Do You Have to Stay on GLP-1s Forever? with Ashley Koff, RD

Today I'm joined by Ashley Koff, who's an internationally recognized dietitian with over 25 years in personalized and integrative nutrition. She's the founder of The Better Nutrition Program and the author of her brand new book, Your Best Shot, which I'm so excited about. She currently serves as the nutrition course director for UC Irvine's Integrative and Functional Medicine Fellowship. Ashley has been recognized by a number of different platforms, including CNN, as a top 100 health maker. Ashley, I am so excited to get your take on all things GLP-1s, weight, and weight health as you're changing the conversation and the narrative. And I'm interested in starting out with asking you about your stance on the increased use of GLP-1s and where you feel like we are as a society today, whether they're helpful, harmful. What is your take?

Well, thank you for having me. And I love that you dove in right to the question. Right. It's so funny because Everyone wants me to have a stance, right? That's the society that we live in. We have to— it's black or white, blue or red, eating or not eating. And I'm just like so purple and in the middle. We have a new tool in the toolkit, but toolkits should be used by qualified practitioners. I think part of the problem is that I fundamentally believe that weight health does not belong in the realm of physicians. I believe it belongs in the realm of dietitians, in collaboration with physicians. So I don't wanna disacknowledge the, or suggest that I'm eliminating the physicians in that part. But the biggest issue is that we're just like, we're burying the lead with a GLP-1 medication. GLP-1 medications are doing something today that is absolutely essential for every single human on this planet. They are teaching us about how our body works. They are the medications, semaglutide, tirzepatide, They are synthetic biosimilar hormone replacements for one or two of our own weight health hormones. So GLP-1 and GIP. And yes, we have versions coming that are triple agonists, quintuple agonists, blah, blah, blah on that part. But weight health hormones, which include GLP-2, GLP-3, which include PYY, CCK, they are in our body's ecosystem to provide a variety of roles that we're now seeing how that actually works. So thanks to research on using an agonist, which is again biosimilar, the similarity is it is designed to, for the body to receive it at receptor sites, just like our own body's hormones. The dissimilarity is instead of it turning on and off in 2 to 5 minutes, it's lasting for 24 hours or 24 hours for 7 days a week. So there's pros and considerations. We can definitely dive into that. But when we understand that these are, these are the, our own hormones, then every research study that comes out saying like, look at this related to blood sugar, look at this related to food noise, look at this related to inflammation, look at this related to cardiovascular health, is showing us where receptor sites exist in the body and where dysfunction or suboptimal function in a human has been keeping those receptor sites from being satisfied. So you're the perfect person to have this conversation with. Let's dive in. But I think my stance is it's a tool in the toolkit. Can any tool can be used inappropriately and not have better outcomes? And tools can be used at the right time in the right amount for the right person, um, and have, you know, really incredible optimization outcomes.

Okay, I love that you just went there because this is how my brain has thought in, in all of the increased awareness and again, a lot of the research studies where they're showing so many benefits to these hormones that we naturally produce on our own. And as you talk about, that I want to get more of your, your weigh-in on is how much we have influence over our own, our own actual production of these hormones and how so many people are, have the dysregulation and those sorts of things that lead to a lower production that lead to increases in food noise. But I'm curious what your, where you feel like we are as far as being able to identify, okay, if these, if these medications help with these symptoms, mm-hmm, does that mean that we can just focus on other natural strategies to help with increasing our own production?

Uh, I love that. Yes and no. Um, so one of the things that bothered me in this space was there was, there's no way to, with a lab test as currently and certainly available for the consumer population or even the practitioner population to assess our own weight health hormone function. And that is because they are designed to be deactivated within 2 to 5 minutes. So I created the first ever weight health hormone assessment, and that assessment's a clinical tool. This is not one of those quizzes that you go through and like a horoscope or you find out you're a cheetah or a lion or something like that. This is work. So I suggest, you know, probably doing it with your practitioner or recognizing it is going to be work to do it, but it asks about lived experience, um, you're around your eating and how you feel. It looks at lab work, it looks at digestive function, it looks at hydration, it looks at breathing, it looks at— which by the way is impacted by stress and trauma— it looks at weight composition. So when we look at all of those things together, can we optimize our own weight health hormones by using other strategies to do all of that? Absolutely. My book is full of examples. I have been helping people with weight health optimization via weight-health hormone optimization since 2004. This is not new to me. The second I saw a bariatric patient was when I learned about what they were called at the time, incretin hormones, and I call weight-health hormones. And so without these tools, I have been able to do that. And it's not, "Yay, Ashley's the best dietitian in the country." I'm great, and many of our colleagues are great, and we're also dietitians, so this is our wheelhouse. But it's also that what ends up happening is somebody, number one, has to have access to us. We are trained as in whole-person, root cause, integrative functional medicine care. They have to have access to resources, and the stars do kind of have to align where we're able to address all of these things and also be able to help them maintain it ongoing. So what's really exciting about this medication is where, in my opinion, with the agonists is where so many other medications have been inferior. So one of the advantages of a GLP-1 agonist is maybe turning around and not putting someone on metformin or maybe not putting them on a high-dose steroid or maybe not putting them on a statin and just saying like, oh, we're going to lower your cholesterol. Interestingly, you still have arterial plaque, you know, like we were actually able to do things, you know, more collaboratively and look at a hormone that can actually, you know, have impact. And the interesting part about the brain receptor sites for in particular GLP-1 is that we're also seeing it help us with not just food noise, but the Food noise can sound like, oh, and I think this is the way it's been delivered, oh, those overweight or obese people, they're always thinking about food. Something's wrong with their brain. They must just, you know, food this, food that. The majority of my patients that actually are or have been challenged by food noise are actually people who have used inordinate and sometimes very self-harming approaches to overcoming those incessant thoughts to try to diminish them and to not eat, right? So they've like created this muscle of willpower that, has been problematic, or they've conveyed to me that they still never feel present at a meal because the whole time they're eating, they're thinking about, you know, what is it gonna do, you know, for their body size. So I think the big picture—

I think you're saying, just to clarify before we go into big picture, you're saying that these, the people that you work with that have the most food noise are the ones who have tried the most like yo-yo dieting approaches and those kinds of things that only fuel more of that food noise long-term. Is that what you mean?

Exactly. Because when you add it, you have food noise and now you have, I've been a failure, failure, failure, failure, failure. And so then you have, I'm going to investigate more and more and more and try and try. The biggest myth about— I hate the term obesity in this country just because the way that it's defined is just weight for height. Like, it's so unhelpful, right? So we really have to look at weight composition. But if we want to, if we want to use it and we want to say, okay, this is obesity, or someone who has, let's just say, beyond 20 pounds of excess body fat on that part, the myth is that they are non-compliant. The myth of a non-compliant patient, that they have not tried. From the years, pretty much from about age 8 until I was about 22, I tried everything under the sun to lose my belly. I tried, you know, I mean, hard, like, garments. Like, there wasn't Spanx at the time, but, you know, I think it just started. I tried those. I tried not eating. I tried only eating certain things. I tried drugs. I tried, um, you know, like laxatives and things like that. I tried binge eating. I tried not eating. Like, You name it. It was not for lack of trying, right? And I think that that's this space where, like, almost calling it food noise is underselling the issue. It's that we have literally— it's a type of obsessive compulsion that has been born out of all of the tries and feeling like a failure, you know, on that part, or feeling like a sometimes winner. You know, there were times in my life where I was sometimes didn't have my belly, you know, that piece.

Yes, such a good point. Okay, and then I, I interrupted you, so I want you to talk about big picture.

Well, I think big picture, what we're also seeing is because these medications work, right? And how one always has to judge what does working mean, pros and considerations. But if they are suppressing appetite, if they are removing some food noise, if for the first time someone doesn't feel like they have that stress or that, you know, they're able to be present at a meal or they walk by a Starbucks and don't walk in and walk out, or they don't like, you know, get mad at themselves for thinking about the Starbucks, whether or not they buy it or, you know, those sorts of things. And we see wins there when we see inflammation lowering, when we see some of these other things that may be the thing that needed to happen for that foundation for somebody to have that, for them to then make better choices. For me, I would say my discovery was magnesium. When I— I've never could understand. I mean, I must have been so deficient in magnesium and then at times in my life, frankly, insufficient, you know, on that part. And when I use magnesium strategically, both as a food and as a supplement, my entire demeanor changes, right? Like I'm like I'm able to poop. That makes me a nicer person, or I don't have headaches or I don't feel full in the same like, oh my gosh, why are things not moving through my system? Because I had slower motility, you know, or I recover better from a workout. So when I experience that, it allows me to double down on better behaviors. And I think that's where this opportunity exists with this particular type of medication that, again, we've tried other things. We tried a class of medications that were— so with our own weight health hormones, with GLP-1 and GIP, they're deactivated by an enzyme that comes in, DPP-4, DPP-4, yeah, comes in. And so there were medications that were antagonists to that that tried to like stop that from working. And that still didn't have the same benefit. So why do I bring up that? Because it tells me it's not necessarily that we just, you know, that the issue is that somebody needs to produce more of the medication, of our own hormones. It may be that our system for receiving messages and then deploying the messages via the bloodstream or via the vagus nerve, that there's— that things are broken there or that they're suboptimally functioning there. That's really important when we look at, you know, one of the primary drivers of vagus nerve suboptimal function is trauma, right? Is stress and trauma. And so that may be our lived experience trauma. That might be, you know, for every time I look at a piece of food, I judge my appearance. It might also be that I was somebody who didn't have access. This wasn't my story, but if I was somebody who didn't have access to food when I was growing up, maybe I just ate and I ate really fast. Maybe the dinner table was a really uncomfortable time period. You know, all these different things. So when we experience that stress around our eating and our eating choices, that's negatively impacting our own, how our, not just the deployment of our own hormones, but how they'll get actually where they're supposed to go, in particular to the brain. So that may be what we have to work on, and that's why we're seeing these medications can be more successful. In the biggest picture, I believe that these medications as a tool, the current ones, I have other thoughts about the coming ones, the current ones could be the greatest chance that we ever have at creating generational weight health. And that is because when we look at helping people become weight healthy today, which is not the outcome of going on a GLP-1 agonist, it is the outcome of really coming up with a personalized plan that uses the tool properly for an individual that needs it or doesn't use the tool— somebody won't benefit from it or doesn't have access. But when we help somebody become weight healthy, that helps them role model healthier behaviors for the people that they're around. I'm an aunt, you're a mom. Like, that helps us show, you know, our partners, our kids, our, you know, communities. And as we do that, that creates a generation that grows up more weight healthy with more potential. And then they also are more likely because of what we know of in utero implications and even sperm and egg implications That, you know, when, when adults are weight healthy, that then they have, you know, a better chance for their kids to be weight healthy. So I think there's huge implications in these. We just have to get into where they're not being used appropriately.

And potential side effects. Because as we were talking before, I said to you, like, it seems like so many practitioners are just fully jumping on the bandwagon of saying, like, these are the greatest thing. They're, they're working for everything. Yeah. And. It to me, like my functional mind is always like, anything that sounds like that is, yeah. Like there's something that I'm like waiting for the other shoe to drop. Yes. You know what I mean?

Yes.

And so I'm interested in, I know that the book is about weight health and ways that we can achieve that. And so I wanna get into that, but what are your thoughts on potential side effects? The, concern around needing to be on them potentially long-term, or are you not seeing that in people that you're working with?

Yeah, I love that question. So one of the things I also just love, like how much conversation there is about this, like with people who, and I genuinely, I'm not mocking, I genuinely think people are really concerned and their functional minds, um, you know, are having these conversations and thinking like, we don't know if it does this, couldn't it do this? And. All of these other things. And so, so first of all, we do know for— liraglutide's been around since 2005. I've worked with patients, you know, since that time period. We also know we have examples from bariatric surgery and we have examples from clinical research to see how weight health hormones work in the body. But this big dissimilarity to our own, this amount of time that it stays on, is really important for us to dive into and understand. What's interesting to me is why is nobody asking the questions of like, what happens if you're on a statin for the rest of your life? What happens if you're on a proton pump inhibitor for the rest of life? What happens when you're on an NSAID?

I have always asked those questions.

You are. Yeah, totally.

It's the same. It's the same thought process.

Totally, totally. You are. When I say the nobodies, it's the like, it's like this aha moment, right? And so we have to be, we have to unpack that. Like, that's why I'm, I'm loving having this conversation here because We should be asking that question about anything we put in and on our body, any of it, right? So when— and again, it goes back to your— you're asking me for a stance in the beginning. I feel the same way about GLP-1 agonists that I feel about red light therapy, that I feel about fasting, that I feel about, you know, seed oils, like any of these other things, right? Like, you— we have to understand how they work in the body. And so what I think that's the biggest mistake or most misunderstood is there are direct effects effects of the medication working exactly as it's intended to, and then there are some things that we have to take note of, which I would call side effects. So when the medication is designed to delay gastric emptying— so let's even go back further— the medication is designed to go into your body and satisfy the receptor sites for GLP-1 and GIP. When a receptor site is satisfied, that means your own body doesn't need to call to action that ingredient to get to the receptor site. So we're seeing a natural— we, we would be seeing if they were doing the research on it, but they did do the research with liraglutide. We see a suppression of our own hormone production and our own hormone deployment. So that's something interesting because remember, we have PYY and CCK. So if GLP-1 and GIP are not being told to activate, what happens to a system that is told not to activate? Well, what happens is it doesn't, I wouldn't say it turns off. I don't think we have, I think there's a suppression. I don't think we have a complete turning off, but we have an alteration in our own hormone function. So that proves the point. If you just stop taking the agonist, which circumvents your whole body system and it goes right to the receptor sites and it does it and it stays on for, you know, an entire week or maybe 5 days at, you know, and then kind of weans off on that part. If that is happening and you just go off of it, and you haven't solved any other problem underlying, and you had suboptimal function underneath there, you are going to have to stay on it forever. That is proof positive. So a society that says, or a practice, you know, whether it's obesity medicine or it's pharma or anybody else that says you have to stay on these forever, is missing another point. Um, with any medication, you may or may not be on it forever. I don't have a crystal ball for your life. I don't know if today you have you have two legs and you go out running and you like to run marathons, or you like to go for a jog, and you're able to strength train. And if three months from now you are pregnant, you are, you know, going through perimenopause, you are— you unfortunately have an accident and you're bedridden, like, I have no idea what's going to go on. And so I think this idea of like, what, what would you have to stay on for life— anyone that answers that question is completely lying to you. But the point is, if you don't make any other— if you don't optimize the function, your weight-health hormone function, and you don't do weight-health optimization, which is what my book is a playbook for, you will have to stay on it to maintain those results. So that's answer number 1. The second one is not only does it circumvent all of your own and deliver it at a very high amount, what the difference between it— that means is instead of being active for 2 to 5 minutes, These are active for about a week. Well, that means that they're pushing a message to insulin and glucagon for how to work all the time. Those messages are only usually being pushed around the timing of when we're eating food. And you know, you're a blood sugar expert. And so when we look at that, that's a very important messaging, but I would call that like kind of a metabolically active state. And so what we're seeing is, and I'm seeing this consistently, and it, I, I'm seeing a side effect that's being misdiagnosed, is we're seeing then that people are not in the turned off stage. So recovery, heart rate variability, sleep, and the resulting fatigue is showing up. And I have some people who are on doses where they're like, Ashley, I have to stop taking this. I am so tired all the time. Not only can I not get to the gym, I just can't function. And what they're being told is go ahead and eat, right? Like they're being, oh, it must be because you're not eating enough. No. You're on too much of a dose for your body. You know, on that part, I had some— a patient told me the other day that she, when she drinks caffeine on her medication, especially the first 2 days, she's like, I'm jacked. Like, I'm uncomfortably jacked. And I was like, yeah, because it's already actually telling your body to go to work and your body didn't have the kind of recovery. So that would be an effect, a direct effect of the medication. That is not a side effect. That is one to understand and should be how we dose differently, you know, and should be how we optimize. Remember that magnesium or, you know, other things. There's a third one that I want to mention, and then let's, let's dive into it a little more. And the third one is we're delaying gastric emptying. So we're delaying gastric emptying in a population where we already have people who have— maybe they're on acid suppressing medications like a proton pump inhibitor. Maybe they're like me and naturally had slow motility, or all the antibiotics I was on were, you know, knocking my motility. Maybe they're magnesium insufficient, magnesium deficient. Maybe they're sedentary, they're not moving around. Maybe they've heard they need to exercise really hard for 30 or 40 minutes in the day and not moving the rest of the day, you know, whatever it is. So when we see that and we see that delay of gastric emptying, we have real issues there because when you delay gastric emptying, you are challenging how the body receives resources. You're challenging the breakdown, the absorption, and the availability of resources. And that can be highly problematic. And then we tell them on top of it, eat more protein. You just need to eat more protein. Well, in a gut that doesn't work optimally, when we throw in more protein, we create a lot of disasters on that part. So what I would say is that brings me to all of, you know, constipation, hair loss, muscle, all of these other things. These are not side effects of the medication. They are effects of the medication working exactly as it's intended to. This is why your Brilliant Functioned brain went this way. They are ones we have to understand. These medications will exacerbate any underlying dysfunction, and they may create dysfunction, and we need to be paying attention to that. It's also why I believe, um, it's so critical that we have these medications— perhaps, you know, they're prescribed by doctors, but they're— they should be— the management of them, and the management, it should be anyone who can do whole-person, total nutrition and lifestyle, you know, with the person to be able to optimize, you know, throughout, throughout their journey on that part.

Yes, we, we 100% say that to so many of our clients because we have a mix of clients who are on GLP-1s and who aren't. And I think that that is like such a good point, is that even if you are taking one, it's not like then you're just on your own and that you're just going to like lose the weight and everything's going to be fixed. It like actually increases the need for you to have someone like working with you and helping to oversee all these things that you're talking about. Another question that I have for you is like, what as a society do you feel like this is creating? Because experiences that I've had, even when we were both at Eudaimonia, and you know, I'm not sure if it's like people are on peptides or they're like taking GLP-1 prescriptions, but it seems like the level of thinness that I have, and I'm not someone that like goes into places and typically like makes note of people's weight, But the level of thinness, like, in that environment particularly, or in other, like, celebrity environments, is, like, a little alarming. And so I'm wondering, like, what your— because I know this, like, how much, how important it is. Maybe you can talk about this too, is, like, the importance of body neutrality and weight neutrality and, like, not judging other people. But I'm just wondering, soci— like, as a society, what you feel like this is, like, Is this moving us in the right direction or kind of like the wrong direction?

Gosh, there's so much moving us in the wrong direction. I, I don't know if I have time to unpack all of that, but I'm not going to, I'm gonna stay focused here on, on weight health. Um, you know, I, uh, so one of the comments that you made before, I wanna double-click on about you and your patients. Um, I think that, you know, a lot of the access, access is such an important access to the medications. The medications have been too expensive. Um, like many medications, insurance, um, But also, I don't understand why insurance is not covering— well, I understand, unfortunately, or I have a cynical understanding, but insurance isn't covering us. And so one of the things that, you know, unless somebody is diabetic or unless they're obese, and I've seen people where their coverage has gone away as soon as they've achieved a certain weight, or somebody has said to me, I don't want to get rid of my diabetes because then my, my insurance stops covering me seeing you. And I was like, that's like the worst message ever in our society. So, you know, I call on the insurance companies. I think they are doing a, like, just a horrific, horrific job. I saw with Blue Cross letters going out where they were taking it away from people who are using it for weight reasons and keeping it for people who had diabetes, saying that diet and exercise, you know, diet and lifestyle is still the proven approach for, for weight. And this is abominable. So let's call, let's, let's call out where we need to call out. But One of the things that I think is so important if you're a physician prescribing this is have a budget conversation. And most physicians will say, actually, I don't even have time to like fully assess the patient. Right. So I just want to tell you, your system is not set up to help somebody unless you have a dietitian like us, unless you have a coach, unless you have a nurse practitioner, you know, a teammate who can come in and have a budgeting conversation. When I know somebody is not going to be able to afford ongoing medication, we look at, you know, maybe the dose being really low so we can extend the time period. We may extend the time period, we may use a once-a-month dose of this. But the answer is never going to be, let me sell you the medication and not sell you the dietitian. And there are too many companies that are doing that and too many, you know, physicians where physician-led entities, you know, that are doing that. And that is wholly problematic and not driven towards someone that measures outcomes other than their, their financial bottom line. So what I said, what I said, we're done there. Onto your question. Thinness. I think thinness is really a, um, a huge societal problem. One of the reasons I introduce a weight-health approach instead of a weight-versus-health approach is that, again, for about 20 years of my life, I was told I had a weight problem, I had a belly problem, but I was healthy. I was the furthest from healthy, and I became increasingly unhealthier because my weight was pinpointed as the only thing. Um, and I think that we really have to make sure As you said, you don't go into a place and you're just looking at people. I mean, any of us that are practitioners know that the quote unquote thinnest, most beautiful looking radiant person in the room could have a horrible disease underneath, or not even a horrible disease. They could have a mental health issue. They could have like any, which else is a horrible disease?

I suggested.

Yeah. And anything like going on on that part. So I think the one thing that we're having is there, it's really interesting to me, um, you know, to the outspokenness of like, gosh, like everybody is just getting too thin. Like all my friends are too thin. Hollywood is too thin. I went into this, you know, place and it's too thin. And I think that that is an access to a lot of things. I think that what we're seeing is there is still this messaging of if you are thin, you are healthy, or if you are thin, this is ideal. I'm a bigger person. I've always been a bigger person. In rooms like that, I feel monstrous. Like, and I try— like I have these moments where I'm like, Ashley, like, you look great. Like you, like, I'm 52, I look phenomenal for me. Like, and at 48, like, my belly was back and I was like, you know, I like, I, I like had so many health issues going on that like figuring out like HRT and like when weight health, you know, I had to figure out that like fasting wasn't what was better for me and how do I activate my weight health hormones. And a lot of the tools, you know, I share in the book are ones that were really important for me. But what, when something happened to me at Eudaimonia, I was telling you, I'd like the plague, I was so sick. Like, I was like You know, that kind of sick where like, I mean, I literally went and hid in a bathroom stall cuz I didn't have a voice to talk to people, but also I was like sweaty and like, I'm just like, oh. And I knew I wasn't.

And she was also, wait, she was also speaking on so many stages and on panels with like the biggest names in, in functional medicine and health and wellness.

Got it. I don't know how I was like terrified too that I was gonna get them sick. But I actually asked a colleague of mine like day one, he's like, how long have you been sick for? He's like, you're, you're beyond, like, you're not contagious at this point. I was like, oh, you know, thank goodness. But I just, you know, felt so badly. But I was in that space and I shared this with somebody the other day. You know, someone came up to me, she had seen me about a month or two ago at a different conference and she's like, girl, I just got to tell you, like, you look phenomenal. And I'm like laughing to myself. And I said, thank you. And I was thinking like, that was the end. And she goes, she comes in and whispers and she goes, you're on it, aren't you? She's like, you're on, on GLP-1. And I was like, and I, and I wanted in that moment, I still wanted to like love her, but like the 8-year-old, the 10-year-old, the 15-year-old who has like had so much trauma for being made fun of and like judging myself. Like, I think I was harder on myself than most of society was, but about my belly. Like, anytime anybody talks about my weight appearance, like— and I had this belief that, like, I'm like, oh, they're actually, like, saying you look beautiful. They're not talking about your weight. I've had to, like, break that messaging, you know? And here she was actually talking about my weight. She's like, oh, you're— you know, and she thought that was appropriate. It's like, what? Like, you don't ask people, like, are you pregnant? Like, you let them lead in and tell you. She thought it was appropriate. So she says that to me, and then she leans in a little closer and she goes, I think you're on too much. She's like, I saw you 2 months ago and you look a lot skinnier now. And she's like, and your clothes are kind of hanging off of you. And I, at that moment, and nothing— like, I am just straight up— and I said, this is so— you know, and I'm like, squeaky voice, I was like, this is so inappropriate. I'm like, you really may have come in here with some version of like, you are my friend, or like, you know, you're, you're trying to you know, connect with me. I was like, like, you can read my book, but like, I've battled my weight, health, my— like, and this side of it my whole life. It is wholly inappropriate to come up and talk to someone about this. She goes, like, I'm so sorry. And I said, I also need you to know I haven't kept food in. I've had diarrhea for 9 days. I was like, I am so sick right now that like what you are seeing is like— I'm like, I'm actually like, thank you that you're telling me I actually look good, because like I felt like, you know, I mean, you want— when you're sick, you know, and I'm like sweating and whatever, she's like, you're glowing. I'm like, I'm sweating, I'm schvitzing, like they would say, you know, whatever. So this whole thing, and I sat there and I was like, oh, I'm like, we are right back there. We're back there to where I remember my friend had a brain tumor and I took her out for, to another friend of mine's 40th birthday. And I said, let's just go to this because like, we're gonna get, you know, there's nothing we can do until Monday when you're gonna, you know, we're gonna find out, you know, what's going on for you and everything else. And we're gonna go to a party and it's about somebody else. And like, this isn't gonna come up. What I was thinking, it was Hollywood, of course it was gonna come. I go to this guy, he's like a super well-known— I mean, he's incredible. It's Tony Horton. It was like, it was so fun to like celebrate his birthday and whatever. And we're in the corner and this woman finds out that I'm a dietitian. So she starts talking. She's just so unhappy about her weight. And she turns to my friend and she goes, I mean, just, you know, I mean, like you, like you couldn't have a care in the world. Like you don't have any problems. Like, I just wish I could be you. And my friend, I was like, and we're out. Like we left, we cried. Like, like I probably got hammered. Like I have no idea. But You know, I think that's part of the problem is like we, we're in this place where, um, I actually think sometimes, so if I think about this medication and I think about where we are and people are asking me, we have been here at so many different times. I ran my practice for 20 years in Los Angeles through Adderall, through Fen-Phen, through every diet, you know, under the sun of people getting too thin, too fast, et cetera. This may be that that time period where we're kind of— maybe, maybe if I could be Pollyannaic, could be that last time period where because we now have access to something that is actually working for people where maybe things haven't worked before in a certain way, and maybe it will be the way that leads them into weight health, either out of necessity because they start to lose their hair or they start to not be able to poop or, you know, other things like happen. But maybe we're at the place where we can actually call out, you know, and I understand Kate Winslet talking about it and I understand these others, is at the end of the day, you're still looking at people and how they look. And you and I aren't doing that because we are, we know that somebody standing next to us could have whatever else is going on, but society is still standing there and pointing at people and how they look. There are many people like myself who have been in uncomfortable moments right now I have a cancer patient who somebody in her community called her out for very publicly for being on a GLP-1 agonist. And she's been trying to keep her cancer treatments quiet. Her hair is falling out. She's losing a lot of weight. And I was like, all right, remember, like, I just give her my speech. Like, this isn't about you. This is about them. There's going to be that moment where, like, she's going to feel really bad and like, we don't— that's going to be on her. 'Um, but right now we just have to protect you.' And so I think this— that's where I am with this, is that this— we're no different. Like, we have always just been a society that calls people out based on how they look. And if somebody is for the first time in their life thin, or the first time in your life that you've known them thin, um, if you want to have a conversation with that about them, tread carefully and see how you want to have that conversation. But if you're a magazine or you're a you know, somebody socially, you know, anything else like that, do not. Like you, it is, it's just not the right space on that part. So I, I'm glad you asked cuz I think it's an important one for us to talk through.

But what advice do you have for people who are feeling triggered by seeing all these changes? Uh, you know, where it's like they might not feel 100%, like they still have, like they're sitting 15 pounds above where they'd like to be from a, a body composition standpoint. And they're like trying to do all the things, but then they're watching other people around them like losing so much weight and they're like, it's— I've talked to people who are like, it's triggering.

Yeah. So let's talk about triggers. Society is triggering. Society is triggering. And there is nothing more triggering, I think, than weight and external appearance. Look, my whole life I wanted to be tall, skinny, and have long blonde hair. I have curly hair. I'm like an athlete build. Like, I mean, I have always wanted to be that other person until I figured out and got to a place where I'm like, I want to be Ashley Koff, RD. And that's what that is. So I am so— what I say to you is I meet you open arms, full love. It is not 15 pounds above your body composite. You might have excess fat, I want us to now, if there's a trigger, that trigger should be, why is my body creating excess fat? Why am I not able to make muscle? Why am I losing bone? Why are my bowels not moving? Why does my skin look like this? If you personally have any signal on you that you don't feel better about for your body, then you're— then the opportunity is to work with us. This is why I wrote my book. Find, you know, grab my book, be able to come in. And to start to decode those messages. It is so friggin' hard, but we have to put up a force field between that and being triggered. And we need to do it with our kids. We need to turn around and say, yes, that person may have lost weight. There are times when somebody loses weight where they're sick. Um, there are times when people lose weight because they're changing the way they're eating, and that doesn't necessarily mean for a good thing. There— we don't necessarily want to be thin. We want to be strong. I'm curious, you know, can that person arm wrestle as much, you know, as well as they used to arm wrestle. Or if somebody is losing their hair, we have to have grace because there are reasons that they can be losing their hair. And by the way, I'm doing these all the time and I'm such like, this is a trying to walk this talk because I am triggered by it. As I just shared with you, I was fully triggered. I exploded on a woman in public in a speaking situation and, you know, and literally lost it, you know, like I don't have any more stuff in me to lose, but I was like, like, this is not like— stop, like, back off. And that's the other part that I would bring up is recognize that the trigger is real because we have tried— most of us our age, I would say, like, I don't know that there's a generation of women like yet to be born. I hope maybe I could say maybe this youngest group, but where we haven't been thrown into this diet and appearance, you know, space. And so if it's triggering you, it's triggering something in you that we want to heal, that we want to come in and say like, hey, like, is there something medically here? You know, are we like in this space where, you know, we want to actually look at medical gets a bad term. That's why I use— I like to use weight health. Is there something from a weight health standpoint that we actually want to work on? And maybe it's the, hey, like, I actually am in being asked like to, the trigger is why am I not loving myself? Why am I looking at somebody else and maybe being uncomfortable with the way that they look 'cause they look different now, but why am I making that about me? And that's the, it's hard 'cause I get real pissed at people who do that about me and I do it all the time about other people. I try really hard. When I say I don't do that as a practitioner, I'm boldface lying. Like I try not to, but as this is, it's so ingrained in me. Um, and then I try to call in my practitioner self, and then I try to call in the, the person who has, you know, first had to, you know, have developed that love and, and forgiveness for her 8 to 20-year-old self, and now, you know, tries to, to infer that for others or confer that on others.

Yeah, no, it's a good point. I mean, I hope that you're right. I hope that it creates more of an opportunity for, like, people to better understand their own triggers, but I just hope that it also doesn't create just this, this like increased obsession around thinness. Um, especially for like younger girls too that are seeing this.

Could we be, could we be more obs— like, I, I don't know. Like, I guess that's the question. Like, is there, like, I, I don't, I think we are like, there is, we've been this society, we are obsessed with this and we might have been pretending for a time period that we weren't. And, and there are people who have been so amazing at leaning into you know, body positivity and body neutrality. I, you know, I get that we have colleagues where it's the health at every size. I like to flip it and say, are you healthy? Are you weight healthy at your size? Like, that's all I care about, you know, on that part. And we can look at that. But I just don't think like— I don't think we have any increase to go like, I don't know. I just feel like we live in a society that is so ridiculously obsessed with appearance. And this is— this is a new tool to abuse. And some people will call this tool a solution in and of itself, and it is just not. And that's where the rubber meets the road.

It's not.

No, it is not.

Yeah, no, it's a good point. It's, it's definitely not. Okay, let's talk about calorie counting. So you obviously focus on the hunger hormones and you can talk about that maybe a little bit more. But for people who have been like white-knuckling their way through 1,200-calorie diets and they don't understand why they're still struggling. Can you explain more of what's happening?

Yeah. And that was— I mean, I tried— gosh, I tried that calories in, calories out game, you know, either just so reducing my calories or so increasing my, you know, caloric expenditure. I mean, at the end of the day, your calories are a source of energy. And so what type of energy you give your body matters. So the quality of those calories is going to matter. That's one pillar of better nutrition. Your body needs to recognize it to be able to use it. Your digestion is another key component because your body— we give a lot of credit today for somebody consuming calories like, oh, you had kale or you had salmon. Those are healthy for you, but they're really not healthy for you until they actually get where in the form that they're able to be used, they get where they're supposed to go and are used. So I think we have to, you know, really double down on, you know, the importance of digestion. And then the other part is calories in the day, like this total amount is not how our body works. If our body gets too much at one time, it's like going to your gas tank and like still filling up the gas even though the tank is full. It's like, if anything, it's wasteful, but it also is dangerous. You know, you've got the, the gas just, you know, wasting out on that part. So the amount, the quantity does matter. That's very different than portion control, but it's about how much does my body need at one time. And then your calories do need a balance. We need a balance of— so carbohydrates provide, I believe, I know there are people who believe we don't need carbohydrates, but I believe that one of the reasons for carbohydrates is that they're a, um, they are a vehicle for delivering other nutrients. So, you know, polyphenols and different types of antioxidants, fiber, magnesium, B vitamins, you know, all these other things. But they, you know, like glucose, fructose, etc., like, you know, they— that does give you quick energy, gives the brain quick energy. Proteins are amino acids, you know, uh, fats are fatty acids. And so we need those, and we want to resource the body as the body uses it up. We want to use the— we want to resource the body. And we see things like with blood sugar as an example, where if somebody was to consume 1,200 calories and say they only consumed it from carbohydrate, I think we all know that then your blood sugar would probably be off because protein and fats help to like kind of act as like a limiting factor for how quickly, you know, carbohydrates go into the bloodstream. But, you know, what we want to do is we want to get those in, in a balance on that part. So not giving your body too much work to do at one time, and not looking at calories in total in the day, but rather looking at— I call them pit stops because I feel like meals and snacks kind of have all of these wrapped up thoughts about like what one is. But, you know, about every 3 hours, you know, when you have a balance of carbohydrate, protein, and fats, your body gets a balance of nutrients, you know, coming in. The final one I'll say on that is I just went on this lovely ode to macronutrients. There's literally no food in nature that is just one macronutrient. There are amino acids or there are carbohydrate components or there are, you know, fatty acids in every— in different foods, you know. So telling somebody to eat protein at the start of the meal is like the dumbest statement that exists out there. I'm very big on— I have a chapter called Shit to Unlearn. Like, that's one of them. There isn't— like, that would just be like freebasing protein powder or just taking amino acids, which I know, you know, some people are suggesting. But when you eat a protein, you're probably going to get some fat. You might get some carbohydrate in there. You're going to maybe get fiber, you maybe not, you know, etc. So I think shifting from a, you know, what's typically an enriched flour, a highly refined flour, you know, a version of a bread over to something like starting with olives or chickpeas or, you know, something else like can be very— I'll use the example of chickpeas— can be helpful. And yes, there's protein in there, but the difference is really choosing something at the beginning that's going to provide the body with, you know, not just like a a very refined, you know, sugar on, on that part. So I think that when we look at calories, we want to look at what's the quality of our calories, what's the quantity we're having at any one time, what's the balance. And then we have this caloric timing, and we want to look at, you know, that, that window for sure.

And so when people say it's— you just— if you, if you can't lose weight, you just need to cut calories, that's what the science shows.

I think some of the worst science that exists that's out there— we have really bad science in nutrition research, and as a result, we have really bad sign. By the way, that's not to call out our colleagues who are nutrition researchers. I want to be clear. I think that's to call out a lot of different factors. But it is very hard. First of all, when you take animal data and you apply it to humans, like any of the data on GLP-1 or things like that, mice do not have to like get up in the morning, like decide if they're going to, you know, go into their kitchen, figure out what to eat, run by— I keep having Starbucks in my mind, I guess, because it's across the street. you know, have Starbucks, like, you know, or whatever, and like make all of these decisions. And they also aren't a product, their vagus nerves aren't a product of like all of these lived experiences, you know, as it relates to food. So we can learn some things from research on animals, but you know, we also need research on humans. And then I'm somebody who actually did one of my, uh, in my residency, one of the things that I did was, um, I was in there working with researchers and I would do interviews. And I remember like several times being like, Dude, they do not remember. This was before we had tracking devices. They do not remember what they had like 3 days ago. And they're like, just pick whatever it's closest to, you know, did they eat breakfast? Did they not? You know, whatever. And so, like, I know what went into, you know, that data. And we've since, like, you know, we've talked about that and there are better tools like Diet ID and some of these others. But still, it still approximates, like it'll show you a picture of steak and that may or may not have been the steak that you, you know, actually had. So I think that what we, we need to come back to is that the research is really not good. But also, most importantly, you are not in that research unless you participated in that research study and you know, were you placebo or not? You're not in there. So your hormones were doing something different than the person's hormones that were in there. Maybe your sex hormones, maybe your weight health hormones, you know, your like, did you start your day exercising? Did you not? What's delicious to you at the moment? What did you have access to? So when society tells us that the reason these medications are working is because they're just causing people to eat less and people lose weight, that's one way that they are working. But that is not the way that they are working. And it's a laziness. There is a laziness that often comes from people who are not nutrition specialists who are, you know, coming in and looking at and talking about these medications and their, you know, and how they are used and also what the, the results are.

A lot of physicians I'm seeing actually even.

Yeah.

Um, but yeah, it's a good point. And I think that even when people say, oh, it's just about calories in versus calories out, or you just need to be in a caloric deficit and, and that's the extent of the conversation, it's like, have you not heard of short-chain fatty acids and like all of these other things? Or it's like, have you not been paying attention to the research over the last 15 years? Yeah. Because it's, it's so much deeper than that. So if you were to, uh, take a person that is trying to optimize their hunger hormones, you're talking about these incretin hormones that you produce, your hunger hormones that impact so much of our hunger and satiety and, and so many other, or signals. Where do you start?

I love that. Okay.

So first things first, let's say where do you start if they aren't going down the path of a medication?

Yeah. And I have a, I have several stories in my book of people who decide, who came to me either adamantly, I'm not using medication, or where it just wasn't a fit on that part. I think the first one is our weight health hormones, GLP-1, GIP, PYY, CCK. Those are just the four that I call them the switch. And I've, because with, they switch on and switch off. And when they switch on, they regulate, they tell other hormones to go to work. They're regulating what type of fat we're making, where fat is being allocated. They're regulating, telling our blood sugar hormones to go to work or yeah, or to not. Appetite and you mentioned ghrelin and leptin. So appetite and satiety are factors in there. Muscle, bone. I mentioned in the endothelial, I mentioned heart health, but in the endothelial lining of our— so those are the walls of our blood vessels. So that's about plaque on the heart muscle, in the pancreas. So one of the things I want us to remember is we don't get to pick working on one part of the body. We don't get to say, I'm going to just work on this and it is going to work on appetite and satiety. This is an ecosystem. So anything, anything as simple as an electrolyte supplement, you put it into your body, it is going to have impact in a variety of different ways and you need to understand how it's having that impact. So one of the key things that I will do and the reason I created the Weight Health Hormone Assessment is to look at what am I seeing as suboptimal function right now? Now, I wish in the ideal world that I had people who came to me before they started the medication to be like, Can you work? And I do have some, but the majority of people come in and they're like, I'm a hot mess. Like, here's— I'm coming to see you because of X, Y, and Z. I've stopped losing weight on the medication. I feel crappy. I this, I that, you know. So maybe we can get people, you know, with this conversation earlier. But one of the things I'm going to do is I'm definitely going to assess digestive function. I'm going to, you know, I want to understand what's going on with your poop. I want to go and understand, you know, do you currently or have a history of reflux? Like, how is your digestive function? I want to understand your history with disordered eating and an eating disorder. If that's the case, I want to understand what your current exercise regime is. I want to look at your total nutrition, not your food versus your supplements, you know, as two different columns. I want to look at them together and see where there may be insufficiencies, excesses, or frank deficiencies. And when we come in there, we're going to have a conversation because if you start on a medication or if you're deciding not to use the medication, Regardless, like, we know that you are going to do better when we optimize these other things. So sometimes the conversation is, I don't know if we're going to need to use the medication, but what I'd like to do right now is I'd like to see how your body responds when I add glutamine, when I, when I help you with short-chain fatty acids, when we work on polyphenols. One of the lowest-hanging pieces of fruit is hydration. When we optimize hydration, which is not drinking more water, but actually helping you become a sponge instead of, you know, being a hose and peeing water out. How do I help you absorb that water? How do we maybe reduce dehydrators, including things like stress? Doesn't mean we get rid of stress in your life, but how do we, you know, make sure we hydrate you and understand the impact, blood sugar issues, et cetera? So from that assessment, each person, something is going to pop up as what we need to focus on. I will say hands down, Brigid, across the board, if digestion is suboptimal, we have to work on that. So whether you're using a medication or not, we have to optimize digestion. And that isn't about taking a probiotic. It might be about taking the right probiotic, but also making sure that, you know, the, the other pieces, maybe you're eating too much at one time and that's negatively impacting digestion. Maybe you can't break down protein that well. And until which time you can, we should use some digestive enzymes, you know, to help with those kinds of things. So what I would say on that part, and the reason I wrote this playbook, it is literally a playbook from assessment through helping you pick where to focus is that there is going to be a different answer for everyone. But suboptimal function is suboptimal function. So if right now you are someone who— I have one of my patients in here that I talk about every night. She's like, I have 3 glasses of wine. I have one for being a mother, one for my kids, one for my partner, and one for my business. She's like, the only one I don't drink about is my dog. And I was like, I feel you. I was like, it is literally why I gave up alcohol. I was like, because I had so many ones that I was like, we're going to be, you know, I'm not going to be able to handle this. Um, but we couldn't just say give up alcohol. Like, that's like— and that's what society does. It just says this isn't good for you, give it up, here's all the problems with it, it should be so easy, don't you want to live to 100 and feeling great and looking great? She's like, I— like, this doesn't work for me. So we first of all figured out, um, for her, one of the things that she does is she takes the magnesium, she puts Epsom salt in a bath and she takes that bath at night. That helps her a lot. Um, she also, um, we, we set a time when she is done working. When she comes home, she is done working. Sometimes that means she actually has to wake up very early in the morning and do some work. Um, but that, you know, and also depends on, you know, what's going on with her family. She also made an agreement with her partner that they would, they have different nights for each one of them based on when somebody wants to exercise, who's doing what with the kids. And they just got really granular on it. Like they made SMART goals around it so that each of them could be better themselves. Um, and they also found time for sex and they were like, Hey, let's find time for sex and let's also find time for a date. Like, even if it literally means we go into a room and we're just in that room and the kids are doing something else on their own and we have, you know, we have a date. So finding those different things were what really helped her, you know, to, to address the alcohol issue. And that was the one that then led to better sleeping, led to these other pieces. She fully was going to go on an agonist, but I didn't want her to go on the agonist before she had reduced her drinking. That was the deal that we had made. And so after doing all of this, her weight health was great and we didn't end up needing to put her on an agonist. Now, is that going to be forever? She's like, what about when perimenopause hits? I don't know. Maybe she'll need them, you know, at that point. So that's again, not the crystal ball of— I'm not sitting here being like, oh, another one in the column of no GLP-1 for right then and there. That worked, you know, for her on that part.

That makes so much sense. So As if someone doesn't, if someone isn't working with a dietitian, which obviously you're a big advocate of, is there a place that you're like, this is where we start most of the time, or this is something that like is working on improving your blood sugar that can help with improving these hormones or, or anything like that that you typically recommend?

Yeah. Thank you for that. And it's a little bit of a hard dance. Um, I was speaking at our professional, uh, conference and, uh, it's It reminds me too that there are very different trained and different dietitians. So, and I don't wanna just say dietitians 'cause there are nutritionists, there are coaches, there are pharmacists who are, you know, who have training and, you know, and these sorts of things. So, you know, CNSs, et cetera. So the question mark is if you have the opportunity and can afford to work with someone who can help you with personalize your nutrition and your lifestyle. And I would say this, If you think you can afford an agonist but you can't afford that other person, you're— the value proposition is off there. I would afford the person and then figure out, do you need the agonist on that part? And it just— otherwise you're going there. I promise you that you're going to hit a wall. But the reason I wrote my book, which sounds like a total just play for me over anyone else, but I didn't feel that there was a playbook out there and I wanted somebody who says, You know what, Ashley, I fell for it. I bought from that online place. I feel really great, or I don't feel really great, but I'm taking this medication and I wanna figure out how to go ahead and do this part. And what I want to acknowledge for everyone is sometimes your investment in resources is going to be maybe you do need some supplements or, you know, a supplement here. For someone else, it might be that maybe we do need to invest in something different for so that you have, are able to do more time with strength training or, you know, any of these other pieces. This will help you sort out where to invest more efficiently and effectively is really what I'm hoping for on that part, which includes our hope, like our emotions, you know, on that piece. So I think that, you know, I don't believe that my book and even, even I felt like my book wasn't enough. So what I did with the book is there's a QR code in there and people go online and they have access where they can message with our coaches. So that a coach can actually direct them to a resource, you know, and say like, hey, this is, this is maybe what I consider, or maybe help them work through, you know, a problem or a challenge they're up against. Brigid Titgemeier, MD, MPH, FACP, it's on us until you and I upend the country and make it that we're the first, like that, you know, practice, like we're available, everyone does have this access and that these medications come in collaboration with us. I think that it's, it is a little bit difficult to, you know, just say like, hey, start here, you know, on that part.

Yeah, no, that's a good point. Can you talk about the interconnection between blood sugar and hunger hormones?

Yes, I love this question. It feels a little silly as I'm telling you, 'cause I'm also like, this is like your zone of genius. So I love that piece. But, you know, number one in "Shit You'd Unlearn," like we had fasting glucose and then we had AM1C, and we have to unlearn that these do not tell us who is in a good or a bad place with their blood sugar. You know, we want more rolling hills. We do not want flat lines. No, we are not looking for just lower being better. This is like, uh, CGMs and, uh, have taken us a bit to the statin methodology of like, just lower it, lower it, lower it. And that's not what our goal is. Um, we want, as an example, when you're working out, for your workout to be stressful on your body. As a result, your blood sugar is going to be elevated, and then we want to, you know, successfully bring it down. Um, but your weight health hormones are directly related because they're actually the first domino. They're telling insulin and glucagon to go to work. So what's really interesting is for a lot of people who maybe they were insulin resistant or saw challenges, if you were diabetic or if you weren't, pre-diabetic, etc., and we were seeing things and we were trying to help you optimize your insulin. Like, how many people is it like, I'm like, "Just add cinnamon to your coffee." I'm like, "Okay." Like, adding cinnamon to your coffee, yes, I love it. Like, there are things that can help us support our natural, you know, insulin response, but If our weight health hormones are suboptimally functioning, then that first domino is not clicking. Then that is pro— that's a key part of the problem that we need to address on that part for sure.

Okay. Yeah, that's helpful. Um, okay. And then anything else that you would say that you feel is so important to be able to, to get out the message of that's like a key part of the book that you don't wanna leave this conversation without sharing?

Yeah, I mean, you've done such a great job of like, you know, I was looking forward to the conversation, but we've actually hit on all of the different pieces of the book, you know, in that part. One of the things that I do in the book is I do tell a lot of patient stories and, and I wanted people to see protocols and I wanted them to understand nuance in protocols. You know, this worked for this person not because they took a magnesium supplement, but because of X, Y, and Z and the magnesium supplement. Right. And and see all of that. But this truly is about personalization. This is about being able to, you know, that our job— it is not whether doctors learn more about nutrition. Frankly, I'm a little concerned if they learn more about nutrition that they're going to think that, like, they're just— it's— we're set up differently. You know, doctors are set up to diagnose and prescribe, and we are set up to personalize total nutrition and lifestyle plans. Like, it's just a different— you know, we all should be curious about our patient and their why, but You know, as a system, we really, you know, need to look at that differently. But I think the stories that are in there should be helpful for you to see that there's a variety of different entryways in. So if you felt like I felt like for so long, a failure, um, or you feel like you're failing, or you feel like you tried something and it's not working— I tried a probiotic and it didn't work. I tried magnesium, it didn't work. I tried intermittent fasting, it only worked for a period of time and then it wasn't sustainable— the book actually comes in and explains to you why just one of those pieces may not have worked better for you. And the idea is, uh, for us, you know, to consistently decode our own signals, hopefully working in collaboration with a practitioner partner, and be able to personalize a plan. Um, but one of the things that the book leans into is this concept of optimizing. And I want us to remember that our bodies are an operating system, and for them to run optimally— and that's what we want, we want optimal health, we want opt— we want to be able to live well for as long as we're gifted on that part, that we have to optimally resource our body in order for optimization. And a lot of the messaging that's out there, whether it's the history of our really dumb amounts of the RDAs, or whether it's, you know, I'm leaning into one tool and saying like, hey, let's just suppress your appetite and have you reduce calories, any of that has been to sub-opt— be okay with or not looking at and keeping our body in a suboptimal space. And so the opportunity in front of us is to figure out how to do that optimal resourcing, um, in whatever way works for the individual.

Yes, I love that. Um, and I think that that is like the shift that needs to happen in order for people to really achieve that, like you said, the optimal level of health. And I think, like you said, your book breaks down all of this information and so much more as a complete roadmap. So I'd highly recommend by the time this episode comes out, your book will be out in the world. So, Your Best Shot: The Personalized System for Optimal Weight Health, GLP-1 Shot or Not, in order to be able to dive deeper into Ashley's work and to learn how you can optimize your own weight health. And we'll include links in the show notes. But Ashley, thank you so much for being a part of the Being Brigid Show, and we will see you soon.

Thank you.