Nutrition and Lifestyle in the GLP-1 Era, Pt. 1

Key Highlights:

• GLP-1 medications fundamentally alter appetite signaling by reducing constant food noise.
• Care should be reframed from weight management to weight health, positioning GLP-1 agonists as a supportive tool rather than a standalone solution.
• Common pitfalls in patients using GLP-1s include inadequate total intake, end-of-day nutrient loading, constipation, dehydration, fatigue, hair loss, and sleep disruption related to delayed gastric emptying and sustained metabolic activation.

In part one of this four-part series, Lisa Jones, MA, RDN, LDN, FAND, and dietitian Ashley Koff, RD, discuss understanding the role GLP-1s play on metabolic health as well as nutrition and lifestyle considerations while on therapy.

Transcript:

Lisa Jones, MA, RDN, LDN, FAND: All right. Well, hello and welcome to Nutrition 411, the podcast where we communicate the information that you need to know now about the science, psychology, and strategies behind the practice of dietetics. And today's podcast is part of a short series on nutrition and lifestyle in the GLP-1 era, featuring a Q&A with Ashley Koff.

I am so excited to have Ashley here today. I want to introduce Ashley first. Her bio is she is the founder of the Better Nutrition Program, the nutrition course director for UC Irvine's Integrative Health Institute's Integrative and Functional Medicine Fellowship and a faculty member at the Integrative and Functional Nutrition Academy, where she teaches an integrative and functional nutrition approach to obesity and weight management. And she is a practitioner for over 25 years.

Koff is leading a transformative movement and personalized nutrition turning better not perfect choices into practical sustainable strategies that deliver real health outcomes. Through patient stories and personal experience, she knows that optimal health is not just possible. It's essential to living your fullest life. She has been recognized as one of the CNN's top 100 health makers, featured in In Style as Hollywood's leading dietitian and has been selected as Weston's global nutrition ambassador. Welcome, Ashley.

Ashley Koff, RD: Thank you so much for having me. This is going to be fun.

Jones: Yeah, yeah. I'm excited because this is like, like all everyone is talking about right now, right, is GLP-1s, so it's hot in the news and I want to dive in because this first episode we're going to be talking about practical nutrition and lifestyle strategies for clients. My first question is, how do you think that this is changing how clients experience hunger and fullness?

Koff: I love that. You know, as somebody who grew up with, you know, my personal story, as I share in my book and will share here, is that I really battled my weight as a kid and one of the things that was always presented to me was just stop eating when you're full. And I was like, okay, great. I never need to stop eating because I don't feel full. Like, I literally, you know, could just eating. And I think it was like, you know, sometimes people would be like, oh, she has brothers. She just like eats like a boy. And I'm like, no, I literally like, I think they even ate less than me. Like, I did not feel full, you know, on that part. And I think that there is that part of it. And then something else that happens that I think maybe for my female patients as opposed to my male patients is something that I would say historically they experienced more of, and that was just the like total like cycle of dieting successes and failures. And as we started to go through that, you kind of like alter your eating in a variety of different ways and then it gets to a certain point where you're kind of always thinking about what you're eating and whether or not you're actually in an eating time period in the day, you're still sort of thinking about and having these conversations in your head about that. And that was like back in the 90s and then early 2000s.

We exist in a society today where information and access to food and food choices and conversations around nutrition and everything else is literally like 24 -7. It's happening everywhere and all these different touch points. So when you look at all of that and you ask the question - and I also want to acknowledge, that is now happening for men, and it's happening in a very fast, intensified pace where historically they weren't part of the diet industry, and then I think the diet industry was like, wait, there's 50 % of the population that we can now target. You know? Like, let's get in there. So men and women today are just constantly having these thoughts and maybe trying to create a muscle that doesn't exist in the human body called willpower and, be like, I'm just going to power through and not eat, but we're still thinking about it.

So what's really interesting about these medications that for me, has really shifted for me when I first started working with bariatric patients in 2005, is that I saw a shift in their own internal hormones changing. So their own GLP-1s. So I want to first start there. When we talk about GLP1s, I think we've created a society where everybody naturally thinks about that as a medication and I want us to acknowledge that we actually have and make weight health hormones in our body. The problem is they're either suboptimally functioning or even at optimal function. They're designed to only stay on for about two to five minutes. For many people that isn't long enough to experience the benefits that we need to be experiencing today. So you asked a very specific question. How is it changing it? What I'm experiencing with my patients when they're using the medications is that they almost feel like instead of having a motion detector, which is what they're designed with, they have a force field. They have something where they're like walking through life and it's like, I'm not like just thinking about this all the time or I'm actually not hungry or my appetite and my hunger have now become two different things, like that physiologically there is a difference and we're designed to have it be a difference. What I want to acknowledge about that is that can have both amazing, positive, intended application, and there are considerations because it can have consequences. When we put something into the body that's biosimilar to our own body's hormones, but the major dissimilarity is that instead of two to five minutes, it lasts for 24 -7, again, really amazing opportunity, but also it is going to exacerbate or potentially even create challenges in the body's ecosystem. So we can dive into some of that as well.

Jones: Yeah. Yes. And I love what you said that because a lot of us, I mean, that's the reason why I became a dietitian too is because it was something I struggled with when I was younger and I was always like, well, I'm still hungry. And my mom was like, well, that's all you have. Like you're done, you should be full. Why are you eating that? Like there's, so then, you know, when I got to pick an education, I was like, yeah, I'll be a dietitian. Like that sounds like, that's all I'm thinking about right now is food anyway. So why not, right?

Koff: Yeah.

Jones: So it's interesting how like looking back, how it all goes back to our childhood and what we did when we were there. So how about talking a little bit about how does it then shift from the nutritionally counseling approach for dietitian. So as a dietitian, like how can we then kind of shift our counseling approach?

Koff: Yeah. Well, the one thing that I think is amazing is if somebody on an agonist can reach a dietitian, like it's gold. You know, I mean, this is the opportunity for us, like, I don't actually think we have to shift. There are some pragmatic pieces and I will acknowledge that. But it's opening the door for us to have conversations that are the right conversations, you know, that are like that are instead of like the quick fixes that are out there. Like, I don't know about you, but I've tried like drinking 64 ounces of water before my meal. I've tried having 20 grams of fiber and fiber crackers before. Like I've tried all these things to feel full, right? And so I was like, oh, you know, when you actually then can have a conversation and say like, Okay, so number one, your body's designed with these hormones. And even if we're using a medication, we want to understand how this works. So what it might be showing us is what's not working better in your body. So it allows me to come back and have a digestion conversation with someone because these hormones are designed and also deployed, they're produced and deployed, you know, et cetera, from the digestive tract. But it also does something else that we can talk about. We can talk about how it's connected, the signals that are coming in, you know, our sight, our smell, our satiety, like how we feel about, you know, what we're eating, the deliciousness of it. All of those things are actually signals for these hormones to be sent. So again, if they weren't working well, then we can come in and we can have that conversation. And then we can do where, which is what I think is right, the true pot of gold, which is that we can personalize. So we can help somebody go from, you might be hearing more protein, more exercise, especially strength training, more fiber. And what I want to do is come in and actually say to you, all right, Lisa, like, what are you actually having? And let's look at that and also let's look at what your body is signaling with labs and with your appearance, so your hair, skin, and nails, and with how you feel at the end of a meal and how your energy is and what your poop looks like and how often you're peeing and like all of these things. And we can assess and say, is your body actually optimally resourced? And if not, we can now, because we're not in this mode of, you know, especially with an agonist in the body, we're now in a place where we can have the conversation because you're going to feel this is possible. You know, you're going to feel like, oh, I can come in and say to you, hey, I'd like for us to work on getting in a minimum of 15 grams, maybe closer to 20 to 30 grams of protein at a particular pit stop, you know, meal or a snack. I'd like to see if we're at three grams of fiber. Could we get to five grams of fiber? Could we do that from foods? You know, could we, instead of maybe having apple juice, eat the apple and you're going to go, wait, like carbs, they're actually okay for me? Yes, we can have that conversation, right? So we can turn around and we can start to help people really learn to optimally resource their body. And for me, I do that through the lens of total nutrition. So that's foods and supplements. And I think sometimes colleagues maybe feel less comfortable having conversations around supplements. But in the space today, number one, supplements are a gazillion dollar industry. I feel like people are taking them in. And so we have to ask about that because they are impacting your total nutrition. I think the second part is we have a lot of food that is due that throughout the process, it's either highly processed where nutrients have been removed from it. And then it's enriched where ingredients have been added back. And those may not be the same. They may not be the same form and they may not be the same quantity. And then there are also just a lot of products that have additional fortification that's in there. So one of the things that we can do with our patients is really help them understand their total nutrition and see if that total nutrition is actually optimal for their body. So that's unique to dietitians. I would say to nutritionists, you know, so it might be a CNS or it might be somebody who's practicing as a nutritionist. But in this space, I think it's really important because I firmly believe that what has historically been called weight management, but I'll call weight health with a nod to our weight health hormones, is actually the superpower in the specialty of dietitians and not of doctors. So doctors may script a medication. Doctors may tell you and eat this, not that. Doctors may suggest that there is a protocol that could be effective for you. But we are the ones that go in and do the sleuthing with you and the collaboration with you to see, number one, is it doable for you? You know, is it affordable? Is it accessible? Is it delicious? Right. And then the second part is, is this actually do we, when the rubber meets the road is when you actually implement recommendations, does the body show us that it's actually able to, you know, optimally function. So to me, the GOP -1 agonist, the world of these new medications, semi-glutide terseptide, is a launch pad for dietitians to come in and say, you know, we're not the, we're not like an ancillary to a doctor. Like you don't go see your doctor and then the doctor's like, oh, let me refer to a dietitian as in like to like go like now help somebody do the, like finish the process, right? On that part, we are specialty is coming in. We are specialists and we are specialists in nutrition. And nutrition happens to be the vehicle by which the body, which is an operating system, actually is able to operate. So you'll see me like step up onto, you know, my box here and be like, GLP-1 agonists have proven why dietitians need to exist. You know what I mean? Like in terms And as you said, and I started the conversation with like, gosh, I wish I had been, you know, had had that opportunity as a kid, you know, to be able to learn it that way too.

Jones: Yeah. And I love that you changed it to from weight management to weight health. That is so needed because that kind of changes the lens as to how you look at it. So it's not like, oh, somebody says to, oh, you need to work on your weight management. It's like weight health. Yeah. It totally changes it. So thank you for telling us about that. And then also, I do like the total nutrition too. I think that that is a different spin on it as well. But it helps dietitians that are listening too because we think about smaller portions and the appetites are smaller. And then you have to take into consideration what are the important nutrient priorities and then dietitians as dietitians we should be helping our clients focus on, especially around protein and micronutrient adequacy.

Koff: I've had a lot of patients on agonists where three things are happening and they are not better. One is they are not eating throughout the day. And they're like embracing what they're calling intermittent fasting. And I'm like, or you could just call it not eating. Like that's not better. And then it's like, why do I have fatigue? Why am I losing my hair? Why am I constipated? And then what's is they're back loading. So it's like, okay, by the end of the day, I'm sitting there going like, well, I got to get in all this water. I've got to get in all this protein. I had somebody the other day who was trying to eat 100 grams of protein at one sitting. I was like, oh my gosh, your poor stomach. And by the way, the body is going, that's going to elevate blood sugar, that's going to make body fat. Like your body can't break it down and use that much at one time in most instances. And then the third one is that sleep is disrupted. So one of the things for us to understand about these medications is by design, by design, I want to be very clear, this is where they're dissimilar from our own body's hormones. They stay on 24 hours for seven days, about seven days in the week. And that's the current medications that I'm talking about. So that means they're delaying gastric emptying instead of from two to five minutes to 24 hours set for seven days. And we know there's more intensity at the early time period when somebody first does their shot or takes their pill. And then it sort of weans over those seven days. So a delay of gastric emptying there is like going to have consequence, you know, in the body. But it's also triggering our metabolic, the job of these hormones is to tell our metabolic health hormones to go to work. It's to tell insulin and glucagon how to work. It's to tell leptin and ghrelin how to work. It's to go, you know, so they're going to these different places. And so they're, it's like a stimulation. Like it's in, so it's metabolic active state during this whole time period. Well, what happens is that means we're not in recovery mode. The body is not getting the signals at that time of saying like, oh, you're done eating. So now let me be in relax and recovery mode. So even though you're not eating, your body is not in recovery mode. And what I see that playing out as is impaired heart rate variability, so where it's lowered, in people where originally they may have had lower heart rate variability. And I also see where sleep is suboptimal on that part, where they're saying to me, like, I might have a little bit more difficulty falling asleep or staying asleep or I feel like I'm like, Ashley, I don't even need as much sleep. I'm like, vroom, room, room. It's like it's this exciting caffeine, you know, and they're talking about that part. And so it's really interesting to me is make sure that we dive into the experiential data and lab data and look at that because all of those things there are not a recipe for weight health. So I want to be very clear about one thing. The goal is weight health, right? It's not about weight or health, which is where we've historically been. The goal is weight health. GLP-1 medications are not a weight health solution. Weight health is a system. Personalized nutrition and lifestyle is when you have your plan and we have evidence that it works for you, that is the solution. A GLP-1 agonist is a tool. Using a tool, we have to understand how we use that tool that's better for you. So for someone, I might use a lower dose. For someone else, I might have them not go higher on protein and fiber the first two days that they're on the shot, especially if they're increasing a dose that week or that month. And then we may have different nutrition for them later on in the week or, you know, other things on that part. But we have to recognize as practitioners, we have to be yet better users of this tool. And that's been my work. My work, you know, this book is as much for my practitioner colleagues as it is for patients because my work has been to introduce this to and empower practitioners. This probably isn't new in the sense of this is the way that we have been practicing many of us and like this is the way that we want to practice, but we do have to really make sure we understand how this tool works and any subsequent tool that comes out how it may work differently because that's going to help make sure, you know, help us understand how to ourselves be better users of the tool and then also how to help our patients be better users of it as well.

Jones: Oh, that's fantastic that you call it a tool because that kind of differentiates from a lot of noise that we hear about it. And how it functions. And I think kind of thinking about patients saying and clients saying, oh, well, can I ever come off of it? Like, do I have to take this for the most of my life? And I do want to ask you that question, but later on. But right now, I do want to focus on like just one simple meal snacker lifestyle strategy that can help clients and dietitians that they can tell their clients, how can I help stay nourished and energized while using these medications?

Koff: Yeah, I think the concept of pit stops. So there's been historically a lot of attention to, you know, guidelines and recommendations that focus on what you get in during the day. And that allows for a lot of variability throughout the day. I teach my clients, and this may not be like 100% physiologically correct, so I'm just going to acknowledge that up front. But, you know, sometimes when you give somebody an analogy that's sort of physically, like, you know, that's sort of there, like it sticks in their brain, right? So for years I've said our bodies are designed more like a race car than a street car. And I needed to do that because I was a child who tried every diet under the sun, including Weight Watchers. And so at one point, I had my 18 points to spend, right? And there would be times where I might spend it where I would do like three to four points, like at three or four times during the day, right? Like I'm gonna eat meals or I'm gonna have meals and a snack and I would do it that way. But there'd be other times where I'd be like, oh, I'm gonna not eat so that like I can go out and eat and drink and have 18 points at like eight o 'clock at night, right? My body was fueled very differently when I did those things. And I think we've gotten into this idea of like total calories in the day, total macros or macro balances in the day, total amount of water in the day. We have lifestyle recommendations like 30 minutes of exercise in a day. Does that mean that I then get to not move my body for 23 and a half hours? Like it doesn't, like we're not helping people when we talk about in the day. So my primary recommendation that I would have everybody focus on, GLP-1 agonist or not, but I would double click on for someone who's on an agonist is think about your body. Think about pit stopping about every three hours in the day to do a couple of things, to look at your total nutrition. So at that time period, it's let me get in protein. Let me get in fiber. Let me get in carbs. Let me get in magnesium, B vitamins, like all of these different things. So look at my nutrition, pit stopping for water. So instead of like hitting, you know, half my body weight in water at like one point in the time day, because I forgot to drink water all day, pit stopping regularly for water, pit stopping to move my body, which is as important as my consumption and any of the other. And then the other one would be a pit stopping to probably like step away from our devices and our computers.

There's actual evidence that we also want to make sure like for our eyes and for our brain that we want to, like, step away from just taking in, you know, more stuff in that part. You know, in particular, staring at our screens. So I think if you take that, you know, and you work with clients and you say, like, hey, instead of giving credit for, like, and really evaluating, like, your totals for the day, can we really look at this pit stopping, you know, frequency, you know, concept, I think that that actually will go the furthest to helping to reduce challenges around things like constipation, dehydration, fatigue, nutrient intake, like all of these others. I think it's a very strong strategy that they can employ.

Jones: Yeah, I love what you're saying that. And then, because I think, too, like over the long term, we need these long term strategies to kind of help move forward. And that pit stop is just, that is like the best thing I've heard because I think it's something so easy. And then it makes me think of like, you're a car, your body's a car, that whole thing with the analogy of cars that we've learned in, at least than I did when I was in school. Like a lot of my professors use the car as like treat your body like a car. You have to fuel it, those kind of things. So I think that's really helpful. So thank you for that. And then I do have one more question for you is when clients start viewing the medication as the fix, because that's a lot of clients are, oh, I have the fix. I don't need to worry about anything else, but they do. How can then dietitians then reframe that conversation towards sustainable habits and long-term self-care?

Koff: Yeah, I love this one. So first of all, the answer to the question that I get asked so often is, do you have to stay on this for life? And my answer is twofold, usually. The first one is, I don't have a crystal ball. Like, I literally don't know what your life is going to be like. And I have experiences with patients who have used it for periods of time and have been off of it and have reused it. I have experienced with patients who have been on it and have been off it. But I also want to underscore in there that that question has belies so much of the negative weight bias that we have in this country because we don’t ask this question about any other medication. Nobody says to my patient who is being put on a statin, you may or may not have to be on this for life, or said differently, they don’t actually set the expectation of use this for a time period, work on your cardiometabolic lifestyle choices and then we’re going to get you off this medication. They don't say that about an SSRI. They don't say that about a proton pump inhibitor. Because there is a weight component to this, that is what is said about this medication. So we have to acknowledge that elephant in the room. It's inappropriate. And our job is to help work on that bias at the practitioner level and also at the patient level.

Okay. So the second part of that piece is, if I don't have a crystal ball on here, what I can tell you is that if you use this medication and if you have any benefit from it, you have proven my thesis, which is that the medication can be helpful for those who have suboptimally functioning weight health hormones ourself. If the two to five minute, if your own hormones, then that two to five minute design is not working and now this medication is working for you, you have proven that your own hormones, that there's suboptimal function somewhere in the system, right? Whether it's their ability to be made, to be deployed, like any of that stuff. So if you do not go in and optimize your own function, there is no chance you can ever come off this medication. I'm just going to be real clear there. Because then this medication, which is a replacement for your own, and while you're on it is suppressing your own production, because your body doesn't need to make it if the receptor sites are satisfied, you aren't going, you're not going to be able to come off of it, right? And that example we do see with statins. We see that example with proton pump inhibitors, you know, et cetera. So I want us to be very clear that the middle area, that gray area in there is a combination of what's going on in your life and are you able to make the choices and the repair work and do the, you know, while you're on the medication and when you're off the medication to continue that, where you get this, you know, where you get optimal, you know, outcomes on that part? So that I think is a very important conversation to have with a patient.

The second one that I think is the, the probably the most important conversation to have with a patient is around budgeting. So unfortunately, our services are not usually covered by insurance across the lifespan of somebody who was going to be using this medication at the level at which they would benefit from it. The other part is many people have intermittent access to the medication. So we have a budget issue that we need to bring up and we need to have a budget planning session on every six months or a quarterly or an annual basis, especially right now. I mean, I guess this is always, but I just feel like budget and resources are really challenging for people right now. And so I feel like we need to make sure we're having that conversation so that I can know as your partner, I can know as soon as possible whether we're going to, you know, if we're going to need to have a plan that's going to have you have less medication or maybe even need to come off the medication or if my services, like if we need to shift how you're going to be able to afford my services, we need to know that because I don't want you to have some success and then remove that success, you know, and have challenges associated.

And then I think the third one is when we're curious about, as practitioners, I think our greatest gift is to be curious about an individual. Why are you making choices? And what do these choices mean to you? And when someone says to you, like, you have to pry this medication from my dying hand, what they are saying is, I have finally found something that is allowing me to not feel trapped or a victim of my body's own physiology and also, you know, from a brain standpoint, what I'm thinking about in that part. Your job isn't to convince them that it is not a fix, right? It is fixing something for them. When we use the term fix, too, again, weight bias because it has this drug sense, right? Like, what I got my fix, you know? And I have a lot of people that would be like, Tuesday is the day that I take the shot. I got my fix, you know, like that kind of thing. And there's a part of that that I'm like, okay, like I never take a five-year-old out on a bike and just say with tough love, go. I'm not going to give you training wheels. Like If I give you training wheels, I'm going to get to the place. And I'm also not going to, you know, say to them, oh, you were like, you know, biking on a flat surface and learned how to do that. And now we're going to go, like, mountain biking. You know, I mean, like, we got to, you know, we have to meet people where they are, right? And so I think in this, like, when I had a patient who came to me and she said, my doctor sent me to you because he wants me off the medication. And I was like, and then she said, I hate food. I have an abusive relationship with it. I'm not going to do anything that you tell me to do from a nutrition plan standpoint. And like, yeah, like when asked a little bit about it, yeah, my digestion isn't great. And I'm a little annoyed about how much hair I'm losing and my saggy arms because I can, I finally feel comfortable in smaller clothes, but I, you know, I'm embarrassed to show my arms. So that and that was like how she presented, right? And I was like, okay, I said, well, I don't think we need like you've been on this medication for less than a year. Like I don't, just because you've hit some arbitrary BMI that your doctor has established, I'm not telling you you have to go off this medication. And she was like, oh, thank God. You know, and I said, like, we might have to find you a new doctor. Like, you know, I was honest. I was like, if they're not going to script it for you, like I can't, you know, we can try the conversation there. And maybe if they know you're working with me, that'll, you know, make them feel a little bit better about continuing to script it. And said the other thing is your body has nutrient, like resource requirements. Like, I didn't set them. We don't get to prioritize. And I said, I just want to let you know, like, it doesn't care if you are bald or not. It does care if your body has the nutrients that it needs, you know, for metabolism. And that's why it's going to deprioritize hair. And it's going, you know, because you only have so much nutrients. And so your body needs that. I said, so if you don't want to do this through food, we're going to have to do this through supplements because this is a weight health goal. I know you're excited about your weight, your physical weight and your appearance, but what I'm telling you internally is we're creating a mess from a health standpoint. And here's the evidence of that. And I said, and the final piece is some of that evidence is saggy skin and your hair falling out and, you know, and, you know, et cetera. And I said, so I do think we'd probably need to look at some strength trainings and changing. And what it required me to do was to unpack. She did not want to go to the gym locally because she didn't like the way that people there looked at her and how she felt and her own lived experience with being made fun of for being larger and, you know, all of these other things. And so I found her a virtual trainer and she now trains four days a week. She had originally, I was like, can we get, you know, to do strength training once a week. And she's happy, you know, and she's still on the medication. Like, it's not my job to turn around and tell you, like, I'm worried that you're relying, you're in a codependent relationship with this medication. I actually told her, I think this might be one of the healthiest co-dependent relationships. You know, we've had that conversation because she's also gotten rid of alcohol. And what I said to her is, you know, three years from now, I don't know. Like, I don't know if you're going to need this or I have another patient who is no longer using the medication, but she keeps it in her refrigerator because she wants, it was important for her to say, like, this is a tool that I will use when I need it, as opposed to I am now a success because I used that medication and I'm no longer on it, right?

So a lot of the work that we have to do is actually help people peeling layers of the onion. And again, this is why this lands with the dietician, right? We were the ones who came in and were assigned in bariatrics as the ongoing management tool. And I don't know why in GLP-1 agonists, I do know why and have a cynical approach. But in the world of insurance and in the way that the system is set up now, I don't know why they've leapfrogged over and been like, you don't have to be working with a dietitian to maintain your access to a medication. Like it would be so simple to have that be, you know, the, you know, sort of the, the way that they differentiate, you know, who has access and, you know, instead of using something that I consider really dumb, which is BMI.

Jones: Yes, BMI. They just need to get rid of the BMI and be done with it. I'm on the same wave with like you.

Koff: Yes. Bye, bye, BMI! Bye, bye. Yeah. Yeah.

Jones: Well, thank you so much, Ashley. This has been an information packed episode that's going to be so helpful for dietitians out there listening. So thank you again for being our guest today.

Koff: Thank you.