Unlocking the Science Behind Weight Loss and GLP-1

Introduction and book announcement 0:00

When we shrink fat cells, we increase the release of toxins, those toxins have to be able to eliminated properly. And so when we look at a protocol for somebody, I still need to optimize inflammation, you know, detoxification. The medication alone won't do that. But to your point, could it be a tool? And I think there's a strong argument for yes. Hey everybody, we'll get right back to the podcast, but I do have some very, very exciting news I want to share with you. And that is that my new book, Brain Defenders, that we've been talking about on the Podcast is now available for purchase.

It is going to be published in August of 2026. but it is available now if you want to learn more about brain defenders go to the website and that is oddly enough braindefenders.com uh this is really empowering information as relates to charting your own brain's destiny now let's get right back to Well, hey, everyone. Dr. David Perlmutter here. Welcome again to The Empowering Neurologist. Today, we're going to be joined by somebody that I've known for many, many years. She is at the forefront of really transforming how we think about nutrition, metabolism, and sustainable behavior change.

It's so important.

Weight health and misinformation 1:24

Ashley Kauff, RD, she is the founder of the Better Nutrition Program. and the Nutrition Course Director for UC Irvine, Susan Semwelly Integrative Health Institute's Integrated and Functional Medicine Fellowship. She's also a faculty member at IFNA where she teaches an integrative and functional nutrition approach to obesity and weight management. So very qualified to have this discussion with us today. The author of the very exciting new book that we're going to be talking about today, called Your Best Shot from Harper One.

She has more than 25 years experience. Uh, she's been leading a movement towards the idea of a truly personalized nutrition, nutritional approach, replacing this oftentimes impossible goal that we seem to want to try to reach with respect to achieving perfection. And she has a far more humane and effective framework, which is better, but not perfect. And that allows a really entree for all of us. Her work translates this idea into practical, sustainable strategies that are grounded both in science and in her real world experience in dealing with patients.

through compelling stories and her own journey, she illustrates that optimal health isn't just achievable, but as she says, it's essential for all of us for living our fullest, most vibrant life. So Ashley's been recognized as one of CNN's top 100 health makers featured in InStyle as Hollywood's leading dietician and is widely regarded as the most thoughtful and certainly innovative voices in functional nutrition today. I'm excited to have her on the program. I will let you know I've had the opportunity to speak in conferences with Ashley over many years and very excited Well, Ashley, it's great to see you again.

I think we were together, what, three weeks ago, as it were, in Westmont? Yes. Yes, I wish I was still there, that weather, compared to Oregon rain. Yeah. You did a crackerjack job. Your message, and we will certainly jump into the book here in a moment, but your message is and has been so important for so long. You know, I think things are really aggressive these days in the world of weight loss. And I was planning to get to this later in our discussion, but I just think let's just jump into the misinformation part of the story that people are just overwhelmed.

Even this past week, we've been seeing people that we know being the subject of deep fakes to sell ideas about sea salt and vinegar or whatever it is to help you lose weight. What are we to do? I mean, weight loss is important. It's not the number one goal. I think you made it very clear in your book, it's achieving optimal health and weight-loss is a parameter of that. But what are people to in this world of incredible disinformation these days as it relates to weightl loss? Yeah, It is really hard to parse what information is better and what is not.

know, JJ Virgin, Gabrielle Lyon, like we're so lucky to have these incredible individuals that are helping transform the conversation around understanding that the body's weight is actually a key performance indicator. You know we know that weight composition, so bone, muscle, even our water content and then certainly fat and You may be someone who app in Los Angeles for 20 ye skinny but also have this you may have fat in the ro need to look at this as indicator. I get pushback individuals who come with a size because what they're communicate that the diet industry has led people to such a bad place, a place of how they feel about themselves.

And as a society, really, from choices. I agree with that, but I would reframe it and not say it's about health at every size. It's at about every investigating your weight health and really understand what your body is showing us. So I think that is the message. Take that a little bit further. What does it mean, your, weight, health? Sure. Yeah. As someone who grew up being told that I never had a health issue, but that, I had to wait issue. I was chubby and as a result cute until I about eight years old and then I wasn't cute and it was fat and I teased for being fat.

Rethinking calories and nutrient labels 6:00

Chubby is nice. I'm always like chubbies why at 52 I still get asked if I am 30. It led me to really endanger myself. To not make good choices. You know, I'm lucky that I have a very resilient body and had a support system. But, you know when we look at that, what I really feel like is we have historically been a society that has separated weight and health. And if you have health issue, so if have heart health issues, if a brain health, gut health you saw a doctor for that and you got a prescription or a treatment protocol for, that weight would be in the conversation.

It would, be, you know, and if you lost, if could just lose weight, it would help whatever your condition was, but we hadn't really brought weight health together. And what weight help is, is understanding that your health is inextricably linked to your weight. So weight is a key performance indicator, But it's really that way composition. We never want someone to lose. Weight. We want to come in and we want help you, help your body run better. And in doing so, that means that we are going to lose inappropriate fat and were going optimize your composition and that's a real shift.

So you're gonna optimize health and as that recalibration of body fat, muscle mass, et cetera, is going happen as a consequence, basically re-establishing health. This is a different concept than what people hear about. I mean, I think you have a term infobesity that I, think, you didn't invent that term, as I recall from book was invented, in 19, when was it? So I first heard it. So Dr. Oz, myself, Jeff Arnold, who's the founder of WebMD, we were asked to speak on a panel at the first ever digital health section of the Consumer Electronics Show.

And I heard someone there at that time use infobicity as it related to in the tech world. And I turned around and I said, you know what? You have coined the term for what my patients are dealing with. That was 2011. So at that point, I was already like, people are making bad choices or they're really having decision fatigue, which can lead to bad performance, suboptimal performance because of the amount of information. Then look what's happened in last 15 years. It's an explosion. Yeah. You really call out the idea that people are just overwhelmed by just some ridiculous ideas as it relates to weight in the first place and certainly weight loss.

And I know that calories in versus calories out is something that it's taken a lot of effort on the part of people like you and me. to really let people understand that that is almost meaningless. You know, it used to be back in the day that if you burn more calories, you would totally burn calories then you take in instantly and magically you're going to lose weight. We now know that there's incredible nuances related to that, but what are some of these ideas that are still pervasive that people can tend to glam onto as it relates to health and certainly weight?

Yeah, one of them is staring at us on every package that exists out there. Um, so I, my quote unquote first job, it was definitely not my first shop, but my professional job. I worked in advertising and I had the privilege of creating ad campaigns to sell sugared cereals to America to tell them how good they were for them. Sorry, everybody. It was a short spell there, but I did real good work on that part, unfortunately. But I call the RDAs really dumb amounts. I think that's one of the ones in my chapter, I'll curse you, it's shit to unlearn.

We have to work Um, but the, we moved from RDAs to DRIs. So, you know, just the RTA works better from a marketing standpoint. But if you look at the fact that the one that we use today for magnesium is from 1997, so literally a different century, it's for a 135 pound woman and a 166 pound man. And it suggests that men need 20% more magnesium just based on gender and body weight there than women.

The switch: incretin hormones and GLP-1 10:12

And when we look at that number, even just 400 milligrams, it is so suboptimal when look what the body needs for magnesium. It could be that actually in the 1990s, maybe we had a little bit less stress, but maybe, or maybe 400 milligram was okay at the point. But I don't have a patient that's under 600 or 700 milligrams And what happens is when we take an amount and we come in and say this is the amount that you should go for. We see on labels 10% of your daily intake or 100% somebody thinks, okay, I've met the amount that I need.

And that's really just the need to prevent a couple of diseases. Theoretically, like it just so doesn't understand the body as an ecosystem. What happens when we under deliver the. When we have suboptimal amounts, then the, basically goes through its prioritization. You can't affect how the is going to prioritize the nutrient resources that it has. So it'll decide to relax your heart muscle, but not relax, your digestive muscles. you may experience constipation as a result or you make experience headaches as result, et cetera.

So I would say that's a significant one. Another one that I work on a lot with individuals is we're so lucky to see advancements. I was so excited that when we first had hemoglobin A1C and I like, oh, 90 day average, like instead of finger prick in the moment, but an A 1C is an average. And so I explain, I try to give the people an analogy, the People, they can glom onto. If you get arrested or you got pulled over for a speeding ticket and the cop says, you know, hey, what you were going 65 and a 35. Uh, if you turned them and say, yes, but my 90 day average has been a 30, like you're not going to get out of your ticket.

You know? Like, that's right. Or whatever. Right. On that part. So what we have today is we better ways and we do need to look at what are the trends in your, your blood sugar. Same with total cholesterol, same with weight, even same the total bone density. So I think what we're starting to understand is just where total calories has failed us, we really need to start to be able to decode the body's signals and we just have better ways to do that today. When you were saying something on the label that really gets you, I thought you're going to say low fat.

That's another one. Low fat cookies that have 26 grams of sugar per cookie and are gluten free, so count me in. You just started, I think, giving me a segue to ask you this question, because we're talking about these influential chemicals then in the body. And you do a deep dive into what you call the switch and the leveraging of control over various types of hormones, some of them satiety-related hormones. I you're really one of the few individuals in this area who has really looked at this and not just look at it and recognize the importance of these types of hormones, but are working with this idea to create programs to take full advantage of manipulating these hormone levels to make it easier for people.

So they do feel less urged to eat the wrong things and eat more of those foods. What is the switch in the context of your book? Yeah, thank you. And there's the core reason of this is like I was able to understand who I am as a person, you know, so I like literally when you would go through this, I'd be like, wait, people told me when I you know, people would say to me, hey, Ashley, like, you eat with your eyes, not with you mouth, all these different things. I remember trying like 30 grams of fiber before my meal, literally 30g of fibers before I started my meals so I could try to feel full.

And I was like what is it about this that isn't aligning for me? And the first place for that kind of clued me in was when I actually met an integrative gastroenterologist who said to It isn't what you're eating or what your not eating, but it's that your body, specifically your digestion doesn't have what it needs to run better. So I started my career and literally pivoted and got on a path to fulfill my life purpose by learning that like, Hey, I wasn't fat for not trying. And my belly fat was actually a sign that all those antibiotics that I had been given.

subsequent medications had really shifted the way that my body functioned and my digestion. Years later when I saw my first bariatric patient, this was about 2004, 2005, I was like blown away by overnight how quickly blood sugar and their relationship to feeling full and satiety and this like literally changed. And one of the physicians said to me, oh, you know, it's those incretin hormones at work. and I was like, what's an incritin hormone? Like we didn't learn it. Can you imagine like dietitians, like medical school, we don't about increte hormones.

I know that- Can I stop you right here? Yeah, totally. Because I want all of our viewers to pay close attention. Cause if you've opened the can, open the door, the increten hormones, I promise each and every one you watching, that you're going to be really interested and you'll know why in just a moment because this is where the conversation is going. You got it. Go ahead, Ashley. Yeah. So we have historically, so I was like, ooh, these incretin hormones, like imagine. And I. Was like wait a second.

you mean that for insulin and glucagon, which I had learned about, we had. Okay. Sugar comes into the bloodstream. Insulin needs to. It picks it up. it takes it to the cells. You mean there are hormones that regulate that, that their sole job and what they're not their soul job, but their job is they are the first domino. And I've been starting my conversations with everyone on like Domino Five and not understanding why, you know, maybe the dominos aren't moving forward. Then you mean to tell me that leptin and ghrelin, and I remember learning lepton, keeps it quiet, ghrelin, grr, or that tells you you're hungry.

You means there're hormones to help those hormones go to work? And then here was the biggest moment. Yes, Ashley, and they exist in the lining of the digestive tract in L cells and K cells. That's where they're deployed. that's Where they are secreted from. And all of a sudden my mind blew open and I was like, wait, all the damage that I Was doing to the my digestive system was to The lining Of the Digestive tract on that part. You mean to tell me that the track that's around the tube is actually important?

That it does something other than, you know, just keep everything going on inside the two and it blew my mind open. And so at the same time that scientists were like, oh my gosh, the Gila monster has a peptide hormone in its venom that similar to one that in our own gut. and that it can stay on, you know, can keep somebody in a appetite suppressed state for 30 days. Like, let's go figure out how we can make that, into a medication. I turned around and was like, wait, we have hormones there. So if our lining of our digestive tract isn't working better, or if the vagus nerve that's bringing those messages there, that not working and it just sort of blew open.

And so from there I started on this weight health approach that was to optimize and I realized nobody's ever going to understand incretin hormones. So what if I call them weight hormones? So I used to call your weight hormone. Now I called them your health hormones and started to help people by tuning up their digestive system and then leaning into and as we got more attention to the vagus nerve, understanding how I could optimize the know, et cetera, from there forward. So that's been, you know it's really been 20 years of work saying like, we can do this shot or not.

You know we have a new toolkit now that we could talk about, but a tool in the toolkit. Let me take a couple steps back. Perfect. So you're talking about glucagon and insulin and then you are looking at things like leptin and ghrelin, which are upstream, but you've identified even further upstream a master control area that's involved in these incretin hormones that sounds deeply scientific and in the weeds.

How GLP-1 drugs work and their tradeoffs 18:30

But so that people can see where this is leading, GLP-1 is what we're taking about here, folks. The idea is that what you are describing is gaining the understanding that, you know, this is sort of the master control over not just how the other hormones are working, but things like hunger as well. And as we may or may not talk about, even the energetics of our cellular function in the brain and the rest of body are in some way influenced by the presence or restriction of things, like GLP-1 and GIP.

So that said, that's where we are right now. You're discovering this, I think, before we have access to the GLP-1 drug. So you're really preparing yourself to be, you know, quite the expert once the drugs start to appear and people start using these drugs. Uh, so I'll let you go. Go ahead. Yeah. Thank you. Cause I get so excited. I, I got out there, Mike, we've got this. Those incretin hormones, as you mentioned, the ones, there are a lot of different hormones that are at play with our weight health, but the one's that we can talk about today much more easily.

And yes, there's a GLP-2, I'm not going to talk about it, GLp-1, GIP, PYY, and CCK. And when I started to look at what those hormones do and also what regulates those hormone, it was like this whole light bulb. Now, the reason I call them the switch is in our body, especially GL p1 and G.I.P., they're designed like a motion detector. They go on for two to five minutes and they are deactivated and are meant to do all their work in that time. That worked in pre-industrialization. That works when we weren't getting a stampede running in front of a motion detector, right?

So today we need more of force field. There is no question that the two to five minutes is challenging. And one of the reasons that we see nine in 10 Americans not meeting criteria for metabolic health is because we have too much coming at our systems and our system's are suboptimal. So let me break that down a little bit again for our viewers. What you're saying is that GLP-1 naturally in the body, when it's secreted by being simulated, in presence of a healthy small intestine and actively functioning case cells, that it remains active in terms of doing what it supposed to do for two to five minutes only.

The reason I want to say it that way is because we have to distinct that with the drugs, the GLP-1, as long as a week. Yeah. So that's really key. And in those two to five minutes, we now know, thanks to the drug actually, that we have receptor sites in the pancreas, in brain, on the tongue, the heart muscle, endothelial tissue. There are so many places that this needs to go. So what's interesting about the GLP-1 agonist, so let's just make sure that everyone, I like to have a little lexicon game.

There are types of medicat which means they work and working in the way that it or supposed to work. There go in and stop things fr think of like a proton p might suppress acid or col might stop cholesterol m We're not talking about that when we talk about a receptor agonist. A receptor Agonists means that it is receiving it and it's seeing it as something that I can use and use in the way that the body is intended. So GLP-1 receptor agonists were created based off of the Heal Monsters venom, which is what we'll call bio-similar to our own hormone.

I want to be clear, that's different than bio identical. If you use insulin, if you're a diabetic and use Insulin, or if use testosterone or estrogen, you've heard the term likely bioidentical. That means it's made synthetically, it is made in a lab, but it made to completely work the way that yours does and come in on that. These weight health hormone replacements, terzepotide, semi-glutide. The first one, liraglutides. So you might know Ozempic or Ribelius, or I can never pronounce the names. You know, Wigovia, Zepbond, et cetera.

Those are biosimilar. That dissimilarity, the core dissimmilarity is instead of two to five minutes, they work for 24 hours. and now 24 hours, seven days a week. So they are exponentially, instead of turning something on, switching it on. They're switching on and keeping it. And that dissimilarity has pros and considerations for anyone who is going to use it If you take something in it activate for 2 to 5 min if it's telling insulin to to five minutes, that's i going out and going, hey all 24 hours of the day f your insulin is getting t That's metabolic activity.

And so what I'm seeing in my patients who are using the medication and how when it's working as intended, this is not a side effect. This is working. As intended is that they are staying more in a metabolically active state. and we're seeing less recovery effort for their body. So we'll see heart rate variability or fatigue. And those have been deemed side effect issues, but they actually are, when people are told, oh, you must not be eating enough. That's why you're fatigued. No, the medication is working exactly as supposed to, But it's taking us, instead of being a yin yang in our body in terms of activity and recovery, and it's making us be much more of the time period where we're active than recovery.

So we can go into more examples, but hopefully that helps you understand when something is biosimilar, it is being received and able to be used. But the reason that people are getting benefits is that at that extended amount of time where it's available. It's going all of these receptor sites, but it is keeping those receptor site. So it keeping your car in the drive mode for a long period of times as compared to where your body normally would be without the medication. Hey everybody, we're gonna get right back to this podcast in just a moment, but I wanted to tell you something really exciting about 40 Hertz light exposure.

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Quick note, Evie is a wellness device and it's not intended to diagnose, treat, or cure or prevent any disease. This episode, as I mentioned, is sponsored by the Optosudix company. So if you'd like to try it, go to Optosudix.com and use the code PERLMUTTER26 and get $200 off your order. I think you're going to find this device to be really quite amazing. Let's get right back to our podcast. I thought that the way you approached your discussion on not just the GLP-1 agonist drugs, but people who are using these drugs.

You did it in a very compassionate, non-accusatory, nonshaming kind of way. And I think, to be fair, that's in recognition that a significant number of people are on these drug population-wise. I mean, it's been estimated the next five years, as many as 25% of Americans are gonna be taking these That's a grand experiment. Who knows where that's going to land, but to be fair, the results by some metrics, if weight loss is the sole metric, or blood sugar control, I might add, are pretty profound if you're just looking at solitary metrics like that.

I will also say that I don't know where it's gonna lead in terms of my field of neurology. that the initial studies coming out, for example, in terms of treating Parkinson's with a GLP-1 agatist drug have been mind-blowing. And I've done some podcasts and YouTube videos on this, and I'm not saying this is what we need to be doing, but I think that, to There's a difference between alternative medicine versus integrative or functional medicine. Alternative means you're choosing something else as an alternative approach.

Integrative, means, you are going to bring everything in you can and make your toolbox really big and whatever can help you accomplish the goal. So, I just want to say that I don't take GLP-1 Agonist drugs off the table in terms of something I'm keeping an eye on as possibly having value as it relates to the brain. I think there's something to pick up on that part. So if anyone is selling you a GLP-1 agonist, and literally they are selling, you so I want to be clear, like as someone who has sold you, I wanna be super clear on, that I sell people on better health outcomes.

Brain, detox, and dosing considerations 28:30

Other people, other companies are, selling an ingredient and they're selling it as a solution. It is not a It is a tool and it has pros and considerations. It will exacerbate any underlying issues that already exist and may create others. What's so fascinating to me from a brain health standpoint is it's enabling us to have a conversation first to show people how the brain works, to help people understand prefrontal cortex, satiety and why our food should taste delicious to us. Even the fact that when we're learning that GLP-1 is a neurotransmitter behind the blood brain barrier, and you can't get there with the medication.

That's different. And so there's things that I think are going to be really interesting for us to continue to look at. But if somebody said, like a lot of people are upset saying like oh you know the medication failed to prevent Alzheimer's from further developing and you were like all we aren't looking at it as that was oral semi-glutide that it was or that there was also oral semiglutides but i don't think we see it a singular solution in that so when we look at what it is helping us understand is the importance of regulating blood sugar as an example you mentioned because we we can't have the blood you I think what we also need to give more attention to is detoxification and understanding that when we shrink fat cells, we increase the release of toxins.

Those toxins have to be able to eliminated properly, right? I don't know yet what the increased amount of this circulating hormone would do in the body. Does that need be detoxified in a different capacity? But we can also look at the glymphatic system and even understand detoxification in the brain. And so when we look at a protocol for somebody, you know, I think we really want to look, and I still need to optimize inflammation, The medication alone won't do that. But to your point, could it be a tool?

And I think there's a strong argument for yes. I also get nervous about where the medication is going. It seems like we're going to be allowed to call What is it called? Orgolipron, the new one that's coming out. It's a small molecule, non-peptide, but it's also being called a GLP-1 agonist. Well, that is not gonna be biosimilar to your body. it skips over the first pocket in the receptor site. I can go further down from a science standpoint. So I think as we move forward and we see research and all these other pieces, there's lot that we need to have a knowledge base around and have these conversations to make sure that somebody doesn't feel like, well, if I just take this one thing, I'm going to be, you know, here's the prevention tool, on that part.

Yeah. Well, There is a sense that, well, these drugs should not have much of a brain effect because they do not cross the blood-brain barrier, by and large. Some of the experimental ones are created such that they will. But that's really an interesting commentary because what we know does cross and glucose, obviously, and even inflammatory cytokines. And those, peripherally, in the systemic arena, are dramatically influenced by the use or not use of these medications. So you're secondarily having a huge effect on the brain's immune system, the microglia, via the and setting the stage for mitochondrial enhancement, if you will, when inflammatory cytokines are reduced and when insulin is more functional.

So that's one argument. The second thing is, and I think you made a great point, is that when these individuals lose dramatic amounts of weight, that we store a lot of toxins in our fat cells that accumulate over years. And, you know, years ago, I remember the we had the biosphere where they put these people for two years in a closed environment. And they got very toxic, yet they're eating foods that they are raising them organically and there's no toxins in the environment. They're self-toxifying themselves.

I guess that's a bit redundant, but anyway. So I think it's very important point. that when people are starting to lose a lot of weight, and I know that you pay strict attention to this, it needs to be part of the bigger discussion beyond your work, that, when you're losing a lof weight you are releasing all this accumulated toxin load into your body and you've got to deal with that. The third thought that came to mind as you were speaking a moment ago is that If a given dosage of a drug, semaglutide, or whatever the drug GLP-1 agonist is, is appropriate for a 300 pound person, what happens now to the drugs dosages when they are now 180? That's right.

Should it not be adjusted? Oh my gosh, David, you just, yes, on a milligram per kilogram basis? Yes, You just OK, so you just like unpacked. I mean, and even going back to your comment about this is a huge experiment, you know, it under it belies and not you personally, but the conversation and so much of the critique of we don't know what's happening with this medication. And I understand where it comes to as a society. We've been very concerned about things that are introduced and where's the research in there.

And it doesn't help a lot of people to say that, well, Lear Glutide's been around for 20 years. It has. I've been working with patients on, you know, using Leer Gluteide for a long time. But I do think that I understand that piece. What I challenge though is, we are also in a massive experiment that has not turned out that well with things like proton pump inhibitors and statins. Statins have incredible, incredible value, but the messaging that just the ability to lower cholesterol and also how low do you lower cholesterol or the idea that lower-cholesterol equals heart health, you know, that you're not at a risk.

And so when we have medication, they are an experiment. One of the reasons I practice in a whole person, whether you want to call it integrative functional lifestyle, et cetera, on that part is, my job as a nutrition specialist is to come in and look at, okay, if we're using this medication how is it working in your whole body's ecosystem? And how do I optimize your body around that part? So I think that's the first part of it. The second piece that you just brought up is so important. One of my jobs, and this is why I don't believe that a medical system that has doctors scripting and managing patients for weight health is a good system.

You have to have individuals like myself. This is where nutritionists and certainly qualified nutritionist come in. But is, you know, every patient, like every time somebody is losing an amount of weight, I'm going back to their practitioner and saying, ''I want to look at your SSRI. I want a look your dose of your statin. And I wanna look a your blood pressure medications.'' Like all of those things because if we can reduce those doses, look how we optimize how the body is working. And you're also exactly nailing it, which is we should be thinking about the dose, the starting dose that we put somebody on, but also the ongoing or what I might reference as a weaning dose.

I do work with individual, I work teenagers who are on this medication and I wanna make sure that I have them using the lowest dose possible so that they're actually optimizing their growth and development, including things like bone health, hydration, brain health et cetera, as we go through. So the sort of mass pharma approach to this medication of here is how you do it. And the idea to use research, it's one of the reasons I'm trying to contribute in a research setting is to us the research that just says you go on it, you increase the dose, You take them to the highest dose.

You keep them on that dose and then you have to just stay on that dose for life, that makes zero sense when you understand the body's ecosystem. It never makes sense. Never makes, in any medication. That's it. And it's not just the LB1s. No, anything. There's drugs across the board. Right. But I will say, again, getting back to what you wrote in the book, I kind of got the sense that you felt there was a time or an appropriate situation to use a drug like this. Absolutely. Hey everyone, we're going to get right back to this podcast, but first I wanted to share some information about olive oil.

You know that I love olive. So here's a good tip. The most delicious olive that you can get is olive, oil that comes fresh from the farm. This is when the olive is at its peak flavor and all the nutritional, uh, good things that we talk about, the polyphenols and et cetera are really at their peak. When you buy your olive oil at the supermarket, you are getting an inferior product because they have been sitting on the shelf for months and they basically grow stale. And that's why I've been getting my olive direct from small award-winning family farms, really around the world, thanks to a fellow named TJ Robinson.

I have done Instagram live with him in the past. He's known as the olive-oil hunter. He is able to source farm-fresh oils that are vibrant, they're healthful, grassy, incredibly delicious, and you can use them on whatever you want. On salads, fish, vegetables, meat, even like I do, on scrambled eggs. So if you wanna taste the difference that freshness makes, TJ is going to send you a full-size bottle, which normally will cost you $39. He's going send it to you for free if them just a dollar that will cover shipping.

And that's how he then is able to introduce all of you to this fresh pressed olive oil club, a club that we are members of. So there's no commitment, just send him a $1. He'll send you a full bottle of olive. You just want to go to getfresh389.com. That's get fresh 389 dot com and he'll make it happen for you. Let's get right back to our podcast. I feel like there, and I also think we are such a weight unhealthy society right now, I believe that we could maybe see, if I'm going to go to my Pollyanna super excited, is the invention of this drug going help us create generational weight health?

Can we help parents and adults, especially today, whether it's grandparents caregivers, parents, aunts, and uncles, et cetera, who can then, by being weight healthy, role model for a younger generation and stop some of the role modeling that has occurred and create shifts. And we also know that when a population as significant as the population who is weight unhealthy starts to change their purchase behaviors, we know has an impact on what's made available. We know when they are weight-healthy, they're able to fulfill their life purpose, so maybe somebody is battling their weight health right now and not coming up with a cure for a cancer or whatever it is they're meant to do.

And even those children and young adults that may need this, but the question is, if we start to help people become weight healthy, does that then mean, and we know this from fertility, from looking at men and women that we're imprinting obesity, we are imprinted diabetes in the next generation when we have individuals that are currently weight unhealthy. That's a concept I think that would need some unpacking, that we are epigenetically but able to transmit these, I don't think I can call them traits by definition,

Behavior change, food noise, and emotional impact 40:30

but you're right, this does imprint and becomes transgenerational to, we call this vertical transmission and it's more than one generation. It can be two generations out. But, you know, I have to say as it relates to, okay, now these people have achieved normal weight health and therefore are more able to contribute and participate in life. I, have seen, and I'm sure you've seen as well, direct effects of these drugs on mood in a positive way on depression and have heard that story countless times that, I was fully depressed until I started taking my Ozempic, whichever one it is.

And is that a direct effect of the drug? Is it a secondary effect in terms of its reduction of inflammation, which we know then plays a role as it relates to neurotransmitters and depression fundamentally? Or is it now they're just feeling better because they look in the mirror and they've finally able to crack the code and lose weight? I don't know. But I think it's clear that you've got to be seeing that, correct? Yeah, I'm definitely seeing multifactorial. And I have a couple of suppositions.

None of this is in the research. I want I wanna be clear on that part. But that's your game. Go I mean, we're like, just like whatevs, but here's what it is, you know, so alcohol reduction, and the what people are calling food noise. Um, want to unpack food, noise for a second, because sometimes, again, in a weight bias society, food noises, thought about as, you know, this idea that we're always thinking about food, like that I'm just somebody who, in front of my eyes, if I am a cartoon character, it's like, oh, steak, fish, et cetera on that part.

Food noise is so distracting and keeps somebody from being present in their life that it affects relationships. It affects their ability to, creates decision fatigue. Some people that I know who have suffered the worst from food noise don't have an extra ounce on them of fat. So we see this medication, I'm using this meditation in collaboration with practitioners. I want to be very clear, do not go out and do this based on my wording. But we are using it in eating disorder and we're definitely using also in disordered eating.

We're seeing that also, in a pilot project with individuals with PTSD with some very significant traumas where This is part of the overall treatment protocol there. And so, you know, there's an interesting, when we talk about supposition, which is if we can lighten the load, and I believe, I tell everyone you're going to lose weight reading my book or listening to my books regardless, because when you unlearn that shit that's in there, um, You're gonna be like, oh, thank goodness. Like I don't have to pay attention to any of that.

We have so much that we have get out of our brain that isn't helpful information. But remember the dissimilarity of this medication because it's bio similar. The diss similarity is that it circumvents your entire digestive system. It is not asking your body, it doesn't go into the L cells or the K cells and tell them to produce more. and then have them go through the system on that part, it comes in and by injection or orally goes right to receptor sites throughout the body. So one of the things that I think is happening there is I also think our gut is getting a bit of a timeout.

I thinks it's getting some of repair work that's happening in the gut and the brain connection is actually being allowed to have some you know, some of that time off and some the opportunity. Now, the flip side of is the reason you will absolutely regain weight if you just overnight decide to come off of the medication is if don't fix what wasn't working in your own production and if were not optimizing that, then when you go off something that's going right to the receptor sites, your production has actually been suppressed in that part.

And your GLP-1 and GIP might be the only ones that are technically being satisfied in the receptor sites, but when they're not working fully in your gut, your PYY and your CCK are implicated. So it's also why I see people who are on the medication, maybe having issues with things like hydration, which PYY regulates. When we look at all of this and we understand that, what we can understand is whether you're on this shot or not, we are talking about an ecosystem approach. But when we look at depression, I want to also put this out here, and this is a little bit of a warning that I wish came with the medication.

And the warning is, be careful. You are going to, in doing something that is so helpful for someone, you are in a way about to blow up their world. I say that with very, as somebody who has worked with weight health for 20 years and has battled this myself, When I still, the other day this happened at the conference we were at, somebody came up and said to me, Ashley, like you look amazing. Are you on a GLP one agonist? And she, and she then said, by the way, I saw you a month ago. I think you might be taking too much because look, your clothes are like loose.

And I said where I sit. So first of all, this is awful that you're talking to I didn't have my voice. I was under the weather. Well, no, in that moment. Yeah. No. And I said, this isn't an okay way to start the GLP one discussion. If you wanted to know and ask me, you can ask. Me, I'm not on a GLT one agonist. They said I also am sick and I've been unable to take anything in for 10 days. So the reason my clothes are loose right now is that I don't have a voice. I was so upset. Were you sick at the conference?

I think so many of us were trying to talk. What I brought up to her in that moment was I said, I just want you to know that my whole life I have feared that people were looking at me and were judging at and I knew that they were because They also told me like even a doctor said like you have a belly like, you know, etc on that part. And you need to know that that's like that hurts me. Like, so even though you're trying to tell me something wonderful, You look wonderful. It's not that you shouldn't tell someone they look When you come over and then say, are you on a GOP one, the way that you're saying that makes people like I have people who just feel very like all of a sudden, very uncomfortable.

Okay. That's like very mild compared to what some people are unpacking. And this is my bariatric patients. patients on GLP-1 agonists. They're unpacking sexual trauma, they're packing lived experiences where they were, you know, tortured or didn't have access to food and as a result just scrambled and ate whatever was in front of that, all of these different things. And so one of the other pieces, while we can say like it's great that it may be addressing depression, I also am encouraging practitioners to really ask people about have you felt challenged by any difficult conversations that you're having with people.

People have lost friends. They're like you used to be the friend that would go out and have drinks with me and now you know that kind of thing. That doesn't happen. I mean you do a virtual conference with a doctor in another state, next thing you know, something arrives at your house and you start shooting the drug. There's no discussion about that. That's what I'm trying to change. Why are you overweight in the first place? And are how do we address all the other myriad issues that are going on with your health?

As we start a conversation, this one or probably two, if you consider blood glucose, these metrics, and it's a very, very myopic approach. So I think that what we can say though is, that there is a place here, but the using this drug requires a much more comprehensive interaction with a professional that really isn't happening, especially now that oral semi-glutide is has become, you know, a thing. So, yeah, I was on a panel with some of the individuals who are, and I appreciate what the companies are trying to do.

They're trying make something accessible nationwide where insurance is not making it accessible. You know that opportunity it's built into their sales model to bring it forward and my comment there was if you don't offer services like mine like nutrition coaching and it wasn't just it not like just to sell the better nutrition program I said but you know you should be referring to us or to someone. who does that. When somebody buys a medication from you, they actually are buying a health outcome.

They're not buying just a drug. And you may do great all the way to the bank, to your venture capital, all of these other pieces, but you don't get to stand up there and say you're part of a solution, a nationwide solution in any capacity because you are endangering lives. When you have people and I say this to physicians to I feel like physicians your model like the traditional physician model I want to be clear of providing a prescription sending somebody off and saying like come see me in three months and we'll do away and check your A1C.

That's not okay in this space. This really belongs in the nutrition and the lifestyle, you know, that coaching, uh, space, et cetera. I think that's important. Yeah. On the podcast, I never really, very careful not to get political. But let me just say it seems interesting to me that there is a big push in Washington to liberalize the availability of these drugs at a time when there's question about vaccine safety, for example, or acetaminophen and its relation to autism, that these things are being looked at and yet This drug that is being used by an awful lot of people globally is their efforts to really sanction its much more widespread application with sort of a myopic view of targeting obesity.

That's the enemy. End of story. Well, truly, You know, one of the factors upstream of obesity is our access, our ready access to ultra processed foods, how addictive they can, I can use that word because it's true, because there's salt content, sugar content and fat content.

Personalized care and closing thoughts 51:00

They, you know, they trigger very deeply set, innate responses that make us want to continue to eat these foods and not trigger the satiety centers that you talked about. And yet I am perplexed by this push, uh, for Ozempic for one and all. It seems that it, it's just not in line with the other kinds of pushbacks. Yeah. There seems to be a, so as somebody who has worked in several different administers, in collaboration with several administrations on this key factor, there is, always seems be, when you say perplexed, I say like, don't understand that we are washing our floor with dirty shoes and expecting to have a clean floor.

Like this just isn't, you know, why am I doing what I do and why did I write this book? Because after being in DC for 10 years, and trying with these places. And by the way, creating weight health in so many of our the current sitting representatives, you know, congressmen and women who are still my patients and who were my patience, but who voting for things that were against access and other pieces. In recognition of that, I was like, we the practitioners and we, the public, have to wrestle control of this.

When our Army, at the time, with the head of the Army and he said to me, We really need you, Ashley. We have such an issue with people who are eligible to join our army." And I said, oh, I was like, you don't have an issues with that. I'm like you have issue for the criteria for who should be eligible. You're using just BMI. And he said to me, he's like no one has a good B.M.I. He said do you know that we wouldn't come onto the field in order to play. Our defense should be that we want people to be as strong mentally and physically as possible.

And many people who come into the Army are at this weight health disadvantage. So how do we optimize that? And he's like, ooh. Then I think he was kind of like I don't know if we can do all this. I'm like you can't, but I can. We all can, we come together and we say as a society the shift has to towards weight-health. If this administration chooses to lower the price of these medications, number one, we should be choosing to be lowering the prices of medications across the board, and we shouldn't be putting blame where blame is deserved in my opinion, which is with the insurance companies and with pharmaceutical companies that are creating cost structures that inappropriately disadvantage the majority of individuals, including myself, in terms of the cost of insurance for someone who owns a company, etc.

All of these things, those are the problems. And that's where we need intervention. So if we make it access to the medications better from a price standpoint, we have solved one piece. Like there's one component. If we do that and we don't solve all the other pieces, if with bariatrics, you had to see a dietician and you have to a social worker, otherwise you didn't get approval for this. Why isn't that at minimum included in that part? Those kinds of things. It's only one of a three-legged stool, and so it's not going to stand.

At minimum. Ashley, your best shot, now that we've talked, I love the title even more. Thank you. I get it now, because it gives people their best opportunity, You know, it's looking as rightly you needed to do looking at these GLP one drugs. Thank you for, for joining me. Um, gosh, It's always great to see you. And, uh, I, might be seeing you in the next couple of weeks. Is that I think I'm seeing in that, like, you can't get away from me in next a couple weeks, the, next, a, couple, weeks after that et cetera.

um, and it just, my favorite, one of my absolute favorite things about you is, um. Every presentation I come to, is that. I love humor and humor. best teaching methods. And so your talks are not just engaging and substantive, but they're so, I love how you leave in humor. So thank you. Well, appreciate that. Great to see you again. Thank you for writing the book and just great information. I think it's going to help a lot of people. Well, to be sure, that's a powerful and, I would say, clarifying conversation.

Ashley Koff has provided us practical and really compassionate lack of blaming roadmap for understanding this weight health idea, one that really moves us beyond the notion, as she well described, of this information overload that is so pervasive today and certainly beyond a notion of one size fits all solutions to a more personalized and therefore sustainable approach that's grounded in the way that our bodies actually function. Her emphasis, again, is on better, not perfect. her switch framework that we talked about and her vision for optimizing the body as we described.

An ecosystem provide exactly the kind of clarity that people really need right now, especially when they're being confronted by a landscape filled with conflicting messages about the safety and value of these GLP-1 drugs, our metabolism and nutrition in general. So if you found today's episode valuable, and I hope you did, I cannot recommend her book enough, strongly enough. It's called Your Best Shot and it's rooted in her decades of clinical experience So a very valuable read. Let me thank you all for joining me and really joining us today on The Empowering Neurologist.

I'm Dr. David Perlmutter. Stay well, stay curious, and continue making choices that help you live your very best life. That's all, for now. We'll be back soon. Bye-bye, everyone.