Ep. 562 “It’s Not a Willpower Problem” – Why Women’s Bodies Resist Weight Loss in Midlife with Ashley Koff, RD

Welcome to Everyday Wellness Podcast. I'm your host, nurse practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. today i had the honor with connecting with friend and colleague ashley cough she's a leading voice in personalized nutrition and is the founder of the better nutrition program with over 25 years of experience and the groundbreaking glp1 optimization system to her name she's helped redefine how we approach sustainable, lasting weight health. Today, we spoke about how her book reframes weight health as a systems issue rather than a willpower issue, integrative perspectives on digestive health and GLP-1s, why many women feel blamed by themselves when weight loss doesn't work, and how her framework helps remove that self-blame, the issues surrounding infobesity and the less is more movement. Effective ways to naturally support appetite regulation and satiety signaling. Key areas of digestive health and why detoxification support is so important. Red flags that she sees for women that are undernourishing their bodies or over fasting. What you need to think about if you are going to stop utilizing GLP-1s. And last but not least, new drug therapies and Ashley's opinions. This is one of these really insightful, thoughtful conversations around not only metabolic health, but weight loss resistance and women in perimenopause and menopause. Ashley, such a pleasure to finally be connected to you. I think we were laughing in the pre-call about the fact that every time I show up in an event, you're there too. So we should be friends. And I'm so glad you're here to be able to spread your expertise and really dive into your new book, Your Best Shot. Thank you so much. And likewise, and I feel like this is the peanut butter to the jelly of your conversation. You know, I think where you've been and I followed your work and certainly where your new book in April is, it's just so important for us to understand that the gut isn't an afterthought and that the body's an ecosystem and how hormones work. So I'm really appreciative to be able to dive into this. You know, your book reframes weight health as a systems issue. I think this is unique rather than a willpower issue. What are the biggest systems you see broken in women, especially in perimenopause and menopause that contribute or exacerbate weight loss resistance? Yeah, I think weight loss is such a challenging term because it's not factually correct. Like that's not what the body actually wants to have happen. So for me, both on a personal level and, you know, and I kind of go through that. And then certainly as a practitioner, I always was really like it sort of was this big aha moment when you kind of realize, you know, the hip bones connected to the thigh bone. And so I'm sitting here thinking at one point, oh, I have a digestive problem. But then I find out we have these weight health hormones and they're made and deployed from the digestive system. And I was like, wait a second. These are all interrelated. And then you hit perimenopause. And this happened to me personally where, you know, my belly had been gone for like a couple, at least a good 10 or 15 years. And I'm like, wait, it's back. I'm like, what's going on? And you realize that in perimenopause in particular, it's not so much in menopause, but because our hormones show up in a different amount and availability every single day and sometimes at different points in the day, whenever they're shifting or they're suboptimal or out of balance, they're directly throwing off digestion. And when you throw off digestion, you throw off your weight health hormones. So I prefer to think about it as this whole ecosystem. And what ends up happening a lot of times is we fix, we find a tool to fix a part, right? We might replace estrogen or we might come in and say, here's a probiotic because your microbiome needs this. But unless we look at a total ecosystem overhaul and optimization, we're not going to be able to see, you know, sort of it all work together. And have you felt, you know, working as a registered dietitian, what has been your kind of trajectory on the perspectives around GLP-1s? Because I would imagine, and like my listeners know, these are not new drugs. I think that they have really hit a point of density and expertise. Like, I think everyone now knows what these drugs are, but they've been around for 20 years. Not necessarily the newer drugs, but the concept of a GLP-1. So through the trajectory of your work as a registered dietitian, what has been your experience? Like, when did you start getting interested in working with patients that are concurrently taking these medications? And what have been kind of your big takeaways? Yeah. So I'd say for myself personally, I was a kid who had a weight problem. And I was always deemed to never have a health problem. And, you know, maybe I had a health issue of like, oh, you need to get your tonsils out. Why? Because I'd had so many ear infections and throat infections and been on so many antibiotics. But even when it was a health issue, it was a surgery issue or it was a medication. Like, here, take this. You're healthy. For me, it came together in my early 20s when I had really hit a rock bottom of just trying everything. So the first thing is the myth of the noncompliant patient. We are not noncompliant. We are trying everything, right? Like, so it's so frustrating. So that's number one. Number two, a gastroenterologist actually said to me, he was trained in more of an integrative root cause approach, said to me, hey, it's not what you're eating or what you're not eating. Your body doesn't have what it needs to run better. And at that time, he was tying together antibiotics and digestion. So I really thought that the key for everybody was digestive health. And then in 2004, 2005, I always remember this because this was the year that Facebook actually came out. So I'm about a three and a half year into my practicing. I'm out in Los Angeles. I have on the one side award winning, you know, Oscar, et cetera, celebrities as my clients. And then on the other hand, I'm training at County Hospital and working at Cedars-Sinai and had my first set of bariatric patients. And this was a year that, I mean, just to put in perspective for everyone, this is when Janet Jackson had her wardrobe malfunction, right? So it's a long time ago. All right. So at that moment, not in school, not in anything I had practiced, I had a doctor kind of flippantly say to me when I said, I'm just so blown away that like literally overnight diabetes is changing in our bariatric patients. and he said he's like oh well that you know glp1 and gip are working and i was like what and it was like i had met it like i saw my entire life flash in front of me i went home i read about all of this what i could find which was pretty minimal and i at that moment in time learned that we have these hormones and that their job is to tell insulin and glucagon those hormones i knew you know to tell insulin and glucagon to go to work or to tell leptin and ghrelin to work and how to work and so I realized it would be like trying to turn on your car and being like, okay, gas, yes. Air in the tires, yes. Oil in the engine, yes. The engine actually works, but the spark plug doesn't work. And you go and you turn it on. So these hormones in our body, they're just this quick switch, but they are so important because they turn on all this stuff. So what's really interesting was 2004 was actually the first year that Bayetta, the first ever GLP-1 agonist, came on the market. So because of the work that I was doing in bariatrics with diabetes patients and in that space, we sort of started to see the weight loss, but it was really diabetes. So this has been work I've been doing for 20 years. And as a dietician, I think I have a very different lens on it because what made me really fascinated and what my work for probably a good, I'd say a good 10 or 12 years was never to think of these medications as anything other than able to be helpful for people who had insulin challenges. Like, that's all we were looking at. And I personally actually just took credit for everything else that happened, like with their weight, because I was like, oh, look, I'm healing their digestion. I'm doing all this other stuff. Well, as the medications became more popular, and certainly as we moved from once a day or even twice a day to the ones that we have now, semiglutide, trisepatide, redditrutide, where it's, you know, they last for about a week, I actually learned that these hormones by replacing them, so their hormone replacement therapy, by replacing them, somebody's body was actually getting something that regulates muscle, bone, fat, blood sugar, inflammation, blood flow, hunger, satiety, I mean, all of these different things. So when I looked at that, I was like, okay, I need to understand like I do with anybody on any medication, what is going to be, what's the intention of the medication and how does it work and how's that going to affect your body? And then what could happen that's not intended and how do we, you know, optimize when those things show up? So really long answer, but it's been fascinating. And for 20 years, I've been able to help people optimize their weight health without the shot, without the oral, without a GLP-1 agonist. But when we say everybody knows about a GLP-1 agonist today, I agree. Most people know they exist. They think they're a weight loss or a diabetes medication. But they most don't know they're a biosimilar hormone replacement therapy. And most also don't know that we actually have these hormones in our body. So that's actually why I wrote my book. Yeah, it's so interesting because I think that even as a nurse practitioner, or even as someone that trained at a big research institution, there was little to no discussion about some of these satiety hormones. And so it's really been in the intermittent fasting metabolic health space that I've gotten familiarized with them. I think what I have found really interesting is how can we modulate satiety? I think that this is a consistent theme because I think when people are satiated, they make better choices. And whether that's with medication or other levers like fiber or hydration, or, you know, you talk a lot in the book about the importance of digestive health, which I think is one of many aspects of your book that makes it quite unique in this space. Really, that emphasis on there's more to it than this. If you think it's just about utilizing these very powerful synthetic medications, it's a larger conversation. And so when we're looking at women in particular, and I feel like women do, whether it's societal pressure, things that are said to us as children, young adults, I think that weight loss resistance is the greatest pain point for women in middle age. All the things that we used to do no longer work. And I'm just kind of using it as a blanket phrase. How does your existing framework help remove not only that kind of negative self-talk, but also self-blame, which I know for so many women? because I always say that if a patient says something derogatory about themselves to me, it's tenfold more extreme in their head that they're saying to themselves. So if they're saying it outwardly to me, it's much more benign than what they're having, that negative internal speak that they're having within themselves. Yeah. And I think it really comes back to, I love that you started there because because I think nobody's ever been as mean to me as I've been to myself. So I really align with that. And I think the other part is decade on decade, we tend to start to like ourselves better or get at least exhausted with those messages. You know, like we stop fighting with our moms or now we're raising kids. And so then we're trying to be a better role model or, you know, maybe we finally are aware, although I think it was late 40s for me where I was like, oh, yeah, my period that happens every month for the last 20 years. Like I'm always this way, you know, like that kind of But I think that we are trying to like ourselves better. And then this happens, right? And this happening is exactly what happened to us in puberty. But that was a time period where we didn't have anything to understand before. So I actually think perimenopause has made me so much better with like, I have an eight-year-old niece and an 18-year-old niece. And I am so much better with them because I'm like, oh, right. Like, this is that rage. Like, and I felt it, you know, that kind of thing. I think what we what is so important from an approach is to recognize that it is not our job to do what it is we've been told. So that's, I think, the most important piece is that what we have actually been told is a big part of the problem. And it continues to be the problem. And quite honestly, in pursuit of trying to help ourselves heal and be the body that we want, both physically and emotionally, we are info beasts. We have so much information coming in and, you know, it can be like, well, I'm going to fast today or then it's like, OK, I'm going to be vegan or, you know, I need to put the well, I'm fasting, but I need to put collagen in my coffee. But does collagen make me out of fat? Like and you have all these different and then I'm like, oh, I shouldn't have coffee. But wait, what kind of water is OK for me? And you're like when you're not breathing like that, we're actually affecting our gut or, you know, our brain is so busy. So I think a big part of it is inviting people to break up with like the shoulds and like all of those other pieces. In this time period, more than any other time in our lives, we actually should really rely on the insights that our body shares with us. So I want to be clear whether you are in a large body and you put on five pounds or whether you're in a small body and you put on five pounds. There's no such thing to me as vanity weight. If your body is putting on fat, that's a signal. That's all that that is. It's not a moral failure. It doesn't mean you've done anything wrong. it means that there's a signal that your body's trying to send that's saying, hey, something about my operating system isn't optimal right now. So instead of using what I'm getting, I'm actually going to be storing it. And I want you to know, like, I want it to be invasive enough. So, you know, so five pounds is invasive. So you're like, okay, what's going on? Or losing your hair, you know, when that clump comes out, like that's pretty good signal on that part. So I think that, you know, and my approach is for us to, number one, I really think hopefully It's to find a practitioner or to find resources like you and I offer where we can actually come in and do it in this way and say, what is that insight? And here's something for consideration. So this is the other point that I think is so valuable for women. There's no right answer. The right answer is not 30 grams of protein. The right answer is when I have 30 grams of protein, what is my digestion telling me? What is my muscle telling me? What is my fat telling me? You know, and we kind of look at that, right? And one of the ones, and I use this, I share this in the book, but is my delicious to me test. One of the things that we've done is we've actually moved from food is delicious and really focused on is food healthy. And when food is not delicious, when you talk about satiety, we actually don't, from our mouth where you have GLP-1 receptors, we actually don't get the signals to stop eating. And so we eat more because we hope to feel full digestively because we're not feeling full from a satisfaction standpoint. So we're not actually honoring the way that the body works. The body would prefer to be satisfied before it's over full, you know, and be able to pick up on that. So I think as we think about women in this space, I think that's really important. And then the second one is, as a gender, we're kind of known as multitaskers or like we can just like to-do lists, like we can have a ton of stuff. Your body wants less on your to-do list. And it really, as you're trying to see what is going to help it, it also wants you to do less at one time. So any of these protocols that are like, do this, do this, you do this, it's like, whoa, like if somebody is on 30 supplements and they or even if somebody is on three, if they can tell me what that supplement is doing and how they know it working that actually where I start I like I need to know like is that glutamine actually working for you And here how we going to know Or why are you using methylene blue Or why are you doing a low dose or what someone might call a microdose of a semi I need to know that it's working, right? And so I think we can start in that space. Less on our to-do list means that our body is actually going to be able to run better. And I think that's really important too. What does comfort that carries you from morning to night feel like? This March, Cozy Earth crafts every piece with care from soft, supportive socks for your steps through the day to breathable comforters that help you rest deeply at night. 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You know, we're not overcomplicating things. It keeps things pretty simple, but I keep telling them because last night they were peppering, do you want us to have a continuous glucose monitor? Do you want us to monitor your sleep on the ORE rate? I mean, all these questions. And I said, if that makes you feel good, great. If you find that data overwhelming, then that's not helping. So the less is more really resonates. And I think the older I get, the more I realize when I started off as a new nurse practitioner with the best of intentions, I would give patients, honest to God, I would give them a list of things to do. And I would keep a copy. Like it was like, you know, they would get a copy and I would get a copy. And I remember, you know, the longer I did, the longer I worked in clinical cardiology, the more I realized, oh my God, I'm just overwhelming them. I need to give them one or two things to do, maybe one. If they're a perimenopausal woman, they might be hanging on by a thread and giving them five things to do is totally overwhelming. So I love that you are cognizant of the fact that less is more being conscientious about kind of running through like whether it's food rules, whether it's nutritional dogmatism. I think it's all well meaning, you know, people on social media, social influencers, healthcare providers. There was so much conversation last night, women were like, should I be carnivore? Should I be vegan? Should I be that? I mean, they're so confused. And they're like, I'm just ultimately trying to do what's best for my body. And I was like, I really want you to keep track of how you feel when you eat. Do you feel good when you eat 40 grams of protein at a setting? Great. If you feel terrible, that's good information. Like all the information is valuable. And so I love that you are having those conversations with your patients. What has been your clinical experience? If someone's not taking a GLP-1, What are some of the ways that you like to help your patients naturally support appetite regulation and feeling satiated? Because I think this is a really important point. I think in many ways, we are so disconnected from our bodies. Like truly, we just eat to eat. Like I watch my teenage or young adult male children eat. And it's like sometimes I'll say, do you slow down enough to even register what you're eating? And I think for a lot of women, eating is a means to an end. It's like, oh, I'm going to stand up and eat. I'm going to eat in my car. I'm in the hospital. I'm rounding. I'm going to eat a protein bar, which I did for years, which is disgusting. But they don't think about food as nutrition or nourishment. It's more like it's a means to an end. Yeah. And I think we've missed the nurture in nutrition, right? And we're meant to be nurturing our body. We're meant to be nourishing our body. So, you know, if something isn't delicious to our body, if something doesn't make us feel full, you know, and I think sometimes we are moving so quickly because we're afraid of what happens. if we slow down. So I even and I give this in the book, but I have my joy assessment. You know, I've just over the years, I've asked people, I think, because like what's going on in the world, which has been like every, you know, 2004, there was I mean, there's just always stuff going on. So one of the questions I started asking people is what makes you laugh? Because that helped me connect with them. And then the other one was, you know, how is your joy, you know, and people would say, you know, I'm not experiencing joy, or I wish I had more joy, or I experienced joy, but then this happens or, you know. And so I started to say, like, what if we actually like track and can look at how we can have you experience more joy? And one of the key things is actually making time, like just, you know, that time to pause. I'm not great with things that are prescriptive. Like if somebody says, go meditate or one of the ones that was really hard for me because of my childhood, you know, just struggles with my digestion and food and things when somebody would say, well, like we should be really mindful when we're eating or you could be intuitive. I could never trust my gut. My gut was broken. Like, you know, it literally wasn't working. It wasn't telling me the right things. So things that kept me from experiencing joy, there were a lot of times where I would just eat because it was almost either to stuff feelings down or to just want to move through the eating experience because it had so much wrapped up in it. So when we flip that and we look at how can we nourish, I use a pizza analogy in the book for fun and for, because I think everybody knows pizza is crust, sauce and cheese toppings optional. And so the crust. So by the way, this is the same if you're on an agonist or if you're not, we might lean into the how of the choices being different. But I have a patient that comes to mind, a 42 year old who was really feeling like at this stage with young children, she was very quickly becoming the mom she didn't want to be. And that was really bothering her. She said, I don't like how I'm showing up for my family. I really don't like who I am as a person. It's affecting my partnership, you know, a lot of things. It was 42. And so she knew she was probably in like early, you know, she's like, I don't know what phase of perimenopause, but went to the doctor and the doctor had said, you know, what about a GLP-1 agonist? Because he heard her say, well, and I have put on weight. Well, for her, the weight, the I have put on weight was like literally the 13th thing on the list. And she actually told me later she didn't even put acne on the list because the medications were like kind of helping, you know, so she's like, I didn't even think I could put that on the list. Back pain, you know, like all these different things. So when I met with her, we came in and we always evaluate someone's digestion. Look, we give credit for foods being healthy. The body doesn't give credit for anything being healthy until it gets where it's supposed to go in the form it can be used and is able to be used. So that's the job of our digestion. So if we don't have optimal digestion, hydration, we're not the body. We're not. It doesn't matter what we're taking. I mean, you know, obviously we can't have like non-food, But, you know, on that part. So we worked on that a little bit for her. I was like, look, you're on these acne medications. You're on daily pain medication. I was like, it is all injuring and insulting your digestive system. So let me give you some nutrients to tune that up. We did that supplementally. So, yes, I totally lean into supplements. And my rationale for using supplements was she actually is a pretty good eater. Like, so I wanted to give her credit where credit was due. But also a big part of this was life isn't doable. I've got, you know, she has five kids and I think the oldest one is seven. Like this was just like if I put more on your to do list and she's like, then I have a husband, then I have a boss, then I have a dog. You know, I was like, OK, we know where she was on the list, you know, like after clothing and laundry for everyone. Right. Kind of thing. And so, you know, I think for this piece, working on that part alone, had that been the only thing that we did would have, you know, we would have seen these similar results. But then we also did a little bit of supporting some detoxification and some other things I shared with her hemp seeds. Like, I love them. They're the wild salmon of the plant kingdom. I was like, this is going to just up your protein, but it's also going to give us some fiber and some nutrients and it's non-carbs. So you can have it with your carbs. You know, we kind of went through. And for her, I really focused on her timing of when she was eating so that we could hit these three hour increments and not get in too much at one time. Well, she told me in the first month that everyone, including her husband, said it looked like she had lost 15 pounds. She had lost five. But at that point when I don't mean that I think that's awesome. We were not tracking her muscle at that point. We tracked that later. And I just asked her to give me some feedback on weights. We were trying to be very conscious of her budget. But within 90 days, she had lost the, we'll call it maybe 15 to 17 pounds of fat. She was happy about that. But the most important thing was she was completely off the pain medications. She was able to hike and play with the kids. She was able to go away on a girl's weekend and drink alcohol and eat and feel like she just enjoyed herself and it wasn't like off plan. And the most important thing was she felt this was doable. And so a year later, she's where she wants to be. She's like, this is my plan. This works. We actually used for her something called a GLP-1 activator, a New Zealand hops that helped her get about four hours every time she took it. So she took it twice a day of increased activation. But to put in perspective, if our own GLP-1 hormone at 100% is like having one shot of espresso, and let's say she was on no caffeine or decaf, that one shot would have been great, right? This activation was like having two, maybe three shots. An agonist is like having eight shots and it keeps you like eight shots that stay on for seven days, right? So they're like totally different, you know, in that space. But using this for her really helped her with her afternoon and evening time. What's interesting is she has said, and she's very proud, you know, and she's like, I'm like the never GLP-1 agonist. And I said, hold on. I was like, you're 43 and a half now. It's like 48, 49, 50. I can't tell you. I was going to say, we had another 10 years. Yeah. Yeah, I was like, I can't tell you. And I was like, and I want you to be okay with that. Now, I also want you to be okay that if finances or treatment, like if there are reasons we can't use this, we've demonstrated, but I want to show you what it's taking for you now, and your ability to do this. And then I also want to, you know, understand that we don't know how your body's going to change, you know, in the future. So I think that's a great example of all the consideration that goes into, you know, and again, this would have been the exact same program for somebody who was on an agonist. We would have just been using the agonist to help them be able to do these things on that part. Yeah. Was it Calicurb that you were? Calicurb was that exactly. To date, that's the only one from the research side that I feel comfortable with. There's a couple others. There's a genetically or bioengineered form of a Saccharomyces that is being looked at. A lot of people, a lot of people in Hollywood are like, oh, I'm taking this. I happen to work with still a lot of people in Hollywood and they're not taking that. They're using semiglutide and they're also promoting, you know, or they're using both or they've used or they use the agonist and now they're using this. By the way, that's not to denigrate anyone. It's just to say, hey, what you use when is really just going to be up to you and your toolkit. Like it just doesn't matter, you know, in that space. But I think that, you know, we definitely have to break up with the idea like CaliCurb will never work like semi-glutide. And that's a real positive for this person. But for somebody else, they may need the semi-glutide. And I think it's fascinating that there are people that are very upfront. I have been experimenting with truly a microdose of terzepatide to see if I could drop my LP little a. The jury's still out. I just had lab run. With that being said, I've been very open about that. It wasn't to lose weight. Have I lost some inflammation? Yes, absolutely. I was shocked. But I think I find it fascinating when people say that I adopted a new diet, but they don't want to admit that they've actually used the GLP-1. It goes back to that people feel a sense of shame and yet they should not. It's just one of many different strategies that people can choose to use to augment whether it's weight loss resistance, autoimmune piece, inflammation, or for whatever reason. And we know that the research is certainly suggesting now that HRT plus a GLP-1 really magnifies the effects of the GLP-1, which I think is really interesting. I think replenishing hormones in some instances, especially in menopause, plus a GLP-1 can be very helpful for shifting body composition, which, again, is this big pain point. when we're talking about digestive health, help listeners understand what you're speaking to, because this is, again, a very unique aspect of the book that I really appreciated as someone who thinks about the gut a lot, that maybe a lot of the rest of us in traditional allopathic medicine are perhaps not as focused on. Yeah. I want to double click on two things that you said that'll lead us into the answer there. That was my experience too. It was about, I think 40, not 50. So as I turned 50 and my years from 48 to 50 were really rough, both personally and physically And I you know we have all these resources right So I tried fasting like a girl I tried continuous glucose monitor I tried the or like all the different things you know that you I a nutritionist I like I leaning into the right supplements right nutrients And then I trained for an endurance event. So I climbed 29,000 feet and 36 hours. And I left that number one, we now know having pretty much ruptured a fibroid in my uterus, but I'm having a very large fibroid and having those experiences, but not knowing it and just not understanding why my belly was back and I had never felt like so badly. And one of our dear friends like said to me, she's like, have you considered like semi-glutine? I was like, no. I'm like, you know, I was like, there's just no, you know, and I'm meanwhile, like I'm writing a book, like, I mean, I'm working with patients, I'm writing a book and I just couldn't see myself, right? Like I couldn't see like how I would go do this. And she's like, you know, I think, and it was so interesting because I also just wanted to experiment with it for the purpose of writing the book. The day that I went on it, the first time, I'm like Oprah, I literally felt like a different person. I felt like I understood my body connected in that part. I also was very concerned because what I ultimately learned from my childhood was that I had very slow motility. So I'm always working on, so I'm like, uh-oh. So I really had to work through the digestive piece. And ultimately, after about three to six months of using it pretty regularly, staying at a very low dose and actually meeting the CaliCurb folks and playing around with CaliCurb, I came off of it. But that was also because I knew I was having a hysterectomy. And so I haven't had to go back on. It's been a year. I haven't needed it or chosen to use it, but I still have it. Like I'm not, there's no chance that like, I have no issue. Like if, you know, what these different pieces are, here's what I want to talk about with HRT though. However, I think what the research is missing is that number one, these hormones work synergistically. So it's not even like that they amplify, but they literally work synergistically. So duh, like if one isn't working, you know, it's kind of like when people don't pick up on if your testosterone is low and you're like looking at your iron and your testosterone relationship. The one issue that I talk about in my book that I don't think is getting enough attention is if you use this and you shrink fat cells, you're liberating toxins. If you add HRT, you're adding steroid hormones that have to be detoxified. Otherwise, the circulation of those toxins from the shrinking fat cells or from the used hormones are going to be problematic for us from a health standpoint. So when we look at some of the concerns, even about the Women's Health Initiative and all of that and who got cancer and who didn't, nobody has unpacked. But I think we can certainly know at age 65 what people's digestion and detoxification look like. So I would just encourage anyone, as I now answer your question on digestion, to think about detoxification as a focused point. And one component of detoxification is reducing the toxins that you bring in. So quality, you were talking about your, you know, kind of replacing ingredients that don't help the body. Alcohol gets, has a whole conversation. We know it's toxic to the lining of the digestive tract and to the liver. So it is going to be an issue. We also know just too much of anything at one time is difficult for the body. So detoxification also requires elimination to be effective. And so that's going to be key. So from a digestive standpoint, your body needs to be able to break things down. That may mean that you want to lean into ways to like liquid nutrition is already broken down in the blender, or maybe instead of having raw fruits and vegetables, you have them cooked or, you know, like, however, we make things a little bit more easy to digest, maybe chewing twice the amount of times that you normally chew to actually break things down. And then one of the things that I see probably the most consistently is that motility isn't working. So things aren't moving throughout the digestive tract successfully. Motility may be magnesium and calcium. It could be impacted by iron and zinc. It could be impacted by you sitting. One of the pieces I talk about in my book is that even though we talk about exercise recommendations, we actually don't lean into movement recommendations. We need to be a body in movement. And one of the places we need to move is what I call midsection movement. So you might be doing great like I am. I'm at a standing desk, but I could also go the entire day and not move my midsection. That's going to not be better for my digestion. So we need to lean into some of those things. And then the ability for things to be absorbed is probably what has been the most underappreciated. And like we started to get it when we talked about leaky gut, but really understanding that the entire lining of your digestive tract, starting from your mouth, and the enzymes and the acids, but also the actual lining. So the integrity of that lining is going to be so important. And that's going to be something that we really need to look at. So as somebody who is on antibiotics or somebody who maybe is adding hormones for great reasons, for fertility or for improvement, maybe with vaccines and with medications and all these other things, we need to look at that and how do we optimize that? And then the final one is elimination. And one of the things that I'm seeing in the misuse, especially on the dosage front and the miscommunication with more protein and more fiber as the recommendation for people on GLP-1 agonists is people are literally not pooping for days. And when they're pooping, they're having hard, dry poop because one of your other weight health hormones, it doesn't get talked about PYY, sits in the colon and it checks your poop and it also checks your body's hydration status. And if the body's dehydrated, it pulls water and it pulls electrolytes from your poop. So when you have that dry, hard poop or it's hard to pass poop, it probably is telling us, you know, that PYY is a factor. So these are all things like I like I way nerd out. It's also why I created an online program and access to our coaches so that in case you have questions from the book, because I was like, oh, like this is a lot. But this is the work that we do need to do, it can feel like a lot. But the good news is, is when you ask the right questions about what isn't working better, you actually can be very targeted in what you need to focus on. And so it's not I've never met somebody we have to focus on everything. It's usually just figuring out what's the thing to actually focus on. Yeah. And I think it's so interesting, you know, when we're looking at women in perimenopause and menopause, like as an example, there's so much going on with motility, irrespective of where you come from your childhood, young adulthood, number one, with less estrogen, less progesterone, less nitric oxide, you're gonna have less motility, less smooth muscle contractility. You think about this piece with the estrobilome, where we have this estrogen processing in the gut and it really speaks to, if the gut's not healthy, there's so much that goes on. You can recirculate your estrogen. You talked about detoxification, which is one of my favorite topics, but helping people understand this is not woo-woo. This is not a green juice smoothie that's gonna be able to detoxify your body. It's like being very thoughtful because by the time we get to middle age, we've been exposed to a lot in our personal care products, our food, our environment. And so if we are not regularly sweating, hydrating, pooping, peeing, I mean, we have the ability to become fairly toxic. And I love that you mentioned when you have fat loss, It can free up stored toxins. Like interestingly enough, I mentioned I've been on this very small dose of terzepatide and probably once a year, my integrative medicine physician will actually do heavy metal testing. And so I just had it done and he said, oh, your mercury is up a little bit. He said, are you eating more fish? And I said, no, but I lost a little bit of body fat being on the terzepatide. And I wonder if it just freed up stored toxins. And so for a lot of people, when our detoxification system is not working properly, again, it's multi-system. It's, you know, our lungs, our kidneys, our liver, our skin, all designed to help us detoxify. When it's not working properly, we can recirculate these things. What are some of the clues for you when you're working with a patient that are assigned, other than not pooping regularly, that are assigned for you that maybe with some of this fat loss or this shifts in body composition that their detoxification pathways are not optimal? Yeah. So if you're getting sick often, then we know your immune system is trying to tell us something. Now, that's also to be fair. And I think it was not having had my own children, but the last two years ago, I was living with a five and eight year old and I was getting sick all the time. And then I also had to give myself a little permission. I was like, OK, like they're they bring in everything. It's a Petri dish, but it was really interesting how much I had to optimize my immune system, you know, there. But it was kind of in this concurrent time of having that, like, you know, I lost about like 15 pounds of fat and it was like, all right, like we have got to. So I think if you feel you notice changes in your body odors, and I have all these listed out as questions, I think that the skin changes are ones we really have to pay attention to. So butt acne, shoulder acne, you know, kind of things changing, like the pallor of your skin, like the texture. And the answer is not just estrogen. So I love the exposure to HRT. It is having a day and it should, but it literally isn't the answer to the quiz, like on every single thing. And so I think that that's like one of those. And for this reason, it's like, if you are adding these things, we have to also be doing this other piece. one of the other ones too that just does not get enough attention and dr stacy i think is so phenomenal on this is our oral microbiome like so if you're breath your bad breath like we've got a lot of attention now with mouth taping i ended up doing invisalign because i you know be as shocked as i was but they diagnosed me they're like you have a really small mouth and you have a normal size tongue and i was like wait i've never i was like i want a t-shirt like i've never been told that you know such a loud talker and big mouth and i was like okay like this is actually something so what's happening is things are getting trapped in here. And from here, it's affecting, you know, everything. So I think that can be really important. I also think mood swings are really, really good to key into. And the final one I'll come back to is joy. Joy is different than happy. Happy is like that song, you know, don't worry, be happy, kind of like, when you are happy, you literally can't be anything else. You can be feeling an array of emotions, it could be the most tragic time in your life. And you can experience joy because you have gratitude for who was able to show up for you or you have gratitude for yourself in that moment. And so a lot of what I will see in this time period that, again, people are like, oh, I bet it's your testosterone. I'm like, let's not just say that when somebody is low on joy, it's just testosterone, right? Or just balancing our hormones. It might be balancing the hormones, but it's also why am I not experiencing joy? And the body's really interesting. And why I tie that to detoxification is that when the body is bothered and isn't eliminating toxins and doing everything properly, it is going to be much harder for you to have the experience of gratitude because there is a mind-body connection. And that really brings us, you know, to the vagus nerve conversation too. If you're in your 40s and 50s and feel like your body suddenly stop responding the way that it used to, you're not imagining it. Bloating, waking, sleep disruptions, food sensitivities, and unpredictable energy are incredibly common in perimenopause and menopause. But here's what most people aren't told. Your gut microbiome is changing right alongside your hormones. And those changes can influence everything from how you store fat, to how well you sleep, to how your body processes estrogen. That's exactly why I wrote my new book, The Menopause Gut. 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It'll take you to multiple options for where you can order The Menopause Gut in pre-sale. Yeah, you know, it's so interesting. Probably, gosh, 10 years ago, I was in the midst of a formal detox with a medical provider. And within three days of starting it, I became and I've never been depressed clinically. I was watching one of my kids swim at swim team practice. And I was like, what is wrong with me? And so I reached out to them and I said, I know enough to know this isn't normal. So I was like, number one, I feel like really, really, really depressed. And they're like, how many days into the detox are you? And I told them and they said, stop everything, because what's probably happening, There's two main phases of detoxification in the liver, third phase is in the gut. They're like phase one sped up and phase two, because I have some genetic things, totally slowed down, came to a screeching halt. And so I love that you brought that up because I think for a lot of individuals, they might not make that connection. They're like, okay, skin stuff, that makes sense. If I have acne or anything, skin manifestations, but maybe the mood changes might not, they might not make those connections. Even for healthcare providers, they may not make those connections. So really important. One thing that I always like to talk to appropriate guests about is, you know, we have this prevailing thought process around we've been taught and conditioned and you and I are both in the same age range. So I know that we both learn this. The way that we lose weight is we exercise more and eat less. and women head into perimenopause and menopause and they're like prevailing dogma is exercise more eat less what are some of the red flags when a woman comes to you and they're maybe they're dealing with some subtle weight loss resistance or it's overt what are the red flags for you that they're under nourishing their body not just like oh it's been a couple days but they're chronically in an energy deficiency state. Yeah. And it's almost, I mean, they come in as like blaring lights, right? You know, and it's usually in the communication, like I don't, and it's like they're, they'll talk so quickly about everything that they're not doing, right? And that's a big aha. So I usually actually don't have to search so significantly on that part. Sometimes we have to figure out, okay, so what's the right order of us then nourishing? Like what are we going to lean into. And I usually take that gut first approach. But sometimes, too, what will end up happening is that they're shrinking the window in which they're consuming calories. So as a result, one might say, well, like, that's great, because I'm not like, I'm like, okay, well, you're asking your body to do a lot unless you've shrunk your day, and you're sleeping in that whole time, you're waking up, and then you're going to bed really early. Like you're asking your body to do a lot with a lot less, right? Like, let's just have that conversation. But also, if you're shrinking the window in which you're consuming, you're actually asking your body to handle a lot at one time. And so when I pointed out that way, and we kind of have a conversation about like, you know, how does it feel like when or how did it feel when the kids would come home from school and all of a sudden it was like game out, like it's mommy, mommy, mommy, like everything, right? And you were still trying and it was all it was like, what if they you had one kid at one time, one person in your life every three hours where it was like, here's what I need from you, you know, that kind So we kind of shifted a little bit to understanding that piece The second part is in the clues and what you not having So if somebody is not having carbohydrates number one I think we have to break up with the notion that any food in nature exists as a carbohydrate a protein or a fat Like they all some combination of these different macronutrients But if somebody not having carbohydrates intentionally because that's been part of their weight loss or even their muscle gain efforts, right? And sort of like leaning into learning about being muscle centric and understanding that part. When we make that shift, like we can understand what is lost from carbohydrates. We can understand that carbohydrates are an escort service, maybe just for fiber, or maybe they're an escort service for a lot of minerals, especially. Some vitamins, yes. Some antioxidants, yes, but a lot of minerals. And when we are mineral depleted, our bone, our blood sugar, like all our metabolism, all of these different things. And then I'll also, if I have the opportunity to have genetic information, that can be really helpful. Somebody says to me, as an example, I'm on this particular B vitamin supplement, And, you know, I have that MTHFR variant, right? Like, and I was like, I don't even know why we're calling it a variant. I think we're pretty much at the point where most people don't have, you know, on that part. But when we look at that, I'll say, OK, so when I look at your food, then actually you aren't actually getting in folate from your food. So I can look at that part. But also, did you know that choline and zinc work the same way that these B vitamins work? And so when you were avoiding the yolk of the egg or when you were not having all the like nuts and seeds anymore because of the fat content. You're not getting in zinc. And so let's look at that part. So that's also where my job is to look at your nutrition as your total nutrition and then say, like, what is doable with some degree of consistency from a food and a beverage standpoint? And then whatever is not doable there, that's what we try to make up for from the supplement side. There's a whole in the world of dietetics, like in the world of physicians, I'm sure in the world of nurse practitioners, there's differing opinions, different approaches. I get challenged by a lot of dieticians on my usage of supplements and feeling like we should be able to do this from food. First of all, telling anyone you should be able to do it and do it this way is not my, like, I just am curious how your body's working and what's going to be doable, you know, and we'll figure it out. But the second thing is, is that it's actually pretty flawed. Like if you look at what we actually would have to do to hit optimal levels, not the really dumb amount RDAs that were established in 1997 for magnesium that we're still using today, but optimal amounts, we really have to look at how like it would be very difficult. So I think we're lucky that we have the supplement part, but I also don't want to supplement first and then under nutrition. So it's a little bit of a, you know, it's a dance of how we do that together. Yeah, thank you for your thoughtfulness. And I'm the first person to say working in cardiology, we tested magnesium all the time. Rarely, if ever, was someone therapeutic. Rarely, if ever. So magnesium to me is a no brainer. It's involved in over 400 enzymatic reactions in the body and with stress. And I don't know any middle aged women that aren't dealing with a little more stress at this time of their lives than at other points. I think it's really, really important just to say, there's no shame if you take targeted supplementation, full stop. Absolutely none. When we're looking at individuals, maybe they're episodically or consistently taking these very powerful GLP-1 drugs, and they come to you and they're like, I have this fear that if I go off, I'm going to gain weight. What are some of the tenants that you work through with them, if they have a desire and working concurrently with their prescriber, this is what they're all in agreement over. What are some of the things that you have found to be very successful in helping your patients with tips that you're sharing with them, whether it's about breakdown of macronutrients, meal timing, eating for satiety, or any other things that you think are really valuable for them to be able to have success long term? Yeah. So first, I would say everything we've talked about. Second, I wish we could say this was an environment where we work concurrently with the prescriber. I just want to acknowledge the environment that a lot of women and men, but a lot of people are turning to getting these medications wherever they can because the medical system that they're in, even their practitioner maybe doesn't believe in it for them or doesn't want that, you know, that kind of thing. Or the way that the system is set up is that my ability to work concurrently with that practitioner isn't as optimal as we would like it to be. So that is my idealized scenario. This is not the scenario in which I work with. I've had people who have come to me who have said, my doctor wants me to, says that I'm at the right BMI and wants me to come off of this. And they're like, they can pry it from my dying hands. I'm going to get rid of my doctor. I'm just going to lie to him. And I'm like, okay, let's have a conversation. I've had other people who have come to me saying, you know, I'm just concerned. Like, I don't know if I want to go on this or I'm on it, you know, and what about coming off of it? So and then there's Oprah. And I'm so grateful to Oprah because I think she has she opens up and has such, you know, just honest conversations. So, you know, she said when I went on this medication at 8 a.m. by 2 p.m., I was a different person. Absolutely. When you have lived a life where you have suboptimal function of these hormones and the system around it, and then suddenly the system doesn't need to work because when you take the medication, it just hits the receptor site. She was like a light bright, like or a computer that was suddenly activated. It was like, this is how the body's supposed to work. What I don't love is that she later said she tried to go off of it because she just wanted to see, could I go off the medication? And she gained 20 pounds. And so her answer there is we can't go off of that. I think that's the wrong communication. I think that it, first of all, for any medication, we should just acknowledge, like if you are on a proton pump inhibitor, please don't just go off of it. If you are using a pain medication, if you're using something else, like I said to my patient the other day, would you go off of birth control, have sex, and just hope that you don't get pregnant? And she's like, what are you talking about? I said, well, that's what it's like when you just go off of a GLP-1. Like if, and here's the if, if you haven't addressed what's underlying. So if you use a GLP-1 agonist in any dose that's here, and by GLP-1 agonist, I'm talking about what's on the market today, liraglutide, semiglutide, terzepatide, redotrute, not what's coming down the pike. If we go on those and you have any benefit, you have proven my thesis, which is your weight health hormones were suboptimally functioning. They may not have been dysfunctional. They might have been delayed or suppressed. And I go through that in my book. But if you go on it and use it to optimize their function, you can't just go off of it. So could you reduce the dose or could you extend the time period between the doses or all these different things, potentially. And that's really going to lean into whether or not we're able to help the rest of your weight health ecosystem work and whether at an optimal amount of your body's own productions, your body can do what it needs to do. Because it may be that based on where your health, your genetics, who you are today, what you have access to, et cetera, you need a higher amount. So we'll have that conversation. So the comment that I will make to anyone is you cannot go off this medication without a plan. And that plan has to be that we are evaluating every week that you are delaying it. So say that you were taking a dose weekly and we decide to instead of take it once a week, now take it once every two weeks. For those extra seven days, I want to assess return of symptoms. I want to assess your ability to continue to eat, exercise, sleep, like do all the different things that we were talking about. and to mentally feel about how you felt, not the exact same way, but about how you felt, say, like day four or day five of being on your medication. And then I am going to have things that we're going to track, usually your weight composition, so your fat and your muscle. That's why I think the most egregious statement that is happening, I really shun, like, I'm very disappointed in any physician that says, yeah, well, my patients have gone off this medication and they've regained all of their weight. Where were you with the first five pounds? Where were you with the first 10 pounds on that part? If your patient ghosted you, that's their problem. But if you are using the term, my patients have used this and they have lost muscle, my patients have used this, gone off of it, and they've gained weight, your system is not working for your patients. That's how we have to reframe this. So when we look at coming off of or weaning, and sometimes we have to, sometimes there's pregnancy, sometimes there's other health issues and treatments that are a factor. You're sometimes I have somebody who's traveling for three months all over the world. Just, you know, now we have the oral option, but we didn't have that. And this wasn't going to be as easy of an option. And so what's our plan for you in that time period? And then I think it's really important to say, and I think any practitioner should always say this to a patient, but I don't have a crystal ball about your life. So just as I said with the woman who feels like she's a never gonna GLP-1 agonist, I was like, I don't have a crystal ball about your life. Like I if that is your goal, I hope that your life unfolds in that way. But I don't ever want you to try to white knuckle or fear a tool, you know, or use something in that way. So I think that, you know, when we look at all of those pieces, what I will say is really important. If I had the opportunity to work with anyone, just like I did in bariatrics before they had their surgery, if I had the opportunity before someone was going on an agonist to assess their digestion as a minimum, assess their digestion, understand what it's telling us right now, and also understand what medications and supplements they're on and why. So just kind of understand what they're doing to support their body and how that's working for them. That would give me the greatest insight into how we can have you on the medication likely with the most optimal outcomes. And, you know, unfortunately, our system isn't set up that way. That's what I'm really pushing for, you know, with insurance and other pieces. But I think those would be the key things to consider. No, that's so thorough. And, you know, we were talking before we started recording that there are some burgeoning new drugs that are coming out. What are your thoughts on the new drugs? I'm already seeing an oral GLP-1 that's being marketed heavily on, not that I watch a lot of TV, but it seems to be the ad pops up every time on streaming services. From your perspective, what are your concerns? Are you encouraged by these new drugs or do you feel like we're opening up Pandora's box? I think there's a very important line to be drawn. So any of them that are in the existing form of the medication, which is a biosimilar hormone replacement therapy, whether it is an oral or an injectable. So I would say that would be semiglutide, tersepatide, retitrutide, liraglutide. Those are the ones that we know of and fall into that space. Those I think I can understand and feel very comfortable in how to communicate. The oral is really interesting because the reason we have injectables is that it is very difficult for a peptide hormone to survive the digestive tract where the acidity is going to break those peptides open. But you and I both know there are like BPC-157 and these others. There are oral versions where they're using something called SNAC, which is kind of funny. It's a sodium transporter. And what it does is it picks a pocket in the stomach and it temporarily makes that pocket a less acidic temperature so that that's how the protein, that's how the amino acid chain, the peptide chain can get through. And then it goes right back to normal. So as far as we know, dosage and oral, and again, we're using these in a variety of different ways, actually for a lot of digestive benefits. So I feel like that could be favorable. So I don't have concerns about that. I'm acknowledging that with oral, I see different issues with patients than I do. One of the things that my colleague brought up that I thought was brilliant was she actually was as a nurse. She was seeing more patients because they had concerns about giving themselves injections. This was the first time. And now that there's an oral, people are not coming to see her. So that was a really interesting. Right. So she wasn't having all of you know, that was a lost opportunity. But with the oral, because you're taking it daily, you may actually have daily digestive issues. Whereas when you do the injectable, you may have one or two days of digestion being thrown off and we alter kind of what you're doing and then it kind of normalizes. The hard line is there's a whole other type of medication called small molecule non-peptide. Non-peptide is what is key there. So those are not peptide hormones. So that is going to be, but they're still going to be called GLP-1 agonists because they're going into the GLP-1 and the GIP receptors. That gives me more concern. Apparently the way they work, if it's an oversimplification, I apologize, but I think they jump over one part of the receptor site. It's like they don't have to go on the front door. They can then go to the second door and let go in. And I don't know what that looks like. And I have too many things from my past of like COX-2 inhibitors and like other medications that came on the market that were almost the same, but not the same. And then there were problems. So I'm going to watch that much more closely. I also really, like if I can just like pick on everything that bothers me in one sentence, why in the world is the majority of the studies just judging the outcome, but the judging the outcome of these medications as the better medication is the one with the greater percentage of weight loss. They're not saying the greater percentage of fat loss. They also, some of them are acknowledging like the Rititrutide studies, liver fat and changes in, you know, and blood sugar, like in all of these weight health things. But until we're in a space where we actually are looking beyond just on this medication, somebody was able to do this. Because look, for a long time, I've had things that people could do where they lost a lot of weight really fast, you know, but that wasn't, that's not the win. That's not a weight health win. So I think we've got a lot of problems coming up. But we also have, we have, we shouldn't have a degree of question marks, like such a significant degree of question marks with the substances that are on the market that we know pretty well how they're going to work. Well, thank you so much for your input and your perspectives. It's really invaluable. Please let listeners know how to connect with you outside of this podcast, how to learn more about your work, or get access to your new book, Your Best Shot. Thanks. I like to tell everyone your best shot should be everywhere in every format. So if it isn't, ask for it or let me know why. I think you can find me in most places, just my name, obviously, it'll be in the show notes, but Ashley Koff, I'm on most social media, Substack, like that kind of thing. And then my company is the Better Nutrition Program. And I have there's a QR code in the book. So even if you get the book at the library or bar it from a friend, do that, because if you have any questions, I set it up so that my team can at least you can at least meet a human who can have a conversation with you. They can't give you recommendations or personally on that part, but they can help you know where to go or how to think about things. And they can certainly help with what could be confusing to you as a person as you go through the stuff in the book. So I'm so grateful for this opportunity. I'm glad it brought us together. Like, that's my favorite part of this. And I really hope that, you know, as sort of the year unfolds this year and next year, we're able to really support women, especially, you know, knowing your audience through perimenopause to break up with so much of the disempowerment. that especially for me, my work, weight loss and weight management have been so disempowering. And I think what you're bringing forward and what I've endeavored to bring forward is just really should empower women. Yeah. Absolutely. Thank you again for your work and your time today, Ashley. If you love this podcast episode, please leave a rating and review, subscribe and tell a friend. Bye.