say, then there's some behavioral things. You know, you can do cognitive behavioral therapy.

51:42You can do acupuncture. You can try acupuncture. There's cytosolic D pollen extract that's been used in Europe for, again, over 20 years that can help with vasomotor symptoms. And I would give a menu of options. There's even more of a menu of options today. And again, whether it's menopause, weight management, if anyone is listening and you go to a doctor who doesn't, who only gives you one option, you should find another doctor. That's just not medicine, you know? And I always would say it's my job to inform and educate. It's your job as the patient to make the decision. It is very empowering for patients when you provide options.

52:20And then I don't know how. So I still practice. And I'll usually lay out what I believe. You know, here are the options. And then you know what? If this were me, this is how I would approach it. It's perfect. We do prescribe hormones. We think that they're very valuable. And I remember because I finished fellowship 2015. 15. And obviously it was very difficult to get information on how best to prescribe estrogen, progesterone, and testosterone, especially for women. I mean, I will say personally, when I started taking HRT, I felt like a new person in 48 hours. I mean, that's fast. It's pretty amazing.

53:02And my kids were like, mom, you need your ABP. I go, what is that? And they go, your anti-bitch pill. And you're like, actually, it's a patch. No, I actually, I actually went for the pill, but they, I was like, okay, fine. How bitchy was I? And they were like pretty bitchy. I mean, it was really, for me, it was, and is a great option. Is there a form that you like the best? If, you know, we're talking about estrogen, progesterone, testosterone, do you have a favorite delivery method? No, because I think it's, you know, it has to be right for the individual, you know, woman. I don't have a problem taking my pill every single night before I go to bed.

53:46I've coupled it with brushing my teeth and the whole science experiment that I have to do now, like the lashes, the skin, the hair, the teeth, I mean, like working my way head to toe, my hormones are part of that. For some women, they don't want to do that. And so a patch, which also lowers the clotting risk is a better, you know, it's a better option for them, whatever. But I think it's an exciting time. And at least there are these options. I couldn't agree with you more. You also have been doing obesity medicine and have a master's in nutritional sciences, which is, I would say, my first love.

54:21And you remember when GLP-1s were not available. And then all of a sudden, GLP-1s, which had been used for... 20 years. For 20 years. These are not new medications, which I think that this is really important. If we were to say, what are the top three myths that you see with the use of GLP-1s? Number one, risk benefit. Because just as we always talk about with our highly polarized hyperbolic kind of way of life today, you either see a headline that says, this is the best thing on the planet, or this is the worst thing on the planet, and it will kill you. And the reality is, it's neither. it's somewhere in between.

55:00So I think when people hear or talk about GLP-1s, the first, second, or third generation, whatever class you're talking about or generation you're talking about, it's really important to, as I like to say, think like a doctor. So what does that mean? That means how do we stratify risk versus benefit? And as you know, it's not just what are the risks. You actually have to ask four questions. What are the risks of the medication? What are the risks of not taking the medication? What are the benefits of the medication? And what are the benefits of not taking the medication? And in some cases in medicine and life, you can actually put real numbers with that, which then makes it very easy, right?

55:48You can say if something's 1 % risk versus 5 % risk, you know, you're going to go with whichever is higher or lower, depending on the question. In In some cases, it's not going to be a number, but it'll be a statement, right? So that's really important because it's not like, should I take it or should I not take it? It's, why are you taking it? What does the data show? And you know, I've heard you talk about it. I hope most people know this right now. There are so many non-weight-related proven benefits to GLP-1s that I don't think we've even seen the tip of the iceberg with their use, their indication, and their benefits yet.

56:28But cognitive protection, cardiac protection, renal protection, body composition differences, cancer, immune system. I mean, the list keeps going on and on. I'm sure they're testing it for nail growth because - Sign me up. Yeah, right? Me too. And so I think that's a big one, you know, risk benefit. I think people need to understand some very simple math, and I am by no means a statistician, but you and I know, because we read medical and scientific studies, that it's all about how you get to that number, right? And when you talk about something that, let's say, has a 1 % risk of a bad side effect, which would be high, by the way, in the world of medication and medicine.

57:14If 10 people are on that medication, you're going to see one of those cases. If 100 people are on that medication, right, you're going to start to see more of that. If 100 million people are on that medication, something that happens 1 % of the time is going to affect a lot of people. And that's what we're seeing a lot of times with these media headlines of GLP-1s. And the last thing - Meaning they're painting it in a very negative perspective. In a difference between an absolute risk and a relative risk, and they're profiling a worst-case scenario that is still, as the saying goes, an increased risk of a rare event is still a rare event.

57:52And I just think people need to understand that. It's numbers and math, right? These are now probably the most widely used drugs in the world. So when you have a couple of billion people taking something, you're going to see a rare side effect more than if only a few people take something. What are your thoughts on safety of these medications? I'm happy to share mine, long-term usage. You go first. I think that number one, what I'd love to see is more mechanism of action. For example, I agree with your statements on it being good for cardiovascular or cognitive. I think that there are a whole host of things that we're gonna see from a positive lens.

58:32My question is, is it because of the improved body composition? Is it because of this reduced inflammation that we're seeing, I don't know. But what I'd love to see, so do I think that they are safe? I think overall, they're very safe. And I think that they've been used for 20 years. We'll probably move into the ultimate mix of optimization, which will be low-dose GLP-1 with low-dose hormone therapy. I had to pause for a second because definitely there's going to have to be some kind of anabolic agent or something to affect muscle, whether it's an anabolic agent or a myostatin inhibitor, something like that.

59:10I can't wait for the myostatin inhibitor. Yes, but I think that they are safe medications. I just don't think it's going to be something like fen-fen. No, no, no. You agree, where for the listener, fen-fen is a medication that people put on to address obesity and it caused... Pulmonary hypertension, valvular heart disease. I think here's the thing that people need to understand, and again, whether they're talking about glp1s or hormones or any other medication including an over-the-counter medication like aspirin you have to know what the data is you have to know what the numbers are what's the incidence of pancreatitis what's the incidence of blah blah blah whatever and that's nice to know that number but understanding that if it happens to you you really don't care whether it's 0.1 % or 1 % or 4%.

59:59It's 100 % happening to you. So you need to make your decision about whether or not it's worth that risk and how high that risk is. Yes, I do think there's going to be a lot of interesting and exciting data that comes out in the future, including the short-term future, about mechanism of action, about the use of these drugs for prevention, about maintenance protocols. Right now, physicians are literally DIYing maintenance protocols on these medications, which is fine, but it would be better if we had some actual data to say this is how you maintain on it. To understand choosing a candidate for it, especially in your sphere of interest, body composition, muscle changes, bone changes.

1:00:47You know, people hear like, you know, you'll lose muscle mass in these. well, what they're not hearing is if you have obesity or overweight, your muscle is dysfunctional. Yeah. Tell me about your concerns or if you have concerns with GLP-1 use. And you just mentioned muscle. I have a big concern with specifically with the higher percentage of weight lost from muscle than for people who are not on GLP-1s. Now, again, what you do not hear when you hear this topic discussed by anyone, anywhere usually is who are you talking about? Are you talking about someone with obesity or with overweight who's on a GLP-1 or are you talking about someone who's already at normal body weight and is maybe taking a low dose of a GLP-1 for other off-label longevity benefits, you know, body composition?

1:01:42I believe there's going to be a role of GLP-1s for women going into menopause. So we're seeing a lot of those things occur on a DIY basis, right? And when you hear a headline like, you're going to lose muscle mass, okay, well, that is true. First of all, it's not true for everyone. It depends. You know, there are a lot of women who take GLP-1s and don't lose weight. And why do you think that is? Oh, God. I mean, I think that But it's really because of that hypothalamic set point. Can you expand on that just a little bit? As you know, there is a reason why 90 % of diets and extreme weight loss fail at the two-year mark.

1:02:23And that is not because people lack willpower or discipline or drive or determination. It's because our brain, and I love this because it's so easy and it could be a Hollywood movie, explanation of the physiology, but our brain wants us in the most stable condition for the organism, which is us. And unfortunately, that most stable condition is often our highest weight. So the hypothalamus senses a loss of weight as a threat to the organism. And what happens when you lose five or 10 or more percent of your excess body weight is your brain starts saying holy shit we must be in a bad situation so i'm sensing this as a threat to my survival i'm going to compensate and restore to that equilibrium by making this organism feel less full it drops the satiety hormone leptin.

1:03:26It increases the hunger hormone ghrelin. It slows your basal metabolic rate by about 15%, sometimes more. So you're burning fewer calories at rest. And what does that do? It drives the reward-seeking behavior of eating so that the organism regains that weight many times more than the weight lost. And that leaves that person feeling, I'm such a failure. How did I, I lost all this weight. How am I now at the two-year mark gaining it back? And by the way, any diet short-term can be successful. Any diet. The key is at the two-year mark. That's what the medical literature and the obesity medicine literature looks at.

1:04:06And so that set point, I think, is so powerful. And I think we do not understand every aspect of it by any stretch of the imagination yet. But I think when people who are already near or at their ideal weight take a GLP-1, it works differently. And the parallel for this, and I'm really going to geek out, but you will love it, is in the world of pain medicine and the nociceptors that are pain receptors in someone who has true pain get upregulated. And so if they take, now I think few people should be on opioid narcotics, but if they did take an opioid narcotic, that opioid works at those pain receptors.

1:04:51If someone does not have pain, what do those opioids do? They make someone high. Right. And I think there's a direct parallel to that. We just don't know what it is. That's interesting. I haven't actually thought about that. You know, with the use of GLP-1s, I've only seen, you know, we've been using them in our clinic for a long time. And then there was medication before that it was remember sixenda yeah of course one of the other fda yeah um i've only had a handful of patients not be able to lose weight on a glp1 like one or two and uh well i don't necessarily know that it's a matter of failing to lose weight although of course i think that's you know obviously a metric that i'm sure many of your patients are looking at i think though there is a role for people who are at their ideal body weight, let's say within five pounds or so, and will take a low dose of a GLP-1 and they won't continue to lose weight.

1:05:52And why is that? Again, it goes to that set point. Why? Because they're where they should be. So that GLP-1 is likely acting on other parts of the body to help improve body composition that we don't know yet. We haven't studied it yet. We haven't really, we don't have that many people in that category of a patient population who are using it in that way. You know, the last thing that I think, you know, to get back to your brilliant question of what do you think people don't know, I still think we have a massive societal problem with GLP-1s, particularly for people with overweight and obesity. You know, we put people who are struggling with weight issues in a near impossible position of being damned if they do and damned if they don't.

1:06:37What do you mean by that? I think that society and medicine clearly has a fat shaming bias and stigma. And we look at people who have weight problems like that's, you know, they must be lazy. They must be undisciplined. You know, for 10 years, I treated patients for medical weight management in my practice. I never saw one patient who came in and said, yeah, Dr. Ashton, I start my day with maybe a couple of waffles with some whipped cream, and then I move on to a couple of Big Macs, and then I'll have maybe a pizza for a snack, and then, I don't know, some lasagna or something. Never. Everyone comes in saying, I don't get it.

1:07:25I'm eating pretty well. Of course, you know, we can always eat better. No, that guy sounded like my husband. He's obviously an exception to that. But like, you know, people know what they should be eating and what they shouldn't be eating. And I think that in general, even in the medical field, we look at people with weight problems like, you're clearly eating all the wrong things. Now, sometimes they are, right? But most of the time, it's a failure for everyone to realize that obesity is a complex chronic disease and there's not just one cause. When you were doing the medical weight management, tell me a little bit about the nutrition plan with that.

1:08:06So the whole reason that I went back to Columbia and got a master's in nutrition is because I found myself, it was the light bulb moment for me as a physician where I was talking to women, every single patient, about food and diet and nutrition. And I was like, it goes back to what I said earlier about credentials. I was like doing my own little research on the side. And I realized I'm just way too type A for that. I really wanted to get some formal education and credentials in it. And when I then started incorporating that in my practice, it was because I kind of, you know, had the epiphany of something that I may have actually created this term.

1:08:56I hadn't found it anywhere else, but who knows, called nutritional gynecology, where I realized that at every major reproductive stage in a woman's life, puberty, pregnancy, perimenopause, they all start with P's, that there is an associated significant metabolic and weight aspect to that. And so I used to be the type of doctor that would refer my patients to a nutritionist or dietician to work with me. And what I would find is that they knew a lot about food but they didn't know endocrinology and gynecology and I knew a lot about endocrinology and gynecology but I didn't know anything about food and so I really wanted to connect the dots on that so when I would see patients from medical weight management it started with you know actually listening and not talking and finding out what is the person's relationship with food and eating been like you know what is their life like what do they like what don't they like, what works for them, what have they tried.

1:09:56And then trying to work with something that as I say, like meets the four S's, safe, simple, sustainable, and low sugar. And that's not going to look the same. That's technically an L, but not an S. Yeah, you're right. Yes. Little like in parentheses. When I started nutritional science, you know, there's this, you start somewhere and then you end up somewhere totally different, right? And when you started with your prescription for nutrition, where was that? Meaning, let me ask specifically, so there's the protein-sparing modified fast, there was the ketogenic diet, there's all kinds of nutritional formulas out there.

1:10:39So again, this is probably not going to come as a surprise to you, knowing me a little bit, it was not the same for every patient, just like their menopause plan was not the same for every patient. I would really, after assessing the patient, which means knowing about their background, their ethnic background, their whole life, as well as their experience with food and eating and dieting and their weight trajectory, it would be different for everyone. And sometimes it was more of a paleo keto-esque approach. Sometimes it was an intermittent fasting, time-restricted eating approach. Sometimes it was something more structured.

1:11:23Sometimes it was something less structured. Sometimes it was as simple as figuring out what their psychological drives were to eat and working on that, not this. And that's what I really loved about it and continue to love about just the approach. You know, anyone who says there's only one way to do something, I think, is missing out on a lot of the fun and the potential that exists. What about foundational principles? So for example, in my practice, from our perspective, we believe that the data would suggest that protein would be foundational for everybody. Agree. In weight management, in any kind of the P processes, so puberty, perimenopause, postmenopause, what are your thoughts?

1:12:16because again, I want to paint the picture that you've been involved in the information landscape since 2006 as a correspondent. So you have seen the gamut. So the question is, where do you think from a foundational perspective, protein fits in? I think it's everything. I think it's everything, but it's not the only thing. And again, it speaks to our problem with avoiding the extremes, right and now everything is protein thank god I mean I'm just saying I've been talking about this for 20 years finally and now I I mean I feel like I have played a role I'm ready to move on you have you're gonna talk about something else now we're gonna move on to anabolics but yeah uh but that's I think that again we haven't even scratched the surface of the principle of food matrix which is you know, that the same food can act differently in our organism, depending on whether it's a smoothie, whether it's a solid, a liquid, a baked, grilled, whatever, whether it's mixed with something.

1:13:24We really haven't even gotten there yet in the world of nutrition. I think that's a really interesting, exciting kind of area. But I think in terms of foundational principles, again, the data is not iffy on this. I mean, protein is not just about muscle mass and body composition. It's literally every process from a cellular hormonal immune function level in our bodies. And there's constant, it's just like bone, there's constant turnover. And so we need to fill the tank constantly. And I think just like we celebrated the FDA removing the black box warning from hormones. I cannot wait for the day.

1:14:04I'm sure you can either, and you can finish my sentence, but I cannot wait for the day where we revise the minimum recommended amount of protein, which most people don't know is the amount needed to prevent disease instead of to promote wellness. That is long overdue. It's coming. It's coming. It's coming. Yes, it certainly is. I'm probably not even supposed to say that. No, I know. I know it is too. Of course you do. It is coming and I'm excited for that. Yeah. What do you think are some of the biggest myths just out there now in the nutrition space? One of the biggest myths is that women should never do intermittent fasting.

1:14:46I think there's a place for it. I think there are people for it. I think it doesn't have to be all or none. There's a massive amount of peer-reviewed data that supports its metabolic and cellular benefits. And I think we need to pan out, so to speak, to use a camera TV term, from one little slice of an endpoint in terms of intermittent fasting to an overall, again, holistic endpoint. Let's start with, do you like it? How does it make you feel? I didn't know those were important questions. Right? Let's talk about something novel. Like, does it even work for you in your lifestyle? And I think that we have a real problem with moderation.

1:15:34I think I'm a big believer, both in terms of obesity medicine and women's health, in the concept of metabolic and physiologic confusion. I think our bodies on some level like habit and stability and on another level, and I get this from my athletic kind of fitness behaviors, like to be thrown a curveball every once in a while. I think it's good for us. I think that adaptation from us as an organism is very healthy. And I think when our body sees the same thing over and over again, day after day, it starts to not do what our bodies really want to do, which is adapt and be nimble and flexible. And so I'm a big believer in occasionally doing a span of intermittent fasting.

1:16:22I do that in my own life and I love it. And then there are times that I don't do it. So basically what I'm hearing you talk about is hormesis, is applying pressure to the system to disrupt the current balance so that the body can go back to finding balance. Strategically, intentionally, deliberately, and mindfully, you know, just so that you're not doing it like as a knee-jerk response or out of panic or desperation. And I think leaning into a sense of curiosity with your own body is the most important thing we can do. And, you know, I don't think people do that enough. Again, I don't think people do that enough intellectually, and I don't think people do that enough physically.

1:17:03You know, it makes me think about this concept of stoicism. I've just been very interested in it lately, this idea of it's almost a level of neutrality and the comfort crisis. People are talking a lot about that, but the perspective seems to be largely male. I don't hear a lot of women speak about it from a sense of, okay, well, what does it mean to be strong? And just listening to you talk, I can't help but think that you must have some kind of mental framework for your internal strength? First of all, I agree with you. I think it is, it's more of a male narrative now. I think you're totally right about that.

1:17:45I went into women's health because I actually believe that women are more stoic than men. It's just that we don't often talk about it. And by talk about it, I don't mean to other people, I mean to ourselves. You know, whether it's what I learned after my ex-husband died by suicide or what I learned today as a woman 56 who is stronger and more fit than I was at 36. It's about kind of the line that I say to myself almost every day is resilience is not really a trait. It's a practice. So strength and power, I don't think is a trait. I think it's a practice, a habit, something that can be cultivated, something that can be expanded and grown.

1:18:35And I think that we don't have that conversation with ourselves enough. Do you think, is there a way to add that in? If someone was listening to this and go, you know what? Jen Ashton has been through the ringer, but yet here she is doing amazing things in the world. What is her practice of mental resilience? I think there is something that a listener or a viewer can take from it, and that's have gratitude, have curiosity, and have faith in your own strength. You know, that saying, whether it's Nietzsche or Kelly Clarkson, what doesn't kill us makes us stronger, is really true. And I don't think that, look, if I had never gone through the suicide death of my children's father, I would have said, you know, it was the hardest thing I ever did, gave birth to two humans.

1:19:32And after that, I felt like I could split a nail between my teeth. And then I had three kidney stones and I thought, oh. Oh no, this is even more painful. Gosh, that's, yeah, that, I agree with you on that. Right? Yes. And then I really thought that, or I thought, actually, I thought I was strong. I'm really not so strong. But I think we all, it doesn't have to be the suicide loss of someone. It doesn't have to be a kidney stone or a vaginal delivery or a pregnancy or a triathlon. It literally could be something as hard as something that someone is doing today. It's different for everyone. But I think that how we talk to ourselves needs so much resuscitation and we're just not getting it.

1:20:16And we're in control of that, right? I mean, you know, how often do you look in the mirror, I look in the mirror in the morning and we start with the, this isn't looking good, this isn't looking good, I don't do that, you know, whatever. No, I'm like, okay, who is screaming at who right now because this is ridiculous. Right. Right. That's how I usually start the morning. That's right. And, you know, whatever it is, it's just, I think we could all improve that. I like that. I think that you're right. You know, I've been, quite frankly, I've been thinking a lot about that. I'm working on my third book and it's, you know, part of thinking about that is how we frame things up.

1:20:55There is a long way to go. And I think that there's a long way to go for the sisterhood of women to be able to come together and go, you know what? I got your back. You have mine. How do we begin to think about this together collectively? Collectively, community is really important and not community that's, again, superficial and not transactional, not because I'm going to help her so that she helps me, because helping her helps you. And actually, you do have a community. I have an incredible community that was really unexpected, unanticipated in agendas. And that's, as you know, agenda like Jennifer in our wellness experiment.

1:21:39That is really, it's women 50s, 60s, and 70s that really love and inspire and support each other and learn together. And it's been unbelievable to watch it grow. But I have a personal community that has helped me and that I hope I've helped them as much as they've helped me, whether it's former patients, patients at the time who literally, Gabrielle helped me heal from my children's father's suicide. My patients helped me heal. And did they help you by just - They helped me in some cases by crying with me. One helped me by arranging my two dogs that were really my husband's dogs to be transported from New York to Florida to live with his best friend after he died.

1:22:32They helped me by remembering the anniversary of my husband's death. So they were really in it with you. Yeah. You know, in OBGYN, you are the doctor that people go through these phases, just these life phases with. That's extraordinary. They are extraordinary and they, I will never ever forget them. I didn't know that I would be able to literally go back to my job after that happened. And I was now suddenly a single parent. I was financially the sole supporter of my children, even before their father died. And I literally didn't know whether I was going to be able to continue working. and it was it really taught me talk about strength or resilience it taught me that you can be vulnerable and strong at the same time and it taught me that you know you can be broken and still be a leader and I was broken and I still after six weeks I could not go on the air for six weeks.

1:23:42And when I went back on television, I think women, we are naturally good at compartmentalizing and multitasking. And that's what I had to do at the six-week mark. I had to do it at the two-week mark in my office with my patients because I didn't have the luxury of taking more than two weeks off. But when I realized that you can be broken and still be a leader, it was very freeing. Perhaps your next book? Oh god that's like saying have another baby. Hey anything is possible anything and everything is possible. Dr. Jen Ashton where can people find you? Love you. On my Instagram at drjashton and on our incredible website is joinagenda.com and agendas like Jennifer.

1:24:31Thank you so much for spending the time it is it's just a privilege and just thank you. Well, thank you. And thank you for making me cry. But I will say the credit goes to you because if you are not the kind of person that provides a safe space to have these difficult conversations that no one wants to have, I wouldn't have gone there either. So I hope a lot of people were helped by it. I know that you do incredible work and this was just an example. You're not a psychiatrist, but yet - Did you know I trained in psychiatry for two years? There you go. Trained in psychiatry for two years. Well, this is why you're so talented at establishing this kind of safe environment, and you do an incredible job of it.

1:25:14Well, I will actually take that compliment coming from someone who has been on air for an extraordinary career. So thank you. And also, just a side note, thank you to you and your husband for the work that you do. I would love for you very briefly to just touch on home base. It's his greatest proud legacy. Homebase.org is an organization that he started over 16 years ago to provide state-of-the-art care for traumatic brain injury and the invisible wounds of war that our veterans face. And they are based in Boston, Massachusetts. As you know, They have an incredible partnership with Mass General Hospital.

1:26:00And Homebase, which started from the Red Sox Foundation, has cared for over 30 ,000 veterans, has saved countless lives. And they really do unbelievable work that is now international. And they have centers all over the country. But Boston is really the flagship. And they've, as you know, they've done incredible, incredible things. which really are not being done anywhere else. That is very true. So if there's a veteran, veteran family listening to this, should they go to homebase.org? Homebase.org, absolutely. They can also look out there. I mean, they have all the information, and they take a new class of veterans and their families every two weeks, intensive two-week program to help people really at their lowest point, struggling from what these veterans have gone through.

1:26:58And it's a real honor for Tom to be at the head of that mission. And I'm so proud of him. That's just a real indication of the kind of person he is. Well, thank you and him for that. It's very important. Thank you.