Nutrition and Lifestyle in the GLP-1 Era, Pt. 2

Key Highlights

• GLP-1 medications are a tool rather than the entire solution, and sustainable success depends on grounding care in self-efficacy, daily habits, and personalized nutrition and lifestyle strategies that evolve as individuals progress through their journey.
• Using a “yes, and” mindset and broader markers of success beyond the scale helps reduce fear, reinforce confidence, and highlight meaningful progress.
• Establishing structured daily, weekly, and monthly check-ins supports long-term sustainability by acknowledging that physiological and lifestyle needs change frequently and require ongoing adjustment.
• Preserving muscle mass and metabolic stability during or after GLP-1 use requires prioritizing optimal digestive function.

In part two of this four-part series, Lisa Jones, MA, RDN, LDN, FAND, and dietitian Ashley Koff, RD, discuss sustainable habits for patients using GLP-1 medications and support for patient transitioning off GLP-1s.

Transcription:

Lisa Jones, MA, RDN, LDN, FAND: All right. And welcome back to Nutrition411, the podcast. And we are excited to bring back Ashley Koff today for episode two. We did do episode one, so make sure you go listen to that for practical nutrition and lifestyle strategies for GLP -1s in the GLP-1 Era. And today we're going to be talking about beyond medication because it's really important, right? Sustainable habits and transition. So welcome back, Ashley. Thank you for being with us.

Ashley Koff, RD: Thank you for having me.

Jones: Yeah. Yeah. So during our most recent episode, we talked about practical nutrition and lifestyle strategies for clients using GLP -1s. Ashley, if you had to sum up that conversation in just one or two sentences, what do you think are the main key takeaways?

Koff: I think the key takeaway for me is that GLP -1 medications are a tool. They are a tool in a large toolkit that we have today for weight health and that everybody needs to be optimizing our weight health hormones, GLP -1 medication or not. And the final component of that is that when we look at the, and we design a personalized nutrition and lifestyle plan for someone, it really has to meet them where they are and everyone is on a journey. So that means that has to continue to be adjusted or optimized to meet them on their journey where they then go, you know, and then it's different times.

Jones: Yes. And I love that on a journey because we're all on the journey or just at different parts of our journey. And one of the things that we're talking about today is really helping the patients maintain progress and then build that confidence as they move beyond medication use. If that's the case, because I know you mentioned in episode one, like they may still be on the medication. Once the clients begin, or patients or clients, begin seeing results, how can us as dieticians then help shift them from a medication-centered mindset to one grounded in self-efficacy and daily habits?

Koff: So I think I would throw the question back a little bit differently. And I would start with, I think our job from the beginning is to ground the conversation in self-efficacy and daily habits. I do think, though, that we have to acknowledge that until somebody has some lasting success in their mindset, that we actually can't do the mindset work, which remember, mindset is a set of beliefs. It's not actual facts. So I think throughout this entire journey, our job is to actually nurture someone to have exposure to the facts. And for me, that's often where I call engaging with what I call a ‘yes and’ mindset. So yes, I could have the lived experience that I have been a on again, off again, success and failure with different diets. And I could also be someone who is figuring out how to nourish my body effectively today, right? I have a lot of people who feel like they're just waiting for the shoe to drop, like they're waiting for the medication to be taken away or for it to no longer work. And there's so much fear in that because they feel so good and they feel like it's an enabler for their choices. So one of the things I think we can do very effectively throughout the entire process, including in the beginning, is helping to create an environment where they can be most successful. In our last episode, we talked about budgeting. I think consistent checking in on their budgeting. And the budgeting, remember, isn't just finances. It's how they budget their resources, things like their time. And it's also how they budget their hope, right? So how do I budget? and think about joy in my life and hope, you know, that this could actually be something that is having a lasting impact or it could be something like, I hate to use the word finally, but a lot of people will say, I finally feel or I finally understand what it's like for my body to be in alignment or, you know, I finally feel in charge of my body instead of a victim to my body, like all of these really, you know, important things. So I think that'sgoing to be really critical for us to do. And the best way that we can do that in my mind is to be an incredible mirror for them, to be a mirror for them, to show them whether it's data driven. I think everything is a form of data, but whether it's lab values, whether it's a scale or measuring things like waist to hip circumference, maybe you have access to a DEXA or a bioelectrical impedance scale, or now they even have on an app where you can virtually check body composition, being able to use that as the marker because a lot of people might be so used to using the scale and looking at that total number on the scale. And we know we were just joking about BMI, but BMI is totally unhelpful. That'syour weight for your height. And we also know your total weight is no indicator of your weight health, like just none on that part. And so we really want to make sure that we're shining back to people and reflecting back where shifts are actually happening. And sometimes those shifts are. You know, I had somebody say to me, I finally said yes to going on a girls weekend. Her husband was so excited because she's like, just never said yes, because she always felt like it would ruin her diet. And she went and she was like, and I had a blast. And I made my choices, you know, and I still and, and it was like, that was like, I mean, we just like mark, we checked all the boxes, you know, it was like, here's community here. There's like time away, here's my identity, like, you know, all of these, you know, really important things. I will acknowledge for myself as a 52-year-old woman that about a year ago, I stepped onto a scale and I had had lost muscle because I had had a surgery and I was like, you know, out for a period of time. And so I've been working really hard to get that muscle back. And so I was actually like, I'm not, I don't actually love using a scale, but I was actually using a scale because I knew that I needed to like have something that gave me a measurable, like a smart goal, right? Like I needed to have measurable data. And I recall getting on this scale and it had stayed the same. And I was like, I remember just like standing there and I'm looking at the number, we'll just like call it 150 pounds. And I'm looking at the number and I was like pissed. And I was like, that number is the exact same number. Right? And what had happened in that part was it like, and I'm looking, I was on a BIA scale. So I also had in front of me, my body fat, I had my water, you know, intracellular, extracellular water, and I had my muscle. And I could see logically that I had lost fat and gained muscle, yet I could not congratulate myself because the 12-year-old in me who went to Weight Watchers meetings who, you know, went in and got on the scale and people either clapped for you or they didn't clap for you, was standing there and was like, I wouldn't get clapped for. Like, it was because the numbers stayed the same, right? And so we have to be the one that turns around to our patient and says, hey, first of all, numbers staying the same is never a bad thing. Like it could be that you had a month of like the hardest month of your life and everything stayed the same, which means that like you actually did awesome. Well, like you actually were able to continue doing, you know, or it could be that you gain muscle and you lost fat if that was the intention or like whatever it was in that part. So I just come back to I think that that part of self-efficacy and daily habits. Now, the one thing that I think is a critical daily habit that we need to work on cultivating with people is you are never going to make the same choices in a day for the same reason. Your body always has slightly different needs, right? It either has accumulated enough resources and as a result doesn't need something, or it is at a deficit because you just had a cold or you stayed up later or you try, you know, whatever it is. So one of the things that we do need to do as a daily habit is we need to come in and give somebody a process by which they check in on themselves. So the way that I teach people is there are certain things that are daily check-ins. There are certain things that are weekly check-ins. There are certain things that are monthly or quarterly check-ins. And there are certain things that are usually twice a year. I'm very rarely on the annual check-in, you know, might be like, you know, okay, the colonoscopy is every couple of years, you know, or that kind of thing. But there's very little that, you know, unfortunately the way our healthcare system has historically been set up is the idea of like, you just go to an annual check-in, right? that's not better. We want to actually check in on these things more often. And I think we can do a really good job of being the one, again, being that resource for people that invites them to do that check-in.

Jones: Yeah, I think it's really, really, really important. And then the other thing too is like strategies, strategies that, and you kind of mentioned, like when you were experiencing what you experienced, but what would be a strategy that best supports muscle preservation and then metabolic stability, whether it's during or after they're tapering?

Koff: Well, I love that I'm going to give you an answer that I think nobody would give when asked that question. I think every the majority of dietitians would start in, and they're going to be right in certain capacities, your protein intake, the diversity of your amino acids, all these other stuff. For me, it is you need to ensure that you have optimally functioning digestion. So one of the biggest issues that we have today set up by nutrition guidelines and nutrition recommendations and how all of us were taught in school and everything else is that we give credit when somebody consumes something. So yay you, you had kale or spinach. Yay you, you had wild salmon. The body doesn't high five you and give you credit until the nutrients are broken down and distributed where they're supposed to go and anything that is harmful to the body or unnecessary gets eliminated. And that's our digestive system. So one of the important things for us to take away here is that we actually, for building and maintaining muscle, we need optimal digestion. How we optimize digestion is also going to be important because sometimes we are bandaiding digestive challenges and those may be negatively impacting our longer-term digestive function on that part. But I would definitely come in to that piece and then understand and teach someone that the nature, remember our medications, our GLP -1 agonists, are a biosimilar hormone replacement. Their dissimilarity is the extent of time that they stay on. And also the fact that they do not require any of the body's ecosystem to operate. They go right in and they go to the receptor site, right? You inject and they go to the receptor site. You take and it goes to the receptor site. So as a result, it's circumventing our own pathways on that part. So when we understand those two dissimilarities, we can understand that the medication may have impact on, not may have, is intended by design to have impact on our digestive function. And so if we don't course correct to optimize our digestive function while on it, then we are going to be at a place where we're at a disadvantage. All the protein in the world is not going to mean anything if your digestive system can't break it down into usable amino acids and then get those amino acids to the muscle to be able to build and repair muscle.

Jones: Well, you just made a case for why it's so important to work with a dietician while you're on it.

Koff: Yeah.

Jones: And even beyond, right?

Koff: And I want to acknowledge to my colleagues why you have to be, there is no such thing as a digestive dietician. I know this because I have to admit in an embarrassing manner that when I wrote my first book and sort of in the media and did like all this teaching and start teaching physicians and I was like focused on digestion. And somebody said to me like, oh, you're that digestive dietician specialist. And I was like, oh no, like I don't want to be pigeonholed because I do weight health and I do cholesterol and I do whatever and so I like worked against that. Today I would offer that like there is no word like there's no world in which a dietitian is not doing assessment of digestion like that is foundational to everything, so if you feel like in your current practice that for some reason isn't foundational or isn't giving that attention or you're like me and you worry about like being pigeonholed, that we are pigeons, that is our hole, like that is the body, like that is so important, you know? So I think it's just really, really key for us to, you know, own that. Again, we are professional specialists in the medical space and our specialty is nutrition. That's our lens, but it's about how the body gets and is able to use the nutrition that we bring to it that is equally a part of our specialty.

Jones: Yes. Thank you for sharing that, Ashley. And I appreciate you saying that because I think that's going to help a lot of listeners because we're called so many things, right? Like over the time of your career, it's like nutritionalists, like nobody can get the dietary, like nobody gets your name right, but yeah.

Koff: Yeah. Well, and I, like I come from, I mean, I, I share it. Like I always, it's like my mea culpa to my dad, but like, you know, he, I come from a household, he's a surgeon. My, my sibling, my brother's a doctor, my sister-in-law's a doctor, many of my friends are doctors. Like I come from that doctor world and I made a very important decision not to be a doctor. And as my five-year-old nephew says, I'm a backwards doctor. Because DR, RD like, you know? He thinks that’s funny. I was like, you know what? I am backwards because I actually start with like nutrition and digestion and look at like how can I then you know optimize the body as opposed to others may be looking and sleuthing at what are the symptoms that your body is presenting and diagnosing, you know, where there's dysfunction on that part. We collaborate, but don't, as a doctor, don't ever call me like, oh, you're my dietician. I'm going to send my patients over to you because I don't want to handle the emails about what to eat. Like that's, no, no. I am the specialist that often am better coming before the doctor. And I'm also the specialist that comes with the doctor because I am able to optimize patient care. And a lot of my doctor colleagues know, I'm like, if I was only able to invite one person to support me on a desert island, it would actually not be the doctor. It would be the dietician because I'd want to be able to figure out how to give my body what it needs. Once there's a problem, yes, absolutely. I want to be able to have somebody who can diagnose and help me strategize how to repair that. But foundationally, the dietician is going to be more important there.

Jones: Yes. There you go. Thank you. So true, but I agree with you. Yeah, there you go. So how can dieticians help clients manage changes? Like they have so many changes happening, whether it be appetite, satiety, or their weight post-medication while they're trying to sustain healthy patterns.

Koff: Yeah, I think that goes back to the approach of daily, weekly, monthly, what am I checking in on? So one of the things that I think can be our job, so we're great as the quarterback. I think that's a really great role for us. And one of the things, because we are more typically involved with somebody's weight and their progress report on that part, one of the things we do need to do is if anyone is on any medications or supplements, which is 97 % of the population, we should be inviting them to and sharing with them when to go back to their doctor and say, you know, you have lost a percentage of your weight here. Hopefully it's mostly fat and, you know, just a little, but let's look at, do we need to recalibrate your prescriptions? Right. So like I will typically use the 10% rule depending on the medication, but you know, so as an example, if my patient loses 10% of their weight, I'll have them reach out to their doctor and say, do we think that this is time to recalibrate a medication and look at that part? I also think that for us we have the conversations too as you're losing weight to look at do we think we need to recalibrate like any other recommendations that we're making like the amount of protein and fiber or different things that you're getting at particular you know stops on that part. And a lot of times that's as somebody gets closer to what we might look at as like a goal weight composition, you know, really like it's not so much about a maintenance play as it is like your body has substantively changed. And I want to look at, you know, how are we nourishing it? Right? You know, and what's showing up on that part? The other part of that is when do we do lab testing? So one of the things that I do a lot with my physician colleagues, when we're sharing a patient is once I've seen the patient, I then reach out to them and in my notes, I'll say, you know what? This person hasn't been great with compliance or has been great, depending, but has only started on the supplements that we recommended, even though you recommended this like two months ago or I recommended this a month ago. They were traveling. This didn't arrive. They just started on them like two weeks ago. It doesn't make any sense for us to do lab work as regularly scheduled. Let's shift that. So shifting timeframes based on what's going on in someone's life. I have the conversation all the time with my patients. We go through on a quarterly basis and we look at their schedule and we'll say things like you know I’ll say like are you traveling? And then also like right now I’m the holiday mode, what do the holidays look like for you? There’s no reason for us to do labs like like a week after Christmas, you know, just because like your doctor scheduled or you decided, you know, a lot of times people are like, oh, I'm home or my kids are home, so I'm going to have this. And I was like, yeah, but if like eating and drinking and travel and illness has been like totally off the rails for two weeks, why would you do labs at that point? You know, like, well, we're not going to see something.

So I think that we, we are really good at like helping them collect data better. A great example of that is I partner with my patients on doing a continuous glucose monitor. I do not want someone wearing a continuous glucose monitor and having all of the information that's out there telling them that they should just get lower and lower on carbohydrate. Like it's the famous, like replace the banana with cauliflower, you know, like kind of example or replace bread with cauliflower. So what I do is I look at the continuous glucose monitor. We look at trends. We talk about like, what is it telling us about your fitness and the intensity of your fitness? What is it telling us about your sleep? What might it be telling us about your hydration, the timing of your supplements, you know, and really diving into that data. I had a physician colleague of mine say to me, you know, I don't think we should be using continuous glucose monitors in anyone who's not diabetic because I think it creates disordered eating. And I said, ah, I don't think you should be using a continuous glucose monitor in patients who are not diabetic. I am a dietician. You should send them to me and then I will work with them because my job is actually, I'm working on their disordered eating. Right? Or I'm working on, you know, and a lot of the disordered eating is the infobesity around like which choice is actually right for me? You know, like we've been, you know, getting information from so many different sources that we may not even know what's better for our body. So I think that that's like the zone of genius for the dietician is to come in and be able to make those recommendations more effectively on that part.

Jones: Yeah, definitely. And that's really helpful too. And then the other thing I have, I want to ask you about is misconceptions because there's so many misconceptions out there. And especially if you're not working with it, like say you're not a bariatric dietician or you don't have the experience that you do, Ashley, like talk to the dieticians that can, how can these dieticians then find help? We want to be able to lead the conversation around realistic and evidence-based care. So is there any advice that you can give us on that?

Koff: There are places I, you're from a continuing education standpoint, you know, I know we all hate that, like we have, like, I have this love-hate relationship with CDR because I go in and I'm like, oh my gosh, you know, but it's actually why it's designed, you know. I think a lot of times we can get really excited about, oh, I want to learn new physiologic stuff, right? There's a new supplement or there's a new, like, how does the body work? If you don't know how to have these conversations, one of the best things that you can do is actually learn from those that are having those conversations and have, I mean, I've been doing this for like 28 years now. So that's why I have this base, right? And I still learn from others, you know, on that piece. So I think, and especially with the advent of AI and other tools, like I think it's really important that we are lifelong professional learners in that space.

Jones: Yes. Well, I appreciate you so much for sharing your knowledge with us. It was great. These last two episodes, I learned so much. So thank you. Thank you for being on Nutrition411, the podcast.

Koff: Thanks for having me! It was great.