Using GLP-1 Agonists in Long-Term Integrative Treatment Protocols

In this special edition of the Integrative Practitioner Podcast Darshan Shah, MD, and Ashley Koff, RD, join Integrative Practitioner Content Specialist Avery St. Onge for a live interview at the Integrative Healthcare Symposium to discuss how to approach GLP-1 agonists with integrative medicine.

Find us at integrativepractitioner.com or e-mail us at [email protected].

Theme music: "Upbeat Party" by Scott Holmes via freemusicarchive.org and "Carefree" by Kevin Mcleod via incompetech.com.

Darshan Shah, MD is a well-known health and wellness specialist, board-certified surgeon, published author, entrepreneur, and founder of Next Health, the world’s first and largest Health Optimization and Longevity clinic. With expertise in all body systems, he has performed over 15,000 surgical procedures, including trauma surgery, general surgery, and reconstructive procedures. As a health and wellness specialist, he has advised thousands of patients on how to optimize their well-being and extend their lifespan. 

Ashley Koff, RD is a 25+ year personalized nutrition expert. Renowned for her ability to translate nutrition science into deliciously doable recommendations, Koff is a longstanding advisor, educator and strategic consultant for the media, practitioners, businesses, and organizations. Today, as the founder of The Better Nutrition Program, Koff helms a team of clinicians, coaches, and experts to create and implement personalized health solutions at scale. She lives in Maine, plays the trumpet, loves hiking and dogs, is a connector, optimist, and humanitarian.

Transcript

Avery St. Onge: Hello everyone and welcome to this special edition of the integrative practitioner podcast live from the Integrative Health Care symposium in New York. I'm your host Avery St. Onge, integrative practitioners content specialist and I'm joined by personalized nutrition expert Ashley Koff and health and wellness specialist and board-certified surgeon, Dr. Darshan Shah to discuss how to incorporate GLP one agonists into integrative health care. 

Welcome to both of you. Do you want to start out by just telling us about yourself and your work? Dr. Shah, do you want to start?

Darshan Shah, MD: Sure, I'll give you I'll start. So, I am a recovering physician and I would say been a physician for 30 years now, my spend the first half of my career in surgery, I did actually a lot of work with patients that required bariatric surgery. And now over the last 10 years, I fully switched my entire focus on integrative health care, and also functional medicine. And I own a set of clinics, I own him, you know, I'm the medical director of it's not a public-school next town, which is bringing kind of this new thought around longevity, health and wellness, integrative health to the masses.

St. Onge: Nice. And Ashley?

Ashley Koff, RD: I am about at this point a 20 year dietitian, who has always practice personalized. And I was able to do that in my practice and do that at scale and have you know, do consulting and individual stuff. But really, when I looked at the impact that I wanted to have it was on how do we make sure that truly personalized nutrition is a part of an expectation for healthcare across the spectrum, you know, regardless of somebody's demographics, or socio economic level. So I started a company called the better nutrition program where we bring those services to businesses and to individuals and to practitioners in collaboration so that individuals can get that as part of their system. And so that it helps to support the outcomes of practitioners in businesses who are doing things like what Dr. Shaw is doing, where they know that so much of it is once they're once they help somebody figure out what their body needs, the real question is Okay, so now how do we go do that? And how do we get data that helps us understand? Are those recommend initial recommendations moving us in the right direction? Or do we need to pivot based on what's going on for that individual?

St. Onge: Okay, so we're going to be talking about GLP one agonists right now. I guess I'll direct my first question to you, Dr. Shah. And Ashley, you can chime in whenever you want. But for those living under a rock, what are GLP one agonists? What do they do? And what are they currently being used for?

Dr. Shah: Yes, it’s actually not a living under a rock question, because I talk about this about 50 times a week to my patients, people don't really understand what GLP one is. And what I spend a lot of my time explaining to patients is GLP ones are actually hormones that your gut next, and so they don't, I find a lot of people think that you know, hormones are made by your glands and your brain and your thyroid, that's hormones. And we talk about how your gut actually makes hormones that are incredibly efficient at controlling your metabolism, and that doesn't through control of your appetite. And so GLP one medications are basically mimicking those hormones, but it's something natural that occurs in your body anyway. And just like discharge shown or estrogen, the body makes it naturally. But now we're able to provide versions of this that we can use when your body is not making enough of it, or you don't have the desire to. Well, that's kind of how I frame it to my patients. Yeah.

Koff: I mean, I think the the most important thing is to actually help people understand as he was saying that you produce this hormone, and that medications are now a tool that we have in metabolic health and in weight health, to help us help people where dietary lifestyle sort of whole person intervention without the medication may not be successful. And so we want to use this as a tool, potentially long term. We want to use this as a tool in the short term, and we want to be able to help them even if we are using this tool, really help them get the overall benefits that that health part, whether its metabolic or weight is what's so important. And that really comes with a whole system approach to using these medications.

St: Onge: Okay, and so you're saying this, this is a natural hormone, it occurs naturally in your body, so I'm assuming there are ways to increase it without the medication. And so what are those ways? And how effective are they compared to the actual medication?

Koff: Sure. So, I want to back up, it's very difficult outside of a lab situation to assess one's GLP one production. But what we see are the downstream implications, as Dr. Shah was talking about, that are, you know, things like challenged with food noise, not experiencing satiety or fullness, metabolically, maybe even despite trying to eat right, you know, your blood sugar's all over the place, you know, in these things. So when we see that we've got good indications that your system that GLP, one is not functioning in a supportive way, or it certainly in an optimal way for your body, there's an additional part of that, where we can identify individuals who have an increased likelihood for poor production of GLP. One, and that's where if there's injury insults, whether it's historic, or whether it's current or a combination to that digestive tract mining, or if, because of what they choose to eat, or what they're able to consume, they're not able to actually produce that GLP one hormone and have it be impactful and when it's needed, then that's going to be where we want to look at a potential intervention. So if we if we I think we would be foolhardy to try to look at success as a marker versus a GLP. One agonists. So I use an analogy for individuals where I'll say that a GLP one agonist is like four shots of espresso, or endogenous production is like one shot of espresso. One of the issues is that most people are functioning on decaf or no caffeine. So there's a lot of work that we can do to bring them over to that shot of espresso. Its lifestyle and dietary. The good news is, it's not too different from the longevity and the optimal health diet, you know, nutrition that we will focus on, but we certainly do need to be targeted on is your digestive system optimal? Not just oh, is it functioning, okay, like, you know, but is your digestive system optimal? Are you taking medications that can be challenging that digestive tract lining? So we want to look at addressing that? And then how can we use dietary choices that will help to promote that endogenous production also, by the way, things like strength training, which helped to promote GLP one production. So when we look at it that way, there is absolutely there's a pro, there's a protocol that we have, there are supplements, everyone kind of wants to know, which is the such such a flawed concept, there is not one supplement, but there are things that will be that can help be much more targeted in that production. So for my person who's really challenged with appetite, I'll use that hops cultivar, that Kallo curve, that's a GLP one activator. For my people where digestive Lee we're probably not producing the in the lining of the digestive tract, we'll use akkermansia as an intervention. For people that have injury or assault, you know, injury to the digestive tract lining, we'll look at college, and we'll look at glutamine. But in all these cases, Dr. Shaw's like from a practitioner standpoint, my team from looking at the nutrition and their total nutrition as a result, we're also looking at things like are you sub optimal and trace minerals, you know, are you insufficient in, you know, your essential fatty acids, because those things are going to help promote. So it's a long story. You know, it's truly personalized. There are some things that are targeted to endogenous GOP one production, but I'd be very nervous about telling somebody to go buy a supplement that's called that and think that that's going to be like the fix, right? Yeah. Right.

Dr. Shah: But I think it's also just a double click on kind of what you're saying, which I love your analogy with the expression of shots. And so it's so useful to think of it that way. Because when we use GLP ones as for exposure sites to help people get over the hump, okay? Well, you have to realize just like any of the hormones in your body, like your thyroid hormone, your sex hormones, the entirety of your habits, and your health has a lot to do with your hormone production, right. So if you are not eating a nutritious diet, you're eating mostly processed food, if your gut is not healthy, if your microbiome is not healthy, if you have sleep issues, all of those things are going to affect your GLP one production. So what I use it as is kind of a bridge while I'm fixing the lifestyle issues and all the other things from a functional medicine root cause standpoint and use it as a bridge to start making some positive changes so we can start getting your natural GLP production back to normal. I think if you look at it that way, a lot of the kind of a negative things that happen with using GLP is kind of goes away because now you're treating the root cause of why the GOP is low in the first place.

St. Onge: Yeah, that makes sense. So how do you identify a candidate for GLP one for the actual GLP one medication, someone who actually needs the GLP one medication and not just those lifestyle changes, especially when it seems like from all of the research like everyone could basically benefit from this medication. So yeah, how do you distinguish who actually needs it?

Koff: I want to address the, I want to address the second part first, which is I don't think the research does at all valid indicate that everybody should be on it. I think there are based on the results that people are seeing everyone has an interest in it. So I'd love to talk about who is actually a good candidate. 

Dr. Shah: I would say at our clinics, you know, we have six clinics throughout the US, we probably see 100 people a week, looking for GOP on medications, and I spend a significant amount of time talking about a few different things. And also assessing a few simple things to see if you're truly getting it up. Number one is what is your psychology and relationship with food, right? If you're using a GLP, one medication, just eat as much junk and ultra processed food as possible, and you're not dedicated to making your true lifestyle and health change your GLP ones are going to be deleterious to you and cause more problems than good specifically in the in the range of metabolism, where you will now go from maybe having a few extra pounds now becoming skinny fat, where now you have lost muscle mass and fat mass and have more metabolic dysfunction than you did before. Okay. And the second part of this is actually looking at their muscle mass looking at their biomarkers, looking at their free fat mass and their fat mass with a DEXA scan, for example, and really seeing like, how, what is our goal here? Where are we headed? Are we headed toward what number of fat mass? It's not about weight release? fat mass? And what number of skeletal muscle mass and if we're not increasing the muscle mass while decreasing the fat mass, we're going in the wrong direction. And so it's really tying goals to what the outcome is supposed to be. Yeah.

Koff: Yeah, I think, you know, there's not much to add to that other than I think the other piece that we're encountering is people are just coming in on the medication. So there's that side of it, where we can't necessarily dictate who is a good candidate, a lot of the work that I'm doing now is okay, so somebody is either on it, or they're, they're saying I am going to go on, and it's like, that's just that's a completely that's the situation. So where I'm in is the space of optimization. So how do we help you achieve weight health, like we were talking here, you know, a part of weight health is that body composition side, another part is reducing your risk of all chronic disease. Another part is, how do we help you maybe this is going to help somebody be more present in their life or, you know, enjoy, you know, certain situations better, et cetera. So what we want to do in that space is be able to meet someone where they are and say, Okay, so do you understand the totality of what this medication is able to do? What it is go when we and then we experiment by having you on the medication? And then we see here is what it is actually doing for you. And so where do we need to go on this continuum? That is your optimal health journey?

St. Onge: Yeah, that makes sense. So, I said it seems like everyone should be on it because I think it's something that sounds really appealing to a lot of people. It's like, oh, you can lose weight, you can reduce your risk of heart disease, you can, you know, reduce insulin resistance, there's so many things. So I guess why isn't everyone on it? What are the risks to the medication? Why would you want to keep someone off of it?

Dr. Shah: Yeah. So I mean, you have the risks that everyone talks about. And the drug companies are meant to tell you, which is like, you could have nausea, you could have vomiting, you could have, you know, those type of things. If you have a thyroid cancer risk, you shouldn't be taking it. But beyond those risks, the risks are what we talked about earlier. Number one is reducing skeletal muscle mass to where it's actually damaging your metabolism. Remember, you're eating less, right? And so you're eating less protein, and you're eating less of all the other stuff. So your skeletal muscle mass going down, actually has severe metabolic consequences, severe strength consequences on some frailty, and also can lead to bone demineralization as well. You need your muscles, your metabolism lives in your muscle. Okay. Secondly, you get nutritional deficiencies as well. And so this is where I love working with Ashley and, and coaches like basically to help people nutritionists help people mitigate the day to day how to journey and this is not about just getting the medication and giving yourself a shot once a week. It really is kind of a day to day, week to week optimization, getting everything else right. So go the positive direction versus a negative direction. Doing it just willy nilly will almost certainly happen is you're going to become skinny fat where you become metabolically unsound, and you end up having negative consequences on a lifespan health span.

Koff: And I think the other part is, maybe it's also this myopic, or really targeted approach on my weight and my body composition, and not thinking about where am I in my journey? And what am I doing to really look at my health span. So, you know, I actually see a lot of people who now are just consuming so much protein and especially who are on the medication well, one, your digestive health really has to be like really good to be able to digest break down and you know, have that protein go where it needs to go. But if you've traded carbohydrates, and healthy fats, and especially like all the fruits and vegetables, you know, and all those colors, those planty oxidants that I like to call, if you've traded those out for protein, you're trading one issue for another. So okay, I may be able to retain my muscle here and now today, but what is my body's cleanup system looking like? What is my body's cognitive function looking like? What is my body's inflammation, you know, especially the quality of protein, you know, and these sorts of things. So I think that's a risk factor. I think the other risk factor is doing anything, especially weight and metabolic related, where you don't put it in the context of where you are, again, as I said, in your journey, your age, etc, is what what do we actually need to be doing now that's investing in your future. And there may be time periods where your body being nourished is so much more important. So if I have somebody who has Hashimotos, right, you know, or somebody who have hypo thyroid, or somebody who's fighting an autoimmune disease, and they're really frustrated with their weight, I totally understand that. But if I take attention away from reversing disease, and I focus on and I provide a medication that, again, is like four shots of espresso, from a hormonal standpoint, there's any This isn't, we're not at the place where we have a lot of evidence around it, I think it would actually be hard to gather some of that research actually see, because it's a much more complex patient. But I think as practitioners, what we're saying is, hey, maybe this isn't the exact right moment, maybe there's something else we can do right now, for you. And in three months, if we achieve this goal, like if we can, you know, reduce your pain, or if we're seeing that we don't have to increase your medication for rheumatoid arthritis, or, you know, some of these other things, then we could look at that intervention. So I think that this content consistently comes back to the role of the practitioner and the practitioner patient relationship, and how this is about true personalization and a truly personalized approach. Whereas you know, if somebody's online, or unable to get a medication, or if somebody is a doctor, that scripting for this medication, and just saying, I understand you just want this in the here, and now, you actually, that's where we're going to have these concerning incidents that are occurring, that can that are totally prevented. They're almost all preventable. And I think that's the unfortunate part is that I don't want to ascribe side effects to a medication that when used properly, can actually be a very successful tool. It's just the what is that proper usage? 

Dr. Shah: Yeah, very well said, like, I feel like, in the next few months, we're going to see so many articles coming out about how these medications are causing metabolic dysfunction. And really, if used properly and with proper coaching and follow up, it's not as not the case. Yeah, he's just being used in the incorrect way. Just like writing scripts for everybody that's caused that to happen.

St. Onge: Yeah, that makes a lot of sense. Okay. I don't want to keep you guys for too long. But I do want to address this question. So, it does seem like once someone goes off the GLP, one agonists, a lot of the time, you know, the progress they've made is reversed or somewhat reversed. So, what does a long term integrative approach to this medicine look like?

Koff: I think there's like, let's just start with I think, like, sometimes it's healthcare practitioners, we make the conversation more complicated or said differently. This feels very alarmist to see research like this. But if you're on any medication, and you immediately stop it, like think of a ppi, proton pump inhibitor, if I have a patient who just stops it, I got a stomach acid flood, you know, like, I've got it, I've got an issue there. If I have somebody who's on insulin, or Metformin, and they decide to just stop it, I have a lot of people who decide to just go off their statin medication, and they just stop it. So I think the first place is to say is that if you make an intentional decision to go on this medication, you you should be investing in a journey with your practitioner and a practitioner team that says, I want to understand that the different phases of my journey, what's available to me. So someone going off the medication because they've achieved a goal is a totally different situation than somebody going off the medication because they can't pay for it anymore. They don't want to pay for it anymore, because their insurance no longer covers it or because their doctor won't script to them for it right. And what I like to do in the beginning, and what we do as a team is really make sure that we prepare people for those situations. If we have the sense that that could happen and right now it is happening just because of the available already have the medication. So if that could happen, you have to have a backup plan in place. And endogenous production of GLP. One hormone is not on par with using a GLP, one agonist. And that's a silly thing to come to compare. But if we support endogenous support of an GLP one, and what in doing that we're actually helping somebody with healthy lifestyle choices, overall, we have a greater likelihood that they will, they will be at a maintenance more effectively, that is not to say that they will continue on a trajectory where they were before. And if we use tools like a continuous glucose monitor, sensor in specific time periods, or an aura ring, or I do silly experiments, like I, you know, have somebody drink eight ounces of water and tell me if you have to pee within two hours, or I have them bite into an apple and on a scale of one to 10. How sweet is that Apple, you know, like these different things, if we know that we are optimizing there, then we're in a better place so that you have a safety net in place that if you do have to come off the medication. The second part about alternates over to Dr. Shaw about it making you have to be intentional with D prescribing of any medication. And this is the exact same. So we shouldn't be inflammatory about this, like, Oh, my God, people come off the medication and all this stuff happens again. Of course it does. It is a medication that is doing something that that we're not asking the body to do naturally. So what's your approach you into D prescribing or helping people come off the medication? 

Dr. Shah: So, at our practice, you know, we were very intentional about the entire journey. And we do this by having them sign a symbolic contract, actually, with our practicing. The first line is I'm going to go on GLP one medications with Nextel and I'm going to use the time period to change my relationship with food. And then we have a lot of different kinds of Mitch are like action items basically, on this contract that they say and agree that they will do number one is we give them a few books to read, such as food by Dr. Hyman is one of the ones I use I use glucose revolution your book like we give everyone these breathing assignments. Secondly, CGM. So we CGM is, I think, an incredibly powerful tool to understand for your end of one year, one person, how does food affect you? So we use CGM for a certain amount of time and Ashley helps us monitor that. We also have them get a bioimpedance scale so they can track the trend of their skeletal muscle mass and putting these habits into place. And putting these kind of following your health journey with biomarkers and a place from the very beginning really sets us up for the long term eventuality of we will wean you off this medication, although we have very specific goals, we talked about what is our fat mass goal? What is our skeletal muscle, and that's when we start weaning you off? There's one caveat is that there will be you know, we're humans, and we live a life, right? Life goes up and down. There's gonna be situations where you might need to be honest, again, there's not like, you're never gonna take it again. Right. But we do have an endpoint for this first journey. Right? That's how we describe it. 

Koff: I know what you said there, too. Because part of what we're doing is we're helping people use wearables, and we're helping them be empowered with under with with wearables, and like the silly experiments that I was describing, that provides such good information in the moment. And we want them to be empowered to be able to assess themselves to an extent. So I don't ever recommend that somebody uses a continuous glucose monitor without it doesn't have to be my team or without a coach and, or a clinician who knows how to interpret the data, or to have you do experiments while you're on there. Because just that data collection can often have people sort of evaluate things like I had somebody who was like, super upset that after his workout, his content, his blood sugar was high, like I spiked after my workout, it was a great workout. So I had to actually gamify it for him, because if I didn't gamify it for him, he wasn't. So what we did was I said, I want us to aim to see if in 45 minutes you can be back down to 100. And so we played with over the course of the next couple of weeks, what were different interventions that he could do after that same workout to see if he could get down there. So that's what my team we work with the for the glucose monitor. But when we do that we we come in, and we're always saying we're going to give you those experiments and monitor those results. Rather than have you just look at this specifically by yourself. Because humans will and especially the we'll call it the layperson, but even my practitioner colleagues will misinterpret our own data based on our emotions in the moment. So another part of this again, comes back to this entire journey should be a partnership and I think that's one of the things to me that feels I'm not sure how like we go back to the surgery days like bariatric surgery. whatever one wants to say about it was designed and insurance companies dictated and then I think Even people are paying out of pocket followed this model to be a collaborative partnership that was ongoing. And that was it was really important from the beginning, you had a dietician, you had a social worker, you had a nurse, given that the surgeon basically just evaluated how the surgery was doing, you know, never we had the other. We're not doing that in this GLP one space, and it's extremely dangerous. It's extremely dangerous. 

Dr. Shah: I used to do bariatric surgery. And I can tell you that without the team supporting me, so we had a psychologist, actually, on the team, we had nutritionist on the team, we had plastic surgeons, and we have this entire team of people that went through the bariatric surgery journey with the patient and GOP ones are creating the same effect massive weight loss of a small amount of time, and definitely needs a team approach. Yeah.

St. Onge: I love what you said, Ashley, about it being a medication and that with any medication, you go off and the effects are going to be reversed.

Koff: And it’s the same with supplements. If I take magnesium every night, and then I stopped taking magnesium, I'm going to notice a difference. I think there are degrees of severity, you know, on that part. Now, for me, I would probably equate not taking magnesium at night with going off of an agonist because I'd be so stressed about the poor sleep. But I think we have to look at that. And also as clinicians be able to be a voice of reason, in social media, in the media, in these conversations, of saying, like not being part of the fear mongering, that's like, Oh, if you go here, if you go on this, you're gonna have to stay on it for life. No, if you make a conscientious decision to go on this, you need to have a plan as your life habits and that's the same with every single medication. Yeah.

St. Onge: Well, that's really all I have for you guys. Thank you so much, again for joining me, and I hope you enjoy the rest of the conference. 

Dr. Shah: Thanks. Really appreciate it. 

Koff: Thank you. Thank you. 

St. Onge: Thanks for listening. We'd like to thank Scott Holmes and Kevin McLeod for providing us with our theme songs. Be sure to visit our website, IntegrativePractitioner.com or send us an email at [email protected]. Remember to like and subscribe to our show. And stay tuned for more live podcast interviews in the next few weeks.

Editor's Note: Transcripts are autogenerated.