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Written by Erin Yeh
The health care industry has a weight problem, one of weight bias, according to Ashley Coff, founder of the Better Nutrition Program. During her keynote address at the Integrative Healthcare Symposium in February, Cove addressed the urgent need to rethink approaches to weight management, metabolic health, and the use of GLP-1 medications. Healthcare is at a turning point, and rather than introducing new science, Cove challenged practitioners to reconsider where the field is falling short and correct course.
Focus on weight
Koff recounted her personal history as “the first patient.” As a child, she was bullied because of her stomach and realized she had a “weight problem.” Over the years, she’s tried different diet strategies, from commercial programs to cleanses (including a seven-day goat’s milk cleanse—which she didn’t recommend) to disordered eating behaviors. All the while, Cove was regularly taking antibiotics, which disrupt the lining of the digestive tract. At each office visit, the doctor offered the same solution: diet, exercise, and weight loss.
The turning point came when a medical practitioner — not a protocol-focused one — suggested she take probiotics. He did not focus on Cove’s weight. Rather, he was “curious.”
“Whenever I say the word ‘curious’, I think of the amazing leader we heard from, Dr. Tirona Low Dog“The job of the practitioner is to be curious,” said Cove, who taught me early in my career that the job of the practitioner is to be curious.
It was this practitioner’s curiosity that revealed a deeper underlying problem for Cove. Her body lacked what it needed to function optimally. The problem wasn’t weight, willpower, or diet. It was a weakness in physiology. This experience shaped Koff’s professional mission of helping patients improve their weight health.
GLP-1 era
We live in a weight-for-health society, Cove says. She rejected the idea of the “non-adherent patient,” that is, the patient who does not adhere to his treatment plan. Narrating her own experience of seeing patients who underwent bariatric surgery, she noticed a reversal in diabetes in patients and how they reported decreased appetite or not even thinking about food. Initially, Koff thought the small stomach was the main cause, but it was actually the patients’ incretin hormones, including endogenous GLP-1s.
It clicked. Koff realized that her weight composition was affected by GLP-1 not working properly due to several factors, including regularly taking antibiotics.
The advent of GLP-1 receptor agonists represents what Cove calls the “GLP-1 era.” There is no doubt that these drugs have had a significant impact on healthcare and other industries. GLP-1s have taught doctors how the body really works. It not only regulates appetite; They also affect insulin, glucagon, inflammation, bone repair, gastric emptying, hydration signaling, and more. In essence, GLP-1s is hormone replacement therapy. They activate downstream pathways but do not repair upstream dysfunction. An integrative approach will use the tool, while addressing the primary drivers of dysfunction.
“If you use a GLP-1 agonist and apply it as a solution, or apply any medication as a solution “…and you can’t fix what’s going on underneath it…you have to keep working on it forever,” says Cove. “But medicine is one of many tools.”
Cove addressed weight bias, not only in the media and society, but also in medical practices. Often, patients feel successful when losing weight using medications — and stop them — but feel shame when the weight returns. They then feel weak, creating a psychological framework that discourages them from using the tools that helped them lose weight in the first place.
“Where was their practitioner when they got the five pounds back?” – asked Cove. “Where was the system that said to them: Why don’t you go back to using the tool?”
Weight bias has caused patients to feel like failures and doctors not to treat underlying health issues. Cove advocates normalization: if a tool works, it should be used without bias or bias.
Healthcare ecosystem
Koff stressed that health care must move beyond standardized guidelines and outdated dietary reference intakes toward a more individualized approach. “We need SMART goals, not guidelines,” she said. “We need to look at the body as an ecosystem.”
The patient-practitioner partnership is the foundation of maintaining this ecosystem. Koff stressed the importance of training practitioners in the field of nutrition, not just knowledge of it. Doctors diagnose and prescribe; Nutrition practitioners evaluate digestion, hydration status, nutrient adequacy, and life experience. Neither role in and of itself is sufficient to help patients.
Cove introduced the metaphor of “pizza” to organize the intervention.
- Veneer: Digestion and hydration.
- sauce: Improve nutrition.
- Cheese: Lifestyle choices.
- Class: Nutritional supplements, medications and treatments.
She said that there is no healthy or unhealthy food. The key is whether the body is able to extract, deliver and use the nutrients effectively and appropriately. Supplements can support hormone optimization (e.g. probiotics, microbial balance, amino acid adequacy), but supplements are not a substitute for endogenous GLP-1s.
“Hopefully, by this time next year, we will be in the weight health business (rather than) weight management and weight loss,” Cove said. “The introduction of the GLP-1 agonist… is actually perhaps the cutting-edge solution that moves us to a place where patients are empowered to be able to create and maintain their own operating systems.”
