Dr Rupy: I don't think GLP-1 medications are the answer for everyone, but I also don't think that they're the villain of the story. For many people, they can be genuinely life-changing when they're used with the right support. So, this episode is for anyone who's made that decision or is seriously considering it and wants to do it safely and with as much information as possible.
Dr Rupy: I can't stop you from taking these medications, but I can help you be informed, what to ask, what to monitor, what to eat, and how to protect your muscle, gut and long-term health along the way. Today's episode is all about one of the biggest health conversations happening right now, and that's GLP-1 medications and their sister medications as well. And so I'm joined by Ashley Koff, she's a registered dietitian, to give you the straight dope on what's really going on beneath the surface. Why so many of us are struggling with something called food noise. Why some people never reach that 80% full feeling. And what it means when your metabolic switches, which are the appetite and satiety systems that should be working in the background, aren't firing properly. We break down GLP-1s, starting with what happens in an optimally functioning body, the roles of hormones like GLP-1, GIP, PYY and CCK, and how they influence hunger, fullness, blood sugar and cravings. And we also talk through what side effects might be telling you, what to monitor if you do choose medication, and whether supplements have a role, including the so-called GLP-1 boosters that you'll see everywhere. Most importantly, this episode is for anyone who wants lasting fat loss and better metabolic health with or without drugs. Ashley Koff is a registered dietitian and founder of the Better Nutrition program, and she trains clinicians as a course director for UC Irvine's integrative and functional medicine fellowship. She's also author of the upcoming book, Your Best Shot, which I highly recommend and has influenced today's discussion. It's a brilliant book for anyone who's considering medications or wants more support or just wants to learn more about what's going on with these new medications that are being marketed absolutely everywhere. On to my podcast with the wonderful Ashley Koff. I think you're really going to enjoy this one.
Dr Rupy: Ashley, why do some people never feel full?
Ashley Koff: Well, this is a really, to me it's a really interesting thing. It's extremely personal because I was one of those kids that was told to stop eating and and young adults that was told to stop eating when I was full and I literally didn't know what that meant. So, I kind of thought I watched my brothers and I was like, oh, well maybe it's their amount. And then as I started to watch other young women or even adult women who I thought I wanted their bodies, I was like, okay, well, you know, and I was newly in Los Angeles and somebody ate like two literal pieces of a sushi roll and I was like, okay, I'll just eat two pieces of a sushi roll, like supposed to feel full and I didn't feel full. And so it was just this really like, I guess that's just another thing that's wrong with me, you know, something I'm failing at. So as a practitioner, it was something I really wanted to dive into and understand. And there's modern day associations that are huge issues. So there are messages that override our ability to feel full. There are things we do in food processing where we remove nutrients or we combine things like fat and sugar, and then they override our body's ability to feel full. But what I'm talking about right now is that the body is actually designed with a mechanism to feel full. And it relates to our weight health hormones, and our weight health hormones are due to arrive at our brain, but also our weight health hormones are part of the signalling in our digestive system that helps us to feel full. So what we've identified is at the genetic level and then throughout the whole body's ecosystem, so brain, gut, vagus nerve, all these different things, there can be challenges and there often are challenges. And for some of us they're multifactorial. It's like all of them are working against us in our ability to feel full. So I think without necessarily an understanding or an acknowledgement of that for individuals, we've made people feel worse because we've tried these ideas of like how to help you feel full. And they're not bad. You know, it's great to eat fibre, it's great to drink water, it's really smart to chew more often, to be mindful when you're eating. But if physiologically your body isn't set up to be successful at actually experiencing that fullness, that's going to be a problem. Now, what's interesting in the advent of the GLP-1 agonist is when we have this biosimilar hormone that now goes in and the similarity is it's designed like our own, our own GLP-1 or our own GIP. These hormones, the place where they're not similar is they last for a lot longer. So they last for 24 hours for seven days as opposed to two to five minutes. When that happens, they can go to the brain and the gut and really ensure that our body gets these messages. So what's happening for people on the medication is perhaps even for the first time in their lives, they're able to feel fullness. For me, it was when I was able to do the work, I mean, as a kid, I wasn't dealing with this when the agonists were available. And so I really turned to how can I repair my gut? How can I work on my vagus nerve? You know, what can I do for my brain? And I don't dismiss the fact that doing all of that doesn't mean that somebody can't still benefit even from a low dose of a semaglutide, you know, or tirzepatide. So long answer there, it's multifactorial, but it's so important for us to acknowledge because that isn't a fair message to people, like, oh, just stop when you're full. I appreciate, I think it's a Japanese saying, but it doesn't work for a lot of us.
Dr Rupy: Yeah, yeah, yeah. I I forget the exact Japanese word. I think it's like Hachi Bun or something like that. I actually wrote about it in my, yeah, I I wrote about it in my first book and you know, there's lots of similarities in traditional Chinese medicine, Ayurvedic medicine, you know, it's like eat to the general concept being eat to 80% full. And I guess my question is, you know, what is it about the modern environment that has led us to not feel full? I I gather there is definitely going to be a subset of the population with a genetic abnormality, but over the course of evolution, our genes don't change that much. So what is it about the modern environment that is leading to this phenomena of people not being able to feel full?
Ashley Koff: And I do think it's important to acknowledge the genetics because what we do see about epigenetics is that they can really impact our DNA, right? And so when we think about and in a very short period of time. I mean, that's part of the work of, you know, optimising your your epigenetics and saying like, I'm not going to be destined to my, you know, to my DNA, um, you know, just because of, you know, on that part. But I think that the like the key thing to understand is that our body is designed with a motion detector. So the motion detector, these weight health hormones, GLP-1, GIP, PYY, CCK, it's like an alphabet soup. There's amylin, you know, there are a couple of others. So these weight health hormones were designed really for success, I think in the pre-industrialisation time period where fullness was something a body response that helped us manage our resources, you know, and make sure that, you know, we have food for tomorrow and, you know, these sorts of things. And in those two to five minutes, they were able to be deployed and they were able to get where they needed to go and to satisfy the receptor sites in the gut, the brain, you know, the pancreas, etc. What has happened is today I like to say it's, you know, it's kind of like someone opened Noah's ark and we have a stampede of animals running in front of our motion detector on the regular. It doesn't know what to do. And in many instances, the travel for the vagus nerve in particular, but it's also the bloodstream, the travel for these particular hormones isn't successful. Like it's not getting there on time. So you may not have dysfunction. You may not have, oh, I'm not able to make these hormones or these hormones are not getting secreted. It just may not occur in a timely manner because of overwhelm. So some of the things that we can absolutely do to mitigate that, to work against that is to come in and say, how do I reduce the amount of motions going in front of the motion detector, right? So when I tell someone, you know, the in between eating, like in between your sort of pit stops every three hours, maybe it's not a good idea to be on social media cruising through all of the pictures about food, right? Or, you know, maybe when the commercials come on at night, you want to actually like either fast forward through them or not watch the commercials because if you see a commercial for pizza, your body like go, you know, here we get, you know, stimulation there and those things didn't exist. So I don't think it's a functional flaw in the human design, but I think that we have to acknowledge that society and, you know, all of this access to information and exposure to what triggers our body to um, state to our brain, hey, maybe you should go look at some food or maybe you want to have something, that's going to be really important. And then when we look at the food side and we look at, you know, when we make choices, this is totally in your wheelhouse, when we make choices that have refined out the the nutrients that help our body feel full, that send those signals, then we're going to be less likely to feel full. So this isn't a carte blanche to say to someone, and I think this is really important in the GLP-1 medication era. It isn't carte blanche to say to someone, okay, your system is broken, take a medication, it's going to help you feel full. It really doesn't matter what you eat. That's not, we're not trying to just get you full on junk here. We're trying to get you optimally resourced. So one of the challenges I have for my patients who now are on a GLP-1 agonist, especially if they're on what I think is a too high dose for them, is they literally may not be hungry at all. Like their appetite and their hunger may be fully suppressed. And as a result, they're not optimally resourcing their body. So there's a lot of work, you know, to do to do in here. So again, it's multifactorial. It's not um, I don't think it's a singular piece, but the answer is always the same. The answer is to come back and identify for your body today what it needs to run better. And then my toolkit for you is to say what tools do we use? There's food, there's supplements, there's lifestyle interventions, and then there's medical interventions. What tools in the toolkit do we use today to support you in optimally resourcing your body?
Dr Rupy: Absolutely. Um, before we get into some of the alphabet soup that you mentioned, uh, and and how you describe these like metabolic switches, I want to put to you some of the um, uh, not concerns, but the skepticism around these drugs, right? So you've got Brian on X and or Sally on Instagram and they're they're commenting, look, people don't need these drugs. They just need to do exactly what you told them to do earlier. Get more fibre, drink more water, chew more, get off social media and move. Um, and these drugs are just sort of like a cop out for a whole bunch of people. I'm being facetious here obviously. But you know, what what is your response to this attitude that actually people who struggle with their weight don't need drugs, they just need to do the basics well.
Ashley Koff: Yeah. So, first of all, there but for the grace of whatever you believe in, go I. Um, we are a society that loves to judge others today. Um, we are also a society that believes that we have the answer. We are also a society that believes what has worked for us is going to work. You know, it's kind of like the 20 or 30 year old that is promoting longevity. You know, it's like, I'm real interested in what you have to say. Um, I'd like to see what you're like at 50 and I'd like to understand where you are at 70. You know, I'm I'm fascinated when I talk to an 80 or a 90 year old, you know, and I'm like, okay, I'm interested to see, you know, how you've navigated this. And they always come back. This is on the side of longevity. They come back and they're like, I have had so many twists and turns and here's what, you know what I mean? And so there isn't like this just like pat answer. So if somebody is just like criticising the medication, I come to you and say, I really think it's an important point for you to evaluate your bias against individuals that are struggling with their weight. First of all, people feel that they are struggling with their weight. My, the reason I wrote this book is I truly believe we are in an inflection point where we can now understand that weight health is what it is. It's not weight over here and health over here. You know, I was told my whole young adult life that I had a weight issue, but I didn't have a health issue. Meanwhile, I was popping antibiotics for a variety of health issues, right? So I think that bringing those two together, and there is no other medication that we judge people as significantly with this. We don't tell someone if they're on an SSRI to just go garden a little bit more. I mean, I hope we tell them to take some walks and do all these other things. And I, for, you know, for the love of whatever, between proton pump inhibitors and statins, the people who come forward and feel like everybody needs to be on this. And not only do we not judge the medication for the absolute known challenges. Those are not, those are antagonists, right? They're not even like an agonist in this part. What they're doing in our body is maybe it's course corrective, but they're creating like very specific changes in our body. So the fact that we're that you're only saying this about somebody who is losing weight or where their objective right now is to actually deal with something and there's a medication that can be helpful, says to me that you have a bias. So I'm just I'm blunt. I'm on there all the time on social media like, thank you for acknowledging your bias, right? I think the second part that we have to talk about today, and we in the day of recording this, we just finished in the states, um, obesity week, which is where obesity medicine gets together. And in my mind, it could really in many ways, and this is not to discount the incredible work of practitioners there, but it could also be called like pharma's launch day, you know, because there were 37 new medications that were launched. What's really important is that they are different than if we call liraglutide and Rybelsus and some of the others like first generation GLP-1 agonist, semaglutide and tirzepatide, we could call second generation because they then stayed on for 24/7. We now have third, fourth and fifth generation and this is important. Those are not biosimilar to your own hormones. So those are small molecule non-peptide going into the system. They may work beautifully, they may work more effectively, but when we the reason that I'm so keen on having this conversation around Ozempic and Wegovy, um, the semaglutide and tirzepatide is they are manufactured, they are designed to be received in our body just like our own hormone, but just stay on for a lot longer, which means you're getting, you know, you have the potential to get that higher intensity. So for those that make those comments about that, you know, I just would ask you, what's your opinion on somebody who needs a thyroid hormone replacement or you who are, and I actually know this because one of them is my patient and he went bold on X, you know, he's got a big podcast and all this other stuff. And I was like, you're on testosterone. Like, what are you talking about? You know what I mean? I was like, like this is like we use we use hormone replacement therapy very specifically to enable the body to do things when there's a deficit of the existing hormone. So that like part and parcel right there. Now, are there appropriate critiques? Absolutely. I believe that that's to do with and we can unpack that, the distribution, who is providing these and how they're being used. And that's where I think the rubber meets the road for problem for, you know, problems occurring.
Dr Rupy: Yeah, yeah. And and and we'll unpack some of the the distribution issues and how people can safely get advice about these drugs a little bit later. But I think we're I'd love to just acknowledge that that, you know, people do have biases and we we definitely get comments on that every time we talk about this subject, which is funny considering we don't get as many when we talk about statins and NSAIDs and and all the rest of it. So it's yeah, it's it's really interesting to see this sort of this inbuilt bias from a lot of people. Um, let's talk and I just want to acknowledge this concept, food noise, and I want you to talk to me as if like, you know, I don't know anything about this, all right? So food noise, we've we've touched on it already. Is this what we mean by food noise? The sort of like, uh, I don't want to say obsession, but like this uh this constant barrage of information about food that I just can't get away from or perhaps you can explain it a little bit better.
Ashley Koff: Yeah. I'll explain it through the lens of my experience of it um with my patients on on that part. Um, I think that it's important to actually be comfortable using the word obsession because what we're finding is for people who have different um, I will use the word addiction and use it very much how it's clinically meant to, um for addictive thoughts and then obsessive thoughts, um that in the same part of the brain, these are the receptor sites where those that those we see behavior and, you know, and uh, you know, obsessive thoughts on that part. So what's interesting is, again, bias, food noise is thought to be an affliction of people who are always thinking about food, probably as a result, always eating it and look at them, they're obese, right? And that's the the conversation there. I have so many patients who will tell me that their life has been negatively and continues to be negatively impacted by all of the thoughts that they have about their food and their food choices, um either in an orthorexic capacity because they've, you know, just been trying, so orthorexia being the the diagnosis of somebody who is trying to have perfect nutrition. So they're constantly thinking like, you know, you get up in the morning and you go over to the fridge and you're like, wait, am I supposed to have water? What time is it? Oh, I'm fasting. Wait, I'm going to be vegan, but I'm not supposed to exercise if I'm fasting, but if I put collagen in my coffee, I'm not vegan anymore. Like and then it's just like this all of this thought process, right? So that's one place where it could be. The other place where it could be is the person who has created a um a a like a recent or even a lifelong experience around food where they're thinking about it all the time and exhibiting quote unquote willpower to not make those choices. So what we've identified is and then of course there's someone who is thinking about it um or is being exposed to images, you know, and it's kind of locked in there. The way that I describe food noise is the thought about, we'll call it food, we could also call it nutrition because these days there's supplements in there as well. But the thought about that at a time and space or to an extent of overwhelm where it's negatively impacting your body's functions. So essentially in that time period, you're not in control of the time frame in which you have that noise. You can think about it a lot like stress about things over which we don't have control. If I'm on social media, I was just talking to you about traveling and like all the crazy stuff that's going on. I'm thinking about it all the time. And I realised last night before going to bed, I have no control over it. I can try to do what I can do with my flights, but it is literally contributing to elevated stress for me and that's negative for my gut, right? So that's negative for then my ability to feel full, that's negative for my sleep quality. So I had to unpack it. The same thing happens with food noise. When we are thinking about food, we're not able to be present. So some of the experiences that people will tell me is they will take their kids out to or they'll have at home pizza night. And the whole time that they're having pizza night, they are having a sidebar in their own brain about their pizza choices and they're not even present with their kids or with their partner on that part. And then they're judging themselves for being a bad parent. And they sometimes go into the mode of I'm going to have a glass of alcohol so that I can actually shut off the noise. And then they tell me I went ahead and I had, you know, four slices and now I feel badly about myself and my digestion feels badly. So you can see where food noise can really as a lived experience can come in and it can be again multifactorial. The issue of modern day is the multifactorial nature of all of these things that are impacting our body, right? Food noise in the pre-industrial time period, we didn't have all of these different things to consider. It was literally there's food, I need to make sure it's available, I need to prepare it at this time, I need to make sure, you know, that when it's done, we do whatever we can to protect it for, you know, when it's available again. Like that was it, you know, the extent on that part. Maybe there was a concern about food safety, you know. So when I was at university, they actually did a study um on so it's like it's old because I'm on the older side. Um they they did a study looking at putting, I can't I think it was doughnuts. In my head I may it bagels because I was in New York City, but I'm pretty sure it was doughnuts. And they put it in the centre of the table from a business standpoint and they asked every they went and had a business meeting and they asked everybody afterwards to report what the business meeting was about and then separately to report what your thoughts were about. And it was like one out of 10 at the table who literally just only reported the business. They were like, you know, and interestingly, that person ate some of the doughnut. Like it was like, oh, I got a doughnut, I had a little bit of the doughnut, but like that was the that had nothing to do. Like it was like, here's how the conversation went around, you know, the business meeting. Everybody else had moments during the business meeting where their mind went to the doughnuts, either to choose the doughnut or to not have the doughnut, right? Um and to look at who else was having the doughnut, you know, and to think about like, and it had nothing to do with their weight. It didn't have to do with, oh, you know, the fat person is the one who's looking at the doughnut and eating it. They they had two of them. No, the person who was a heavier weight may have been the person who was sitting there the whole time being like, I don't want to be judged and so I'm not going to eat the doughnut there, but I'm thinking about, boy, I'm going to go get a doughnut or I'm so glad I brought my lunch and it's back over in my room, you know, or whatever it is on that part. So food noise is a really important way for us to understand and food noise is just one part of, unfortunately, the noise of the experience of our lives, you know, that we're carrying. Um, and I think it's a really, I think uh Gabor Maté does a really good job of of looking at this. You know, there's a lot of um and Amy Agapian, these are doctors who have really been focusing on trauma. Our trauma has our own noise and so sometimes our food noise is derived from our trauma. So say that food wasn't available to you when you were a kid, if there's food that's presented in front of you, you have a relationship that goes back to that early trauma and that might be contributing to your food noise. Um and for whatever reasons, again, multifactorial, it's harder for you to turn that switch off on that part.
Dr Rupy: Yeah, yeah. I mean, like there's certainly the extreme end where you just have these constant thoughts about food in multiple scenarios. But I'm thinking about it from a subclinical level as well. I think over the last 10, 15 years, and you can blame lots of different things. I think one of them is squarely social media and even like putting the finger at myself, like this is all we do. We create information uh and we we share content around food and how to eat for health, how to eat for certain conditions, etc, etc. But this information overload and you talk about it in your book, infobesity, it it is certainly something that I think afflicts uh people who don't even have any issues with weight or or food. You know, people asking me in my in my group chat whether they should have collagen or not, uh whether they should be eating at a certain time, if they're going to do time restricted feeding, what should the window be? Should it be 16 hours? Should it be 14 hours? Like there's so many different questions that we're all um asking ourselves and it's I think in in large part due to the uh the information that we're presented to and that we're consuming on a day-to-day basis.
Ashley Koff: I'll share with you, I think I shared this when we did a pre-interview. I definitely talk a little bit about it in my book, but in 1996, I was working for a global advertising agency. So my client was Kellogg's. Um, I also was working on Clairol and De Beers Diamonds and so this was not unique to the food industry, but what we're talking about is unique here. And we came up with something that uh um was to basically figure out like my mission, we called it 360 branding, and my mission was to figure out how we can get you thinking about Kellogg's cereal 360 like, you know, in a 360 circle or 24 hours in the day. So basically it was like, you know, you put this around and at the time, right, there was no social media, there was none of this stuff. So it was like, okay, so when you go into the store, what could we do when you're in the store, right? To direct you there, like so that's like, is it an end cap or is it something on the floor or is it um, you know, when we come in and you and you've got kids, we have the um the cart, uh we create kids carts and we put a, you know, sponsored by this and it looks, you know, there's the fun character that they want to go get. Um and then we're like, well, if you're driving to the grocery store, let's make sure there's a billboard and then let's also be on the radio. And then you're going to get something in the mail and then when you have your cereal box at home, let's remind you to do. And then let's call you during dinner time. I mean, it was all of this, right? So this is that modern day, like I talk about pre-industrial, we could probably talk about like 1970s forward. And this was all before social media. So social media has just, you know, 2011, it was the consumer electronics show. I was on a panel that was like Dr. Oz, it was the head of the American Diabetes Association, Jeff Arnold from Sharecare, uh who founded WebMD. And we were talking about, you know, the introduction of what was now was digital health, right? And we're having this conversation and everyone in the audience is so excited and they can't wait to tell us like about all of their different digital tools. And the marketer in me, like my brain, and that was when I came up with like, I'd heard the term infobesity there, but I applied it to to our bodies because I was like, we're not going to succeed. Like we are going to and this is even if you have good information, the ability, like we have created fully codependent relationships. So your chat right now, I'm being equally offensive, so I'm just very clear on that part. Like all like anytime that we're responding to people, we're facilitating a codependency where they feel like in their moment of stress about their body, they can go and have these conversations and someone is going to attach to them and tell them what to do, right? My job is to come in and to tell you, don't. Don't listen to that person. They don't know you, they don't know your body, they don't know the why behind your choices. So if you want that for entertainment, that's totally fine, but don't do that from a healthcare practice because your body like quite honestly right now cannot stand the consequence of all of this information. And that's what we're really seeing in where we see the diseases of modern weight health challenges.
Dr Rupy: Yeah, yeah. I mean, I'm seeing this across the board. I mean, this is one of the reasons why I don't listen to the news in the morning. And I I used to be an avid news consumer myself, but like I just can't anymore because it just puts me in a bad mood and it lingers at the back of my mind and then like causes worries and then like because I'm just so constantly available to multiple people, like, you know, I I've got this thing at the weekends where I have um what's called a kale phone. Uh I don't know if you've heard of this concept. It was popularised by uh a blogger called George Mack online. Um and there's this concept of the kale phone and the cocaine phone. So your cocaine phone, nothing to do with the drug. Cocaine phone is where you have um all your all your apps, social media, LinkedIn, email, all that kind of jazz. And the kale phone has got none of that. It's a completely different number. Only your loved ones have access to it. Um messaging all the all your sort of essentials, but nothing else. So just pure sort of uh love from your family and the rest the other phone you you put away and you only use during work hours. And honestly for me, using that kale phone at the weekend has just given me so much more space. It's reduced my it's like doing a like a a cleanse of junk food at the weekend, you know, like for my brain. It's just it's been pretty pretty remarkable for me and I feel like we could do that in so many different uh areas of information, one of which being food.
Ashley Koff: Yeah, I love that. I didn't know that's what it was called, but I tried that and I failed. Um it it failed with like I let one friend um who's a friend but also from a work standpoint, I gave them that number and then I was like, okay, so then they texted me something work related and then there was one time where my other phone wasn't working, so I grabbed this one. I was like, oh gosh, now I need Instagram on this phone and you know, boom. And then I like woke up and I was like, wait, I have two cocaine phones. You know, I was like, I got to get rid of like I'm like I got to get rid of what I'm paying for. But I also love like you're a parent and you've got a one-year-old. Um I um I don't have kids but I have my my niece and nephew and then, you know, I have my dog and he was a puppy. You know, when you when you are interacting with a brain of a one, two, like pretty much up to like about a five-year-old and and when you you know have these animals in in their young time period, not to compare the two, but when you are the caregiver in that space, you have a degree of presence that you understand they are like the like they can see everything. So I like there have been times where I'm like, oh, I'm totally faking it. They have no idea that I'm like completely on my phone, not paying attention and they're like, Aunt Ashley, when are you going to be ready to like talk to me about this? And I was like, what? I'm totally playing the mermaid game. Like I'm right here. I was, you know, like and I'm so busted, right? Or I realise that like in a moment I'm missing something because I have that bifurcated attention, you know, and I'm like, I was going to take a video of you while you're running down the hill. This happened yesterday. My friend's two-year-old, I've never met him, came to town, he's going down the slide and I go to take a a video of him because I'm like, she is going to want this. Like this is insane, it's so fun. And he went down so fast that I had I threw my phone on the ground and had to grab him because he was going to hit his head on the back of the slide. And we just like looked up and I was like, oh my God, Ashley, why the video? You know, like on that part. So this I think is like this is the it's such a great way to use things that are non-food related for all the biases, you know, that we carry with us. And one of the things I was so conscious of in the book is not coming in and trying to be like, here's like let me either judge, everybody's been judged. So I'm not trying to judge you. In fact, I'm trying to show you like how to let go of judgment. But we have to work on separating out mindset and act and absolute and fact, you know, so mindset situations could be like, yes, I was the person that battled with this and today these are the things that help me or yes, that used to work for me two months ago and it not working for me today is just a signal from my body. It's not that I'm doing something wrong. So we need to shift to what I call a better not perfect mindset. But I think on the the infobesity side, like if you do one thing from this conversation from your best shot from thinking about weight health, if you become a better vetter of where you invest your resources, your time, your money, your hope, I think that's a really big one, and you only invest in what your um a source that is what I call a bullseye source, someone who knows you, your body and understands your why and then is also going to be there to help you evaluate the ROI of that choice, like, you know, how did this play out on that part, you are going to be so much more successful in being efficient and effective with your resources and and with your health outcomes. So I think that that part of it and it's not for somebody not to enjoy your chat, it's for them to inquire about, you know, through the chat to say, huh, his conversation about collagen is really making me wonder why my mindset, which are beliefs, they're not facts, why my mindset is making me think that more collagen would be better for me, but I don't actually have the evidence. I don't have the physiologic facts that are showing me that when I increased collagen over the course of four weeks or eight weeks, um I had this outcome and so it's a better choice for me right now. I think that's where we can evolve, you know, these collaborations too, you know, in terms of what you're bringing forward and then what somebody actually does with their practitioner.
Dr Rupy: Yeah, yeah, yeah. I think it's about being more scientific about this and actually looking at endpoints and starting places and um, you know, I know food diaries, lots of people have differing opinions of food diaries. My personal opinion on food diaries is that they can be very useful as a means to instigate behavior change, to observe behaviors that you want to um alter or remove. Um uh and uh I I think like the the more sort of scientific we become, um and data driven as well, the the better we can be um confident about our choices as well.
Ashley Koff: I love I love that you um I'm going to double click on something you said because I think that science today um can sometimes be a bad word. So I love that you said like be scientific about it and be scientific about it for ourselves. But also acknowledging that science, um science the research uh that's being done, um large scale research, uh the the coverage, so the media coverage of research, which is usually like a bite, you know, a sound bite, it often doesn't disclose who actually was funding the research. So research scientific evidence is also one of the biggest challenges of to our weight health and and creators of infobesity because there's literally a study for any to back me up on anything I want to say here right now. Like if you like I can be like, oh, there's a study for that, you know, here's this. But when it comes to my patients, I'm often times like, hey, I appreciate that you're bringing forward science, um and I appreciate that someone on social media is talking about science. You are not in that research study. So what we can do is we can use that research study to help inform my train of thought as a practitioner, but as an individual, and there are tons of platforms, many people who I think are phenomenal. Um I'm on a panel with with with several of them in the coming days and it's already come up a little bit contentiously in our pre-panel that I'm the only practitioner and I said, so I love what all of you do, but you're spewing research and my patient isn't in there. You know, my patient is in the yes and, right? And so famously, I had people who um emailed me voraciously, very angry about a study, I mean, hundreds of emails about a study that came out about omega-3s being bad for prostate health. Turned out the study was not well done and it certainly was not covered well in the media. So I spent a day because I'm I'm known for for my work in that space. This was like 10 or 12 years ago. Um but I spent a day like literally just doing media. So I then I went home and I'm like, oh my gosh, I've all like I got to get back to all these people. I'm willing to go like 70% of them were female. And I was like, okay guys, like so um a study about a prostate should just be like a like unless you're emailing me about someone you love who has a prostate um or someone you don't love or whatever, but someone who has a prostate, like we shouldn't be diving into this and you spent the entire day angry and doubting your choice and it was a bad study, right? So I think that's one of the other pieces. Um we're seeing that a lot right now in the states where a lot of, I think this extrapolates across the world, but where people are asking you to be pro or anti a particular study. And I'm just as a practitioner, I am, you too, we are curious about a human and we use evidence, but then we come in with our curiosity and we're like, hey, how can I apply that evidence? So I just want to double click on that because I do think that people there's um in this world of podcasting, there are a lot of people who are telling you what the evidence says and that that should apply to you and it just unless it's an N of one study that's done on you, it's not going to be what applies to you on that part.
Dr Rupy: Absolutely. Yeah, yeah. There was I mean, we always refer back to this BMJ study from a few years ago about the term evidence-based medicine and it's not what generally people outside the field would imagine. It's it's not just looking at the data and being driven by specific guidelines. It's a combination, like a Venn diagram if you like, of yes, the data, the patient's experience, the patient in front of you, and also the practitioner's experience as well. Um so it's, you know, when the confluence of those different things, that's how we practice evidence-based medicine, not just blindly uh being led by a study, um especially like with with the the number of poorly done nutrition studies out there. Um on the subject of stuff that you hear in the media. So 2026, I think is going to be the year where lots of people are sort of beaten down by the marketing around these GLP-1 medications and the like. Um and are going to try, you know, trying to get access to some of these or at least learning more about them before they embark on their own uh journey. I I want to start, you know, um by talking about these medications more broadly, um where they came from, as you've done in your book, uh and then sort of uh diving into how one might think about this from a intuitive point of view, a scientist's point of view when you're doing your N of one experiment, um and how they can look to to get this support that sort of that bullseye, that that that person that can be their their rock and their anchor for this.
Ashley Koff: Yeah. And let's try to do it as as simply and I will challenge myself to do it very um directly too because I like I look, I wrote a whole book on it and I audio record the book. If you want to hear my whole story, like on it, you know, we we can unpack it there. The I while I was traveling down this path of understanding our body's weight health hormones, um, you know, key markers for me, I go through my own story, I go through helping people with digestive health optimisation and seeing them improve overall with weight and other other factors. Um one of the big awakenings for me was when I had a bariatric patient and I saw like the first handful of them and I saw almost immediately, you know, these changes, inability to feel full, inability to, you know, have uh just altered thoughts about food, you know, like all the different things, you know, that we're talking about. So for me, that was a wake up call to understand what was going on in the body where the rubber meets the road in the human body is that our weight health hormones, even when they were 100% optimally functioning, um and that isn't just the production and the deployment and the secretion and them getting to the receptor sites. It's the whole, you know, them being like all of those pieces, right? So when we look at all of that, they only last for two to five minutes. And that means and they're then degraded by an enzyme. So what the people who ultimately discovered the ingredient were looking at is, I wonder what else exists in nature that could potentially extend this. And the extend, that's actually one of the medications, extend is in the name, right? Because it was like, hey, if we could take two to five minutes, what if we could keep it on for a day? And then it became, what if we could keep it on for longer? And they're looking around and trying to figure it out. They even tried medications and they still exist that would challenge or turn off that enzyme that degrades our own. But what we found was that didn't extend the life of the others, you know, of the ones that uh weren't degraded successfully. Um I think that also tells us a little bit about the whole system not working and not not just being the hormone. So it turned out uh and I think this is like super cool. Um and it's a fun way to win a a conversation if you will at the dinner table. When people say, oh, those GLP-1 agonists, they're snake oil. You can say, no, no, they're actually Gila monster venom. So the Gila monster is a prehistoric animal um that I think is has provided us with a modern day tool uh to our modern day weight health problems. So it's kind of interesting on that part. By design, the Gila monster doesn't want to, it wants to be in a cold, dark place by itself. It doesn't want to go outside to to look for food. It risks, you know, death, um being, you know, and it's in crazy heat, you know, in the deserts and these sorts of things. And so it was designed with what I wish they would find a way to mimic, which is the ability to um eat the fat from your tush so that you don't have to eat food and that's what gives the body, you know, what it needs. But it also interestingly uh has in its venom something that is biosimilar to our own hormone. Uh so the the way that the peptide chain, so the amino acids in that part, the way that they're designed, they they saw the similarity there enough so that so that our human body could, you know, could receive it. Where that one stayed on for 30 days. And so what they did was they went back to the lab. I think they're still working on a 30 day or maybe a six month, you know, on on that part. They went back to the lab and they were able to figure out how to manipulate those amino acids into a form that where it could now be received as biosimilar by the body and it would not need to go through your body's own pathways. So it totally circumvents your body's own pathways. And it goes in and it stays on for about seven days. Now, anything when you get the medication, um it goes in at that dose, it's going to be a higher amount and then it's going to decline from there. So we also see that with people's symptoms, you know, and other stuff. So that discovery was the creation of a biosimilar hormone. As I've already commented on, now there's all sorts of other discoveries. So the one thing that I would say to anyone hearing this at any point in time moving forward is know whether or not what you are taking and what you're agreeing to take, whether it is a biosimilar hormone or whether it is a different kind of medication. And that's going to help you understand how it's actually going to impact your own body. But it's really cool to think about, you know, that as a design and again, just noting, we do this in multiple places, you know, in terms of medications. I can also acknowledge that the same thing would be happening. If you took a teaspoon of sugar and you created Splenda, it is the exact same process. You go in and you look at the molecule and then you say, huh, what if I could change the molecule so that I no longer have calories going in, you know, no longer have carbohydrate going in, but there's still going to be sweetness and what ended up happening is it's it's more intense, right? It's thousands of times sweeter. Um and we would make the assumption that if we put that into the body that it's it's going to satisfy us from a taste standpoint, but it's obviously going to do other things. And so with the medication, it's obviously going to impact things um more, you know, in a more significant way because of the intensity of what has been created.
Dr Rupy: Yeah, yeah, yeah. And and so so this is the the the whole class of medications, but there's so many different names out there and I just want to give clarity to to folks when they hear GLP, GIP, like all all the stuff like fourth generation, fifth generation now that you've been telling me about. So what what for for navigate help us steer the the ship here.
Ashley Koff: Okay, I will. Yeah. And depending, um you know, I think depending on when this is out, I'm actually working on a um so one of the things that I did with my book is I it I knew that I can't put everything in the book and have it time stamped. I mean, you know that. Like as soon as your book comes out, something else. So we have a there's a QR code in there and there are all sorts of resources and you have access to a health coach. So a lot of great things. Um but one of the resources I'm in the process of creating is a um a spreadsheet that shows this so that people can understand what to be thinking about. So that will be available to your listeners. You know, I'm sure I'm not the only one, but I think through the lens of of weight health I want to share it. So that first example, the extendtide and the liraglutide, what we were talking about there, those were injections and those were created and they stayed on for one day only. So if you were doing an injection and those were mostly for diabetes because they they didn't see the same extent of what I'll call quote unquote weight loss, even though I don't want that to be our goal, that's what they were what they've been approved for. So if something, if you're taking something and you have to inject every single day, then it's most likely that's in that class. I also have to acknowledge, um I have a little bit of dyslexia, uh I don't pronounce things properly and sometimes I don't read them properly. So if I say the name and it's like kind of in the zone, that's where you should be thinking, right? Okay, so we can we can handle the rest offline. So with those um medications and then we moved into, so I called those the first generation. And that was the single injection, there was nothing that was oral on that part. And then we moved to semaglutide and tirzepatide. These are agonists, they are peptides, so they are made of amino acids and they are um meant to replicate your body's own, but they're biosimilar, not bioidentical as we talked about because they stay on for longer. Semaglutide is only a GLP-1 agonist and tirzepatide is GLP-1 GIP. And that is the difference between a single agonist and a dual agonist, okay? So when we have those, those are injections and those injections have been where they stay on for roughly somewhere in the neighborhood of about um seven days. So you're probably doing a weekly injection. There might be a case where somebody is using a lower dose and injecting twice a week, but you know, there there's that space. And boy, are there a lot of names. Like so there's Ozempic and Wegovy and Zepbound and um I there are a bunch of them. Um they're also to make things like totally worse is uh in terms of trying to keep up with all of this, they also are um have been available in vials um either from a compounding pharmacy or even from the company. And so they might have different names there as well. So especially, this is a huge buyer beware, if you're getting something and you don't know what it is that you are taking, you have to find that out because that's going to actually tell me what it's doing in your body. It's not a side effect, it is the actual effect of the medication. So those that category there, and I would call those the second generation because we went from one shot from a shot once a day to a shot once a week. Those medications are going to be ones that are significantly delaying gastric emptying because instead of delaying it for two to five minutes, they're now delaying it for 24/7 on that part. Um instead of uh making you metabolically active for two to five minutes, they're making you metabolically active for 24/7. So they may have implications on your sleep, on your heart rate variability. They may have all these wonderful implications of helping to address um gut inflammation and blood sugar, you know, because they're telling insulin to go to work, um telling talk to glucagon, so those are your hormones that regulate blood sugar. They also are impacting bone and also muscle and the type of fat mass that are allocated. So there's a lot going on in that part. Uh appetite and hunger, which we you know, we've talked quite extensively about. So for those, what you want to think about in your head is the difference between two to five minutes and 24/7. So if we look at that, what it is going to do is any underlying dysfunction, it is going to exacerbate. So if you already had a delay in gastric emptying or if you already had bloating or you have acid suppression or you are already constipated or you have loose stools or you um already have difficulty sleeping or you already have a low heart rate variability for a variety of reasons, it's going to be exacerbated. In some people, you might not have those existing, but it might create those because now the body is working in a different way, right? So I think that's really important. So then when I get into the third generation, the third generation are what they now call triple, quatro and maybe quintuple, like so they're agonisting all of these different things. So this is the one I can't pronounce. It's like retatrutide or retatrutide, anyway, it's the one that starts with R and it's got a tide at the end. Um it's a triple agonist and it's moving beyond GLP-1 and GIP into glucagon and glucose and really looking at that part more specifically. And then we get over into a whole other class of medications which are being called um small peptide, small molecule non-peptide. The reason for non-peptide is they wanted to make it oral. And the ability or like a peptide molecule is very, I don't know that we can, I might be, I think I would misspeak if I said absolutely, but I think the challenges to make something oral that are the peptide are much more significant. We see that in other peptides like BPC-157 and others where it's newer on the market and we're not necessarily seeing the oral do the same that the injectable did, you know, so we're we're just looking at at those differences there. So that would function in a different way in the body. And then we also are seeing ones that are attacking um in a good way, um potentially, uh agonisting um and I assume there will also be antagonist, which I'll come to in a second, but things like amylin and other uh hormones that we know a little bit less about, you know, and kind of how they work. So I suspect that what we'll also see in those is that they have a direct impact on certain areas of the whole weight health ecosystem uh and maybe um for certain people with with, you know, conditions specific, there may be advantages to using them or um, you know, but there could also be other disadvantages. I use the term agonist and antagonist and I just want to to sort of clear up the lexicon there. GLP-1 medications right now are called agonists and that means they're aligning with what the body, that's why they're biosimilar. They're aligning with what the body does and helping to support the body in in doing that function, likely at a to a larger extent. When you have an antagonist, it's coming in and it's saying, hey, I don't like what's happening in the body. Boom, let me, you know, let me antagonise that, let me cut that off. So again, there you're going to have very different functions, you know, for um for medications. And my personal bias is that we have the people who have dismissed, um I will say this is a professional bias. Those that have uh dismissed the history that we have with liraglutide and semaglutide in particular, but with the biosimilar peptide hormone replacement therapy and said like, oh, these medications are new, we don't know how they work, what's going to happen to people. I think they were incorrect and I feel like that has been a messaging that has been problematic. Now, we don't necessarily know everything about how they're being used today compared to how they were being used, but we have a lot of information on uh and again, from research studies, which you may or may not be as a patient, you may or not be in them, but we also have a lot of evidence-based practitioners because we've been using these and we also have been understanding, you know, we've been adjusting them in patients and you know, things like that. When you get into small molecule non-peptide, we do not have the history there. Those are new medications. They may be similar to other small molecule non-peptides and we can get some learning from that, but I think that that's going to be a space where we are going to want to proceed very cautiously. In my, that's how I'll proceed with them professionally.
Dr Rupy: Gotcha. Okay, that that was amazing. A real like uh expert's layout of the land in terms of all these different drugs. And I appreciate that that last bit about the degree to which you're comfortable using certain medications given the the amount of history that we have on side effect profiles and safety profiles. Um so what I'm hearing is, you know, some of the first gen that uh we were using in type two diabetics, you know, the we we know a lot more about how these drugs are working. The newer molecules, particularly the non-peptide oral molecules. Are they are they coming on the market soon? Because I
Ashley Koff: Right now.
Dr Rupy: Oh, right now. Oh, right now.
Ashley Koff: Yeah, right now. So that's the um everybody's like and and I'm a little bit concerned about, I mean, I think that the data, you know, they've done their diligence from a data standpoint, but they're they're coming out to the market pretty quickly.
Dr Rupy: Wow, okay. Um okay, so that that I mean that's for me as a as a practitioner, that's more concerning I would say than the than the um the GLP-1s becoming more available. At least we know how those work and we can tolerate those, but um okay, um so in terms of who, I mean we've talked a lot about the the the sort of underlying issues around how people can't feel full, the food noise, um who are these and given what we were just talking about evidence-based medicine, you know, it really depends on the individual. Broadly speaking, when should people be thinking about some of these medications? What things do we really need to make sure that we've checked off before we even consider what is available in the drug landscape? And I know you've talked about in your book, you know, the obviously there's dietary changes, there's mindset changes, there's also supplements. I'd love to to dig into that sort of the the pre-game before, you know, getting to the main event if you even need to attend the main event.
Ashley Koff: Yeah. And boy, I wish I had the luxury of like having every patient just follow like, come in, let's work on this, then let's move to this and like, you know, it's like usually I'm getting like most of my patients are, oh my gosh, I've been on this, I'm not losing or I was losing and I stopped or, you know, I was on this and I had to come off of it because I like I'm, you know, my digestive system is a mess or you know, all of these different things, right? So I recognise that, you know, when we like I just again, I meet someone and I'm curious. Um if I had the ability to meet you in a moment where you're in the consideration mode, the number one thing I would ask you to evaluate are your financial resources. And that might sound kind of silly, but let me unpack it for you. If the medication, even if you're getting this medication from insurance, you need to be able to work with someone like myself, my team, um a physician, a health coach, like a combination, someone who can help you throughout this journey because this is something that requires constant check-in and it should require a multidisciplinary approach. As an example, I as the dietitian would say to my patient after 90 days, I'm so excited, you've lost 10% of your body weight, or maybe it's let's say it's 180 days. I'd like you to go back to your physician um because you have been on a statin and that statin was dosed according to your weight or it was dosed according to your cholesterol. And I'd like to ensure that you're not on too much medication now based on an update to where you are because that could be negatively impacting more things in your body, you know, etc on that part, right? So that's like an example. Another example could be as you change your dose, we could see as you go up on your dose or even the decision to go up or down on your dose or extend the amount of time, any of these things, we should have a plan and a conversation about that because if it alters your sleep significantly or it alters your digestion significantly, we don't want to cause a problem that uh where for your weight health system when we're trying to optimise your weight health system. And then the third one is we have to account for either your insurance no longer covering you, like and almost immediately. They're not giving people like a ton of time, you know, I mean, maybe it like three months, which could feel for them from a business standpoint like a lot of time, but for you in terms of access, like it's not going to be a lot of time. So you need to be able to afford the medication or to have a plan, you know, in place. And then on top of that, you also want to be able to work with someone when you achieve where you kind of want to be, assuming that you achieve that, to figure out what that maintenance plan is, right? So we're not when we move from losing fat, retaining muscle and bone to um or if we're using it to address inflammation or if we're using it to reduce cardiovascular risk or whatever, we want to consistently, you know, be evaluating that. And I in the ideal world, like I would be paid for by your insurance. Um I'm not. Like that's like I'm only paid for in a very small amount of cases and usually for like one session, you know, like they think I can just like wave a magic wand and, you know, tell you everything you need to know. So I think the financial part of it is going to be really important um in that space. And one of the reasons I lean in a little bit more on the dietitian and the health coach side is because at every step of the way, you're going to be peeling the layers of your onion to understand where you want to make adjustments in your lifestyle choices and that's going to be important for you to be able to uh work with someone on, you know, where it's like, if we use the analogy of stopping smoking, it may be that the situation of everybody takes a smoking break has been what has kept you smoking because you don't want to be the person who's not going on the smoking break. So now we have to figure out for you what's what are you going to do in lieu of the smoking break, right? And so those are some of the things that, you know, we really have to be able to to help you and and work through. So I think financial assessment is is really important. The second one is at every stage of being on it, you do need to be, as I just was talking about, monitoring your body's physiology. So in the ideal world, that's before you go on a medication. If you go before you go on the medication, if we can at least know, I don't have to solve it, but if we can at least know if there's underlying gut dysfunction or gut challenges that are going to be more challenging for you, then we can work a little bit on um at least giving like what I like to do, I call it scenario storming. I'm like, okay, in the event that you're flying, um like if you know you're flying on Wednesday, I say with a giggle right now because some of my people are flying on Wednesday or maybe going to get out on a Friday. But what I was just doing with my patient was um we switched the day that she got her that she gave herself her shot this week because normally she does it on Tuesdays and I don't like her to fly the day after. So instead we did this one on Sunday so that she had a couple of days after because the experiencing the experience of a long flight is very delaying on gastric emptying and then you add the intensity of the medication and it would have worsened, you know, gas bloating, constipation, you know, some of that stuff. So when we look at when we're able to be proactive about that, we really reduce the side effects and we optimise your ability to to be able to use that on that part.
Dr Rupy: Yeah, yeah. And and just on that point, Ashley, um as we bring this to a close, I know there's so much more I'd love to talk about, but we're we're running out of time. Um when people are on these medications, I guess the pushback that I've certainly heard from my colleagues, um are that you you really can't tell the individual to start consuming more of the right foods because they're they've got their arms tied behind their back. They they can't physically consume any more. I mean, I I'm speaking about this with no experience of of a patient on a GLP-1 medication. So I'd love to learn a bit more about your your thoughts on that because and I think that's certainly what people would imagine because these are drugs that impair appetite.
Ashley Koff: They're on too much medication. So I like I can answer that one flatly. Like you should not be so the same thing would be, imagine if we like so to try to come around the bias associated with like all of this comes back because it's like we talk about and this is not you, this is society, these people who, right? And it's like our hands are tied behind our back. We never say this with statins. Like I have people who are on a statin and they're down to 20 of their LDL is 20. And they have no testosterone, right? And I'm like, you got like we have got to like like you are on too much and unless I have like and this is the practitioner's uh, you know, I am not the the cardiologist there, but unless you can you can validate for me why 20 is so much better for that patient than 80 and not because the drug companies are telling us that we can just lower and lower and lower the amount, but that really the whole ecosystem, right? Because we know low cholesterol does not make you heart healthy. Like it is a factor in that part and certainly not just low LDL on that part. And so, you know, in that space they're on too much medication. So if I have a patient who is on a a semaglutide or tirzepatide and they are incapable of getting in an optimal amount of nutrition for their body between food and supplements, they are on too much medication. And that's a conversation and that might be a life conversation, you know, it might be, hey, for a period of time, this is how we're going to do it. I'm I need you to have um let's use somebody who uh I had a guy that um he uh a famous actor who I worked with him on a a movie and he had his jaw wired shut. He played a villain and so it was wired the whole time. And uh but he had he needed to look he needed to look and be ripped. He was still deciding, we were trying to convince him not to do a lot of the um not a lot of his own stunts because I was like, I don't know how I can nutritionally meet your body's needs, right? But he was so muscular. And so we were like, he was like freebasing protein drinks. I mean, we I it was I was like, okay, like if first it was every three hours, then I'm like, I think it has to be every two hours. And then I was, you know, adding in like electrolytes between that, you know, and all this other stuff because I'm like, I can't meet your body's needs, you know, and this is like we're not getting in like delicious food at this point. But we got to figure out the reason we have parenteral nutrition is when somebody can't take in food orally, we will do IVs or you know, we'll bring food in in other ways. And so I think we have to remember that that a medication that stops somebody from eating and even I would I would offer that the medication is the wrong dose and I will say this to my patients, if they do not eat regularly throughout the day. So a lot of them will tell me they're not hungry at all and then they're just eating at night. And I was like, no, you are screwing up your sleep, you're screwing up your digestion, you are committing yourself to never being able to come off the medications. We're we're killing your metabolism. Like I can go on, you know, inflammation is negatively impacted. So I can go on and on on that part. So we have to be comfortable saying that you the amount that you should be on and you know, it's kind of like it can feel very attractive to people to see an HOV, right? How many times have we been so in the states we have these highways that you can drive on that if you have two or more people in your car, you can go and and or maybe sometimes it's three or more people and you can drive and it's like less crowded, right? And it's a way to get away from the traffic. And if you are only one person, like how many times are you like, I just want to go in the HOV lane, right? Like we all want to get there faster. When it comes to your weight health, the answer is not always to take the it's almost always not to take the HOV lane. So slow it down, reduce the dose, maybe put more time between the dose and let's give you time where we can actually nourish your body.
Dr Rupy: Yeah. Ashley, um thank you so much, honestly for your time and thank goodness you wrote a book uh for all the extra questions I haven't asked you. Uh your best shot, it's out right now in January across the world. And uh if you enjoyed Ashley's voice, you could uh hear her talk about it as well and talk through the book. But thank you, honestly, you're awesome. And uh if we have any more other questions, I'm going to ping them to you and then we can do a part two or some social content as well.
Ashley Koff: I I love that. And for everyone that feels like this doesn't sound doable, the book is the flip side to everything I said here on the actual what is doable. So hopefully that makes everybody feel better. But thank you so much for having me. And I do love your podcast because I think that people are really getting what they need to uh vet their choices a lot better. So I really appreciate what you do.
Dr Rupy: Epic. Thank you. Appreciate that.
