Beyond Weight Loss: How GLP-1 Agonists Are Redefining Health with Ashley Koff, RD

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GLP ones we are going there. Ashakov. I am super excited about this interview. Yeah, I've been counting, literally counting days, then hours. And because there's so much confusion around GLP1, what it does, what the drugs do. So we are going to unpack it. And I think. I think before we even start there, you've been in the biz for a long time. We've been, like, circling around each other forever. What got you excited about GLP1?

Yeah. So. And reminding ourselves that GLP1 is actually a hormone that is produced in our body. Right. And in the lining of our digestive tract. So my personal story probably should have gotten me excited about GLP1. I was a kid with a lot of antibiotics. I battled what I thought was weight and belly and just not eating well, but didn't actually learn until much later that it was digestive issues and certainly injury to the lining of my digestive tract. So as a result, I struggled with appetite cravings. I'm an athlete, so I would go and be like, I can train like a boy. I'll eat like a boy. And that kind of thing I was like, didn't work out physiologically so well. So I think some of those pieces, in hindsight, this is so important to understand. So I definitely want to come back at some point to how we think about kids as it relates to that and understanding even pregnancy and fertility, because so much of this is being built at that point.

Glad you said that because I keep looking at this going, it must be that we've really messed this up. Messed up, you know, that. That our natural state of being was to be really good producers of GLP1. And we've really messed it up.

Yeah, yeah, yeah. So we've really messed it up. I will also say I think we're going to continue to Learn more that genetically there people where they are just less good at producing. So we know people from a methylation standpoint, where their efficiency is an inefficiency, you know, it's detoxification, et cetera. When we especially. Because again, where it's produced and how it's deployed, we do understand that that is going to be something that has genetic implications. But like we always say maybe like 20, 30% genetics, right? Definitely like 70, 80% epigenetics. So we have screwed it up. We have. When somebody has those injuries or insults to their digestive tract lining, that is going to be my, what I'll call GLP1 Persona. So when we're taking a quiz and we're saying, should I optimize my GLP1 if. If I have those or if I have a disease there, if I have Crohn's, ulcerative colitis, celiac, you know, et cetera, I'm going to know I need to focus there. So what got me interested in is I really started my career totally selfish because of my own experience helping people optimize their digestion. And this was 2001. 2002. Wow. No one, no. And we were like, you know, we were still convincing. So first of all, we only really had lactobacilli. We don't even, didn't even have bifidobacteria, you know, and it was at a time period where I had to convince practitioners that the gut health was actually related to somebody's health goal. Right? So in that space, we're coming. I mean, it's like, seems like ridiculous.

I literally had one doctor tell me there was no such thing as adrenal gland burnout, and then another one tell me that there's no such thing as leaky gut there.

So, by the way, still today, when the other, you know, and I'm like, okay. And I also had, you know, the IBD patients where people would say, oh, their nutrient has nothing. The nutrition has nothing to do with it. I mean, come on. On that part, right? So we had to learn that. And something very interesting happened to me. I was working on digestive health, but needed to make money, see some more patients. So I'm in Los Angeles and an opportunity came along to work in the minimally invasive surgery department at, as an outpatient dietitian at Cedars. And I thought bariatric surgery was the worst thing ever. I had seen it in my residency. I'd seen a couple of people. It had been, you know, they were non compliant, theoretically. Like, if the whole thing had not been done right for them. And, and I had this ego. I'm like, I can help anyone lose £100 and I can help them keep it off. Oh, the ego of youth in this space. Or to any practitioner who says, like, you know, there's a perfect way of doing this, I'm like, we're lucky. I can get to the better way. So I started working in bariatrics and it was an over the night. What, like, literally overnight, the patient goes in, has gastric bypass. By day two, diabetes is gone. And they would say to me, ashley, I don't know if I can get my protein in. I literally don't have any hunger. Like, I just, I forgot all day. And it was like their, their whole world was disrupted. Like, I'm forget to eat. I don't, you know, I can't get this amount in. So I didn't actually even. It was probably like a year or two before we actually identified this is something called your incretin hormones. And we started to understand that your GLP1 hormone is actually the master regulator. It's the switch that flips on insulin and leptin. So leptin being our appetite satiety, right. And insulin being for blood sugar. So when we realized that that was there. To me, what always came about, whether it was the band, the lap band or the gastric bypass, is how do we make sure that we're getting that result in? And then also, what happens if that result doesn't stick around for people? And that was my, like, it became this fascination with these hormones and how do we do it? And I certainly have explored all the things that, you know, that you talk about and that are so important for people. Protein. First, the amount of protein. You know, are we getting in our fiber, Are we not getting in empty calories? Are we doing enough strength training? Because fitness impacts our, you know, and our fitness approach, all of those things. But it's only been in about the last, I would say four to five years with the explosion of the microbiome, the really intensified effort to understand how the microbiome works and sort of what are those triggers. And then additionally, some of the research that's been done on key ingredients that has really helped us understand how we can naturally optimize endogenous GLP1 production. And the answer is, who should be doing that? And we should say absolutely, I mean, literally everyone. So that is the answer. It's probably very similar to the conversation around detoxification. You don't go on A detox because you're eating crummy for a week or whatever. You have a detoxification system. You want it working optimally. So we want our incretin hormone system working optimally. So that has to be part of our approach for everyone. The difference is who you are is going to depend on whether or not just doing it endogenously is. Is an opportunity and it's going to work for you. Or are you somebody who would also benefit from what we call exogenous? So for the. Not the people that don't know that wor that would be what we're doing outside of the body. That is a medication and we're going.

To go over to those too. There's so many questions, but can I just say it is bizarro to me the amount of misinformation and like flat out hate on the Internet about these medications. Like it is a head scratcher to me. I was posting something about like, if you were doing these, here are the things you want to make sure you do to preserve your lean muscle mass, which by the way is the same thing you do if you were going on any diet.

Right.

All diets. You lose lean.

Right, right.

It is not unique. Ozempic and a dietitian.

Yeah.

Put in my little DMs. She's like disgusting.

Yeah.

Yes, yes, my face. But I'm like, who does that?

Yeah.

I mean like all these attacks around. This is so interesting.

Well, I think there are two things. The first, because I just went through this experience. I posted a delicious pizza in air. No, I posted a pizza in Arizona. I was out on a. A date with my brother going to a basketball game and he happened to go to, you know, this amazing pizza place that's like so well renowned. And I posted the most beautiful looking pizza and I had somebody post, as a dietitian, aren't you ashamed? There's gluten and dairy. Like these are inflammatory. If you'd say that, you know, and I was like, whoa. So I think we have to recognize that you're in a culture of attacking people just, you know, for as a hobby or because yeah, we don't have enough magnesium. I don't know what the answer is. Right.

We'll have some chocolate.

Yeah.

Be fine.

And I think the other thing where there is a perception whether you yourself have battled either weight health or battled metabolic health and. Or you haven't. And so that hasn't been your journey of judging people for what we'll call the cheating. Like you're not Doing it the real way. And I think what, what we both share is the recognition that we have a lot of tools in our toolkit. And when somebody comes to us, whether it's an individual or they're reading your books or, you know, you're reaching millions of people, what you're saying is, hey, there are a lot of tools in the toolkit. And so we want to look at what are all the tools and help you figure out if you today what's going to help you be successful. And by the way, that might be different. You might need a different tool, you know, in four or five years, etc. Anyone that doesn't approach it that way and sees that there's a right way or one path or what somebody should be doing, I hope that people just unfollow them. Yeah, like that's the answer there, right? Yeah.

Right. Like, there's no one food that's villainous and all that. That stuff drives me nuts. So then with that GLP ones, how would someone know if they're optimally producing that?

Yeah, this is a really important question because I wish the answer was like, we've gone on this journey with blood sugar where, you know, you could get your. You could get a regular fasting glucose, which is what your doctor would test. And we're kind of. Nobody's like, that's. I mean, that's not that helpful in the moment to get that test. Then we moved over to hemoglobin A1C, which is a 90 day, but it's an average. So, you know, if you're looking at that, you're not. It's not telling me if, like at 3 o' clock every day you have a high spike and a drop or, you know, some of these things. So it was better than the fasting glucose and now we have fasting insulin. Right. And so fasting insulin is going to give us a better measure and things like maybe also looking at inflammation. So we've been on that journey. We're not on that journey yet with GLP1, because GLP1 is actually designed just to be produced and go away. So it's actually very interesting that the body designed something to literally be like a light switch. So it turns that on and then it goes away, and then it turns that on and it goes away. And it does that in the presence of food. So in order for us to test that, we can do it in a lab and we can certainly do it in a cell, meaning like a cell culture, you know, and looking at that. But to test it in a human, it's very difficult. And I actually wouldn't put any stock in the blood work today where somebody says, oh, I tested your levels. So what we've done is I will never tell you that you are high or low in GLP1. And if anyone says they can tell you, they're. They're lying to you, like just flat out on that part today, like as of the date of us recording this. Right. And if anyone wants fig that test, please reach out to me. Because we want it, we want to get it out there, you know, to the population. So the other thing that we can do is then we can look for indications that your GLP1 is suboptimal. And that would be things like. And we have a quiz where people can do this for free to just see. But it would be things like, I talked about all the different digestive stuff. So if I, if I regularly use medications, if I've had, you know, antibiotics or high doses or. You're like me as a kid, you know, you take a lot. If I am, I found out I was gluten intolerant or I celiac or, you know, there are many things that can attack that gut lining. If I'm somebody who for certain reasons can't consume fiber, or if I'm somebody who maybe doesn't consume any animal protein, or maybe I'm somebody who doesn't consume these types of essential fatty acids. There can be things that can give me an indication on that front. And then if I have the opportunity to look at somebody's labs, I can also. And wear a continuous glucose monitor sensor. I can also get information on that part. Now, here's the kicker. Do we need to do any of that? Because we answered a moment ago and said everybody should be. So why not be intentional about optimizing your GLP1, which every dietary recommendation you've ever given literally is for optimizing GLP1 on that part. Yeah.

So funny that the things that will optimize GLP1 are also the things that will help you lose fat, put on muscle, will help, you know, with better blood pressure control, better blood sugar control. Like, you look at the things and go, this thing does all these other. Yes. Like to do a talk on all sorts of different health benefits and talk about it and every single one it would fix.

That's right. So and so. And that's also where too we can turn around and say, for those of us that are experts in this field, what we have been telling you for 20 years is still the information to be following on that part where I think we're a little bit more like there's, there are areas of opportunity because of the medications now being available is that we're getting a little bit more hyper focused on things that can actually really help with satiety or really move the needle with an insulin response in terms of insulin resistance. And you know, some of these other pieces where people have maybe been investing in and really trying to do the work they've been following your advice, they're, you know, going in there doing and it hasn't been working for them.

Right.

So there are certain things like that. Like for me, I found that for many, like a subset of my patients, I shouldn't even say subset because it's somewhere like 60% of Americans don't actually experience feeling full. Now, I'm not talking about overfull, but in that moment when you're eating and maybe you're being mindful or not, you know, whatever, but you're, you know, my love, yada yada. But, but I'm eating my food and I have an amount and I feel like, okay, I. That's the amount that I'm supposed to have. And when I eat that within an, like, you know, within 10 or 15, like I feel good. So I'm not chasing for something else. Right. And we've tried all these different ways to people maybe experience satiety, like have fiber first or have something crunchy or drink water or make sure you, you know, take this or like all of these other things. And that hasn't been working. So in that instance, the fact that we now have tools that can actually target GLP1 more effectively, those are starting to show benefit for those that significant body of patients of mine that don't experience satiety. So some of those areas I would say are a little bit different, but at the foundation, it really is the same stuff.

You know, I look at all of this and so we've got less than 7% of the population who's metabolically healthy. We have, I remember hearing some stat years ago that by 2030 that we would be 100% diabetic. And I go, that is the most outrageous statistic. No way. However.

Yeah.

You know, so you look at the high degree of insulin resistance and then you look at someone who says, okay, you know, I'm ready to take this on. I'm going to start doing all the right things and nothing happens because. And I had a great mentor early on who said, you do not lose weight to get healthy. You have to get healthy to lose weight. And so you need to get metabolically healthy to be able to burn off fat and build muscle. And so they start. But they've got to improve that insulin sensitivity and that, that, you know, you look at me go, okay, that means you better sleep better. Maybe you need a cpap. Yeah, you better start lifting weights. But you're too inflamed.

Right, right.

And at a decondition, to lift weights, you know, you need to really shift your diet around. But you're hungry.

Yeah.

Cravings. And I think that if there's something out there that can help people get past that. Yeah, yeah, We've got a crisis. Why wouldn't we use that?

Yeah.

The risk reward ratio is so clearly on the reward side.

Yeah, yeah. And sometimes we need like, it's the same way of, you know, maybe why we use an elimination diet. Or I don't tend to call them like straight out elimination, but I may take certain ingredients for somebody and say, let's. Or I do our digestive tune up all the time. So I'm like, okay, I want you for 30 days, I want you to do the things that support your digestion because that's going to then tell me how your body's responding. We can go. So for, in this instance, we can turn around and say we have different resources. When I think about GLP1 and the body, I think this analogy will land. I've been trying it out in places, so we'll see if it lands for you. But so in the continuum of caffeine, something that we all love, and when we think about, when we think about a GLP1 agonist, so a medication, and they're a GLP1 alone, there's GLP1 GIP. By the time this is out there, there'll be, you know, one that's gotten three different points, et cetera. But let's just call them these agonists as a, as a class, they are like having four shots of espresso in the moment. So the idea there is you're getting more caffeine and you're also going to get something that maybe sticks around for longer. So endogenous production, or what our body produces of GLP1 is like one shot of espresso. The issue is a lot of people are trying to get results on decaf or no caf. And that in that case, does that work for you? Yeah. So in that space, there's all these reasons to say for some people they will experience benefit if we can get them from decaf or no caf to one shot of espresso for other people, their body and just where they are, they can't function and they need to be at that four shots. Now, I don't want to keep you on four shots forever. Could it be that you need two and a half for the rest of your life, potentially? Could it be that you go from four to one and then something happens in life and we need to go back to two, three or four? You know, there are all of these ways and that's your relationship with your practitioner and understanding your body. But if I've got someone on four shots of espresso, I also need to understand that I am intervening with a hormone that is going right into their body that normally is not meant to stick around. And it is sticking around for at least 30 minutes, so it's sticking around for a longer time. That means I'm going to use the words side effects. Side effects are not negative. They are just here is what is happening as a result of going on the medication. So I think we just need to be doing a better job of saying, where are you on that continuum? And before I make a choice about, you know, what we're going to use for you. So let's make sure that your body can handle four shots of espresso and let's make sure we have a plan for what if tomorrow you need it that wasn't available to you, you know, or that kind of thing. And so these are the things, the conversations we should be having instead of the, oh, my gosh, I can't believe they're using a GLP one, which is just. Is somebody who is actually not solution oriented in my mind.

Now, when someone takes a GLP1 agonist, what's the mechanism? Because you said that when, you know, I know when we eat protein, we have fiber. I've been really playing around with allulose. For those of you that don't know, allulose is a rare sugar that doesn't raise blood sugar. Insulin. I heard about it years ago and so I actually started converting my products over. Yeah, it's the thing that Quest was using.

Right.

And so I was like, this is really interesting. But I was more interested. I'm like, oh, it doesn't raise blood sugar. And, you know, and then I started to see all of this research and the research is wild, what's coming out. And then I was just at Metabolic Health Summit and they were showing me how they would take it, eat a.

Candy bar and Drop their blood sugar. Yeah.

What are you talking about?

We aren't quite sure how it, what it does to the microbiome. And I think that's really interesting. I think it does some very positive things. One of the reasons I like allulose is it's 70% as sweet versus regular sugar. So unlike all like monk fruit and these others with stevia, which are more.

Sweet, which I always get worried about.

Yeah.

It's like, is it turning you on to go more sweet?

That's right. And so it's dialing up. So one of the like, like fun free experiments that I have people do is their sweet taste bud test. So you bite into an apple like on a clean palate, take a couple of bites and see on a scale of 1 to 10, is it a 7 or greater? And the number of people who are like basically freebasing monk fruit and Zebl or stevia, like it's nothing, who are at like eight, nines and tens, you know. And we have to do this full reset for their sweet taste bud because you're right, it's affecting psychology and microbiome. So I think with Alios, it's. That part is really interesting, you know, to sort of look in that space and all of these are part of those solutions and tools. An agonist is a little bit different. So it is a hormone that you're injecting. So think about when we inject other hormones. So if you are diabetic and you need insulin and you inject that. Right. So it's fast acting going into your body on that part. Maybe if I use testosterone cream or you know, something else in that way. So it's overriding. It's not actually asking your body to produce anything. Right. That is why if one, if ever anybody is trying to equate endogenous production and exogenous or what the body makes versus this medication, they're. They're having like a, it's an, it's not even apples to orange. I think it's like an apple to broccoli conversation. Like, we're just not in the same space. Don't. Don't talk about it. So I think in this space, what we want to understand is that if we are injecting a hormone, you are going to have implications in your body of a higher amount of a hormone that is your body's actually only designed for it to like go away. But the upside benefit of it is you have all these receptor sites and if you, when it, when that light switch goes on, if in your body, that light switch doesn't mean that those, like 12 lights go on. Then if it needs more time for those 12 lights to go on, if you take an agonist and it hits all those 12, then suddenly you get full action. Right. Like the room is lit on that part. And what we're seeing is many people on, the light switch goes on maybe only two or three of those things. Right. And so that's, that's the difference with.

When they're doing things like protein or fiber.

Right? Yeah.

And that's part of the question. So you look at the things that naturally raise it, and as I started to dig into this, I go, probably this is something that was. We've always had, and we've just so disrupted our gut microbiome that we've messed everything up.

Yes. Yeah.

Because if you look back ancestrally, what was our diet? It was, you know, we would eat animal protein and lots of fiber. I remember hearing Laura Caden say that we was. We're eating like 100 grams of fiber a day. And I consider myself to be like a fiber here, Right?

Yeah.

But I'm like 56.

Yeah. And you're not like me where I was. So I grew up with this, unbeknownst me, this diet, like, belly issue. And literally, if I would eat any fiber, I would. I just would bloat out. Right. Because I had no good bacteria. So it took me a long time to repair and to do that. But there, you know, I think we have to recognize in each individual what is that capability in that part. And I also want to be really clear financially. Like, we've both worked in Los Angeles. Like, you know, we've worked with people who have. Where access, theoretically, from a financial standpoint is not an issue, but for the rest of the population, it's a significant issue. And so I think one of the things that I'm loving about the medications is that when used properly, when used strategically in partnership with your practitioner, when you're evaluating blood work, when you understand who the person is, you can use that. And somebody can now have success increasing their fiber or success, you know, increasing their protein. And I also don't want you increasing your protein unless your digestion can handle it.

It.

And that means that we've got to make sure. Because if you can't break it down, if you're on a proton pump inhibitor, if you are, you know, or somebody.

Where, or you've been doing a vegan.

Diet forever, like, so the answer has to be multifactorial. But you're like the core part for us to come back to is these are tools and their choices. A choice for no one should be don't optimize your GLP one. Right.

And I love to say diets are tools. Choose wisely. So I love, I love all the tools. So when someone's doing something, assuming we've like, we've optimized their microbiome, they're doing protein, they've got fiber. What is the typical. We release GLP1, some of the other things. What's the. Is it like 30 minutes and it comes back down. What's do we know?

Well, I mean it's a 30 second like it literally is 30 seconds. Yeah. So 30 minutes is the medication 30 seconds. And again, I'm not like I'm giving you numbers of what I've heard and what people you know, from a research standpoint. And it is really. Because it's really hard to read research it. Right. And even in the research you have people reporting certain things and they're measuring it, but we're not, they're not measuring somebody who's just out in the wild like drinking coffee and eating, you know. Oh, by the way, coffee. Yes. And for many people coffee and tea have an appetite suppressing and it's like aha. So are we, you know, we used to always just attribute that to the antioxidants. You know, in that part some people were like, oh, you're getting in water. I'm like not really the way I grace it.

So it's very quick.

Yeah, quick.

And then the medication though, you've taken the medication and yeah, doing it once a week. So it's just, it's not hanging out there, it's just correct doing.

And so one of the things with the medication is you do. You should. And again, this is why I the one place I don't. I understand why it's available in this way, but I don't recommend it. Is taking this as a medication without a practitioner oversight and without sort of nutrition counsel and coaching really available that way? It is. And what like you can. It's kind of the wild west out there and are also people that are. And I'm not. I love compounding pharmacies. So I'm not saying compounding bad. I'm just like, I want somebody to be able to verify for me that the what's in the compounding is actually what you're supposed to get. There's just. Yeah. There's just cheats that are out there. Right. That they're Selling you something that's. That's been.

So don't buy this online.

Don't buy this online. Don't know what. Or from a practitioner who is just literally, who is willing to do an online script for you to. And selling it from a compounding pharmacy. And you never, you're not, not seeing them as a practitioner. That's not the way we do medicine anyway. But I think it is important to remind people, so when you do this and you're taking it, you actually are going to try to get up to the dose that is going to be better for you in the moment. And that really depends. For people. I've seen some people who start at the lowest dose and they do great in that space. I've seen some people who start at the lowest dose and they start off having side effects. Okay. We can almost always address those side effects. So it doesn't mean you need to go off of it. And we typically don't want you going on and off. So that's also, you know, something we can speak about. But then you're going to increase your dosage on that part and be able to get to a place where you're getting your optimal results. And that optimal level to me is very much about where you are still wanting to eat. We're not trying to shut off the desire to eat. We're not trying to shut that down. But where we see appropriate weight loss, so we might say that's like one to two pounds. It also depends on who the individual is. Where we see nothing else negatively happening, maybe where we see more rolling hills than spikes, if appropriate, you know, for your blood sugar. And then we would keep you on that. There are some people that. It will stop working, so it stops working. So in that instance, include what? Well, there, there is a sense for some that you're. That the body is adjusting from a hormonal standpoint. I don't know if that's valid or if it's basically what I have a suspicion in my head, which is, is this really just the plateau experience? And we should just accept a plateau because we know fundamentally a plateau means your body is adjusting.

And so when we say it stopped.

Working, you've stopped losing, they've stopped losing weight.

See, I just look at this whole thing and if I were the benevolent dictator of all things nutrition.

Let's do it. Yeah, yeah.

It would be any of these things. You would sign a contract. You only get this if you come in and do an inbody or dexa. So you're tracking Your fat free mask.

Yes.

That you would absolutely be tracking your food intake and optimizing, making sure you're eating that protein first and getting in the amounts that you need and doing resistance training. And if you end up and willing.

To track your, your blood markers so that we can be at all.

And if you aren't, this should not be a thing.

I'm not going to script it for you because.

Or any diet for that matter. Because it is so much worse to go on a diet diet, lose weight and then go off the diet, paint it back than to have never done it. Yes, you're better off not doing it.

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Doctor Shaw and I, we were actually just, you know, presenting on this at Next Health. We have put together a protocol. See, I've had the protocol for how to do the endogenous side and also how to support patients who are wanting to have hit their goal and are wanting to either stay or to come off of it. And he's been scripting and, you know, figuring out that part. So he actually taught practitioners here that you absolutely need to have a contract. You went through that. So it's right there. So it's, here's the contract, here are the things I want you to be able to do. And in the event that you're not able to do some of those, let's have a conversation about what that means. But you are not going to keep getting the medication. You know, on that part that's really important. What I do with people though is also make sure that we have a budget conversation. So for many people, they are actually going to end up paying out of pocket for this, like $1700.

See, that's where I mean, then. Yeah, why wouldn't we go to a compounding pharmacist?

Right. Well, so. Oh, even the compounding felt like. So the, the cost of these is, depending on where somebody's getting it at, could be 300amonth. It could. But compounding is not much less expensive. Like, so there are core ingredients there that are going to be expensive. The difference is, or, and the question mark is, is how much do you need? Right. So if I'M at a higher dose, it's going to go away sooner, you know, et cetera. Sure. But I will sit down and say, are you prepared for the next six months, for the next four years to pay X? Which also includes seeing me or working with, you know, one of my coaches. Here's what the blood work. And by the way, we can get your insurance to cover some of the blood work. I don't necessarily need fancy labs. I just need to make sure, you know, we're looking at this and is also going and, and the, the supplement side of things. And if you're not willing to do that, then I'm going to talk bariatric surgery and I'm going to talk my, of my endogenous production and my other tools and say maybe we're going to take the slow scenic route because I don't, you know, as much as you wanted that, that faster acting, I can't in good conscience start you there and not know that I'm going to be able to take you to success.

That's fantastic.

Yeah. And so we have to put that together from a protocol standpoint. And for those of you that are listening that are like, yeah, I'm already on it or I want to be on it, or my patients are just saying, put me on it. Okay. So if your patient is saying put me on it, somebody came up to after our talk and said that. And I said turn around and I said, hey, and by the way, I love to shop at Target. I said turn around and say, said go to Target. Like not that to get your GLP1 there. But literally I'm not, I'm not here to be that low, that low cost option that isn't going to deliver long term outcomes.

Well, I mean, would you go to your manicures and say, I really need my haircut.

And it's like, it's. Yeah.

You go to the person that knows how to do this correctly.

That's right.

And this isn't, I think people think this is just an easy and just get it. But you're messing with metabolism. Yeah, yeah. And any diet.

Yeah, that's right.

Because losing losing weight without tracking it, losing muscle is so devastating.

Yeah.

And especially if you're 40 plus.

Yes.

We have to be so careful about this.

Yeah. And I think for perimenopausal women, one of the physicians that we work with who helps us nationally, she also does hormone, she looks at blood tests and will adjust from a hormone standpoint to make sure, number one that we're not Missing a hormonal reason that this is slow or that this is happening. So there's that side of it. But number two, that we have a baseline so that we can then, you know, so if you're 50 and you're like, where am I? That at 52, we can turn around and we can still optimize. We did have several dietitians come up and say, you know, in New York, they're constantly hearing and seeing friends and patients where the doctors are scripting for the medications and they're not suggesting a follow up. And I find that just really bad medicine. You know, we, we couldn't do that with bariatric surgery because you actually couldn't get insurance to cover it if you didn't have a diet, at least in the beginning, you had to cover a dietitian and you had to cover social worker, which we haven't even talked about how trauma. And, you know, all these other factors are in there. But I think for. If you're a practitioner listening to this, you have to make that decision. If you're not going to provide that support yourself with your resources, you need to partner. And you and I are both very dedicated and you're extremely skilled at this, of making sure the practitioners stay in their zone of genius and then outsource what isn't theirs, but make sure that's delivered. So their system offers that there are things you can do at scale. Make sure that those are being offered, though, in this case.

And here's the thing, that's how you create a successful business.

Right.

Why would you want to do all the stuff that you don't need to learn all these things?

Yes. Yeah.

You know, I was, when I was doing my talk yesterday, I was saying, so they talk about how doctors get an hour of nutrition, but they get zero of exercise. But the reality is these are complicated things. It doesn't seem like it.

Yeah. And also I feel like, shouldn't we be saying to doctors, okay, the recognition is you actually are not trained on this. This. So as a result, what I'd much rather train you on is how to ask or how to support your patient in getting connected to the person that can help them with nutrition. Right. That's actually what the doctor should learn. So the doctor should learn how to be the quarterback or how to be the team player in that space, rather than saying, I need you to be the expert. Because honestly, I want the doctor to be the expert at diagnosing. Right. Like, that's really important to me. But as a dietitian, I'm not coming in and saying, hey, I'm going to diagnose you. Some of my colleagues may, but I'm not. And then they turn around, I'm going to say, but I'm going to be the one that's going to be here with you to help put together a plan from which we can start seeing if that works for your body. I have 50 coaches that work for me around the country. 50 coaches. Because I don't listen well to people you and I are talking about that. I like to tell people what to do. Well, guess what? That doesn't translate into them actually doing it. So I then gracefully hand them over to my coaches who create smart goals and who work with them and who help them figure out and who also give me feedback and I can give the doctor feedback and see say, oh, okay, this is where we need to adjust. Or the person is actually not doing any of what you discussed or they're doing what you discussed and we're not getting better outcomes. So that's. It needs to be a team experience with you in the place that is your zone of genius.

So, you know, one of the big things you hear about this is people go off and gain all their weight or they have to be on it for life.

What?

What? And, and I'm really unpacking these. I got this great research article the other day. All the different things GLP1 agonists can do the body. I put my son on it for neuroregeneration and we've been slow, low cycling him on it where he does it every other week at a low dose. But the kidney function, cardiovascular. I was like osteo, osteoporosis, osteoarthritis. I mean I was like holy smokes. So is this something that someone could low dose for life? And I heard another practitioner talk about how she was basically microdosing it. I mean super low doses it. And I just wonder if there's other applications we're going to start to find or are you finding that someone kind of goes through the rehab, they use it to help get them going. They can start to taper it as they're building up, get back their gut microbiome and getting these good habits in place.

Yeah.

Do you think this is something that someone would need to do for life or do you think they can.

So I think there are a couple of things I'd love to start at the macro level. I don't really know of a class of medications that if you just went off of them immediately, you wouldn't have any side effects, Right? Like, so if I go off of a proton pump inhibitor, I have a backwash of acid. It's like the worst thing that you can do. If I'm somebody who takes insulin and I stop taking insulin, I'm going, yeah. So, like, if I needed it or if I'm, you know, I'm using it, like, so I think we have to downplay this concept of what if I needed to be on this for life? So we identify that this is the health enabling tool for you that is going to be supportive for one year, for 10 years. Somebody asked a question in our session. What? Well, you know, my patient is saying they're going to be on this forever. And I. That really bothers me. And I was like, why are you bothered? Like, they're your patient, you know, so like, maybe what they're actually saying to you is, I'm afraid that nothing will ever work and I need this. And so maybe my job. And I said, with respect, I think you're a physician. As a dietitian. My job, not your job, is to help you feel less codependent on it and to feel empowered and maybe to at some point in time decide that it might be the right time that we lower a dose or, you know, that we do something. Because I also want to prepare people for the reality that unfortunately, if you had a cancer diagnosis and needed to go through treatment, maybe if you're. I don't. I personally wouldn't want a patient on it while they're pregnant or trying to get pregnant. I don't think we have the data there, you know, some of those things. So we know life is going to happen and you may need to come off the medication. So I think we should just let go of what if you're on it for life. I think we're both saying, so what if you're on it for life and you actually have a healthy, long life or, you know, this, and you're able to achieve your goals and live how you want to live. Great. You know, on that effort, I think there's another side of it that says, look at all of these downstream benefits. It could possibly be upstream of metabolic health and of being able to eat better amounts for yourself and of being able to lose the stress associated with food noise, of being able to be present at your. The dinner table or at the meeting. Somebody that I have that's on medication said that she can't ever be at a business meeting where there's food because she Literally can't be focused. She's like, I'm living two brains. I'm so focused on what the food is that's there, whether I should have it, whether I shouldn't, you know, all that, that I'm actually not hearing the, the business conversation. And she's a high powered executive and this is actually helping her break through. So that's interesting to me, right, to be able to say, like, look at all of these wins that we could have.

I wonder too if one should break through with that feedback loop, if that's just gone.

So, so this is interesting. So I actually think the only evidence that we have which is not going to be very positive is from bariatrics because with, I don't think like me personally, I've been working with people about say about 15 months. So it hasn't been a long time. So I don't want to overstate and be like, oh my God, yeah, I kept a buffet for years and you know, whatever. I mean, a lot can happen in 15 months, you know, or in the subsequent time. But with bariatrics, I would find that many people experience tremendous challenges. Year two, year three, you know, et cetera. Some people had done beautifully and were able to use their, their surgery as a tool and maintain and other people really had to try other interventions. And now even including, I have a, some bariatric patients, history of bariatrics, who are on agonist and we're seeing a positive, you know, a positive play there. So I think that we have to look at this as a trajectory where we don't know what is going to happen from your, from a long term health standpoint, this is a tool that we could use. But what I will say, say hard and firm is before you decide to go off the medication, before you intentionally go off the medication, you have to have a plan. You've got to make sure that at minimum you're at that one shot of espresso. Right. And that's what we have to do naturally and that you're going to be able to commit to the lifestyle behaviors, including your nutrition and these others where you'll stay at that one shot of espresso. Otherwise, I don't have a good sense that you're going to be able to be successful there. Right.

I mean, and here's.

Yeah, mess with anything like these arguments around GLP. 1 Agonists are literally people yelling like because they can yell. I had somebody come out. I think she was very well intentioned and maybe just kind of wanted to like show off in front of the doctor. Definitely not in front of me. But she was like, well it does this and you know, downstream interact with this and it would do this other stuff. And I was like great that you know the mechanism. I was like, you get an A on the test. I'm actually talking about the patient and the patient over here is a human. And I'm trying to figure it out. And I'm honestly not going to know for you. I'm not going to know like if, if somebody comes in with a severe liver issues, I'm going to work on their liver. But if like if they are also if part of that can be because we're seeing great results with fatty liver with agonist. So I don't want to like sound like I'm dismissive to everyone on that part. I just think, I think the drama around it is, is totally misplaced because it's deflecting attention from what. Where we actually should be. If you are coming in and you don't have you, you check the boxes for why I need GLP1 optimization, then that is going to tell me that you. There is intentional work that we need to do in your body for your body to get healthy. And that tells me that this is where you should be investing. Right? And that's where the focus should be. The focus should be on us understanding like we do with anything else else. Where could there be areas of concern. So if somebody's on a proton pump inhibitor and they also are deciding to take a semi glutide, I'm going to want to look at some things there, right? I'm not going to go into all of those. If somebody is on biologics for an autoimmune disease and they want to go on a semi glutide, I'm going to look at some things there. If somebody is newly trying to figure out the right hormonal balance for them and they have the semi glutide, those are the conversations. And I do also think this is going to be where I'm going to take the opportunity to talk about. It is, is. I think it's really important for us to consider in a body that is, is rapidly doing its cell work to develop and hormones that are newly developing. And I'm Talking about a 12, 13, 14 year old child where somebody is so worried about their obesity and their diabetes at that point, which I completely appreciate. They have zero confidence because of access, because of family history, like all these other things that this kid is going to have A fighting chance to have a healthy. The body is the first step with that child. Bariatrics or a medication. And I think the answer could be yes, but we have to do this other stuff, otherwise we're compromising their future health. And I think that's an area where, that's probably the one space where I'd love to try, if possible, to do some of the endogenous work. I just understand what I'm up against, you know, on, on that part. Yeah.

I remember we tried on Dr. Phil, who. We did the teen weight loss H. There were so many issues. You would never know until.

That's right.

There was the school, there was the parents.

Yeah.

I was like, oh my gosh.

Yes, totally.

Oh my God.

Yeah, yeah, yeah. And, and, and at that point too, you, you, you have to be thinking about where like I want you to, I want to try to have you have as positive experience around food and things like that. So maybe intervening with a medication here so that you feel more empowered and not so negative about yourself. So, so that's another area where agonists are helpful. We are able to take somebody who feels like a serial failure in their life and their health.

So much complication around this too. And what happened with your, you know, all the metabolic dysfunction. And I just, I learned that early on I go, oh my gosh, this is not, this is not because someone's lazy right now. There are so many issues.

Yeah.

And I remember early on I met one of the doctors at the Big Losers and because they were going to hire me for the teen show and I was finally like, it was, it was like, yeah, no, I, I can't do this. But the doctor literally said to me, I'm watching them and they just eat too much and they don't exercise. And I'm like, oh my God.

Yeah.

Oh my God, Yes.

You know, well, I, I did work on it. I did shedding for the wedding with that same dot with one of the physicians. I don't know if it was this name.

Say his name.

Yeah.

And I did, I did Celebrity Fit Club and they told me, they said, oh, this person is failing. She's non, non compliant with your diet. Which by the way, when I hear non compliant, I hear somebody hasn't actually done their job to figure out what needs. And it turned out she had horrible IBS and the diet was high in fiber and she was just like all the time feeling badly bloated for her weigh ins. Like she literally was not losing weight because she's just, you Know, trying to do this. And they said to me, instead of addressing that on tb, this, I got the call and it was actually, sometimes it's good for us to show that people fail despite having all the help that you could offer. And I was like. And I worked with her for another five years and she did beautifully. But I think in that space or in chatting for the wedding, where it was like, they just need to exercise more.

Exercise is actually not the thing.

That's right. That's right. And maybe they're like, you know, some of them actually need to just be able to relax and have some fun in their life. You know, I mean, I think if we can't make this deliciously doable, I don't know, kind of how we, you know, how we meet somebody where they are. So I think that there's. There's so much. I'm just so grateful that you wanted to have this conversation because it's. I think we can take to task kind of everyone here. I think pharma's not doing a great job because they kind of are just in here and are like, look at this miracle drug that's been created. I think practitioners who are just scripting and not sort of helping people actually have a conversation, you know, you can even use this recording with your patients where you could say, hey, I want you to listen to this first to understand what we're going to do. Right. We have actually done your systems approach work for you by having this conversation, you know, and do that. And then individuals, if you're going to just jump in and, like, buy and take any old car off the line and just hope that it runs really well for you for a lot of years, like, that's your problem, you know. So I think that we've got to. We have to accept, you know, accountability across the board.

What a reasonable approach, maybe.

Right, that's right.

Now you've created a guide that we're going to be making available to everyone. I'm going to put it at jj virgin.com forward slash, cough. Koff.

Not cough.

Like the cough. That's right, Koff. And what is in the guide?

Yeah, so I wanted to share a lot of this information because in case you weren't like, putting us on, you know, 0.5 and taking notes and all of that. So in the guide, you'll get this information and also direct you over, if you want to, to our site where you can do the GLP1 option optimizer quiz. And then I'll just answer the question. I mean I don't like you heard from us. You everyone should be optimizing. But if you really need to take a quiz for me to tell you whether or not like the majority of us still need to invest, find that. Take places. There you go. Yeah, yeah. Absolutely. Great. That's perfect.

Jjvirgin.com cough yeah, and I hope this is just the one of many.

I hope so too. Yeah.

Be sure to join me next time for more tools, tips and techniques you can incorporate into everyday life to ensure you look and feel great and more importantly, that you're built to last.

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Don'T miss a single episode@subscribetoj.com See you next time.

Foreign. Hey JJ here.

And just a reminder that the well.

Beyond 40 podcast offers health, wellness, fitness and nutritional information that's designed for educational and entertainment purposes only. You should not rely on this information as a substitute for, nor does it replace professional medical advice, diagnosis or treatment. If you have any concerns or questions about your health, you should always consult with a physician or other healthcare professional. Make sure that you do not disregard, avoid or delay obtaining medical or health related advice from your healthcare professional because of something you may have heard on.

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