The Four PIllars of Weight Loss Part 2 Save

Hi, everyone. I'm Jack Cush with RheumNow. Welcome to our therapeutic update on obesity. You may have noticed this month we have a campaign on obesity. It's called The Obesity Imperative.

This series of videos is titled The Four Pillars of Weight Loss because it deals with the foundations of weight change that are not medicinal or surgical but are the things that must happen if meaningful weight loss is to occur for your patients. The pillars of weight loss: stress, exercise, nutrition, psychology, and sleep. This leads to lifestyle change, better communication, behavior modification, and all those are more important than anything pharmacologic that you might do or anything the patient might voluntarily do on their own. We need to deal with obesity and rheumatology because it's a major problem. Forty percent of The US population, one hundred million people are obese with a BMI of greater than thirty.

If you include overweight, it's over seventy percent of the population. You are familiar with and very effective at managing comorbidity and rheumatology, but do you really have a plan for obesity? Most of us don't. But yet we know obesity causes disease. It worsens disease.

It handcuffs treatment responses and leads to overall poor outcomes. Despite it being a problem, I don't have a plan. The title of this campaign, The Obesity Imperative, tells you that there's a primacy to all of this. There's an urgency and that there's a need for change both for you within your practice and for your patients because everybody's seeking a better outcome, and this is a modifiable behavior. So we're pulling back the curtain on all the things you don't know.

It's not just going to be about GLP-one therapies and bariatric surgery. It's going be a lot of other things. In this video, I want to give you a three minute script that I've used in discussing obesity with my patients. I think that most of what you would say, Yeah, I discuss it with my patients, but nobody follows my advice. Heck, they come to me, they visit with me, they pay me a lot of money, I write prescriptions, and they don't even take the medicines that I prescribe.

And you think they're going to change because I tell them eat less, exercise more? Well, the interesting thing is that you're pretty good at advising smoking cessation because you know it's important. You're very good at vaccination reminders or initiating the management of high A1C or lipid levels. But yeah, there's a problem with weight loss, diet and exercise. It seems very frustrating, but when I looked into this a number of years ago, I was shocked to find out that maybe the one or number one or number two reason why patients finally lost all that weight they should have lost was because a doctor told them they should.

So what is the tipping point when someone wants to lose weight? It's usually, a health trigger, a health scare. That usually gets their mind going, and that leads to autonomous motivation, where they're going to seek either psychologic or physical, well-being by losing weight. They have to believe that they can do it, that there's a self efficacy involved, that if they could or learn how to change modifiable behaviors, that that would lead to success. They have to be ready, they have to have goals, and they have to have realistic expectations.

The physician's specific advice can't be fighting with them, yelling at them, or telling them why this is horrible and whatnot. You need to feed into the patient's own motivations with supportive information, with a supportive plan. When the patient perceives that you're not judging them, but instead that they trust you and you're there to help them, then you can get to a doable, actionable plan. They know, you know that diet and exercise is very difficult, but what can be done to make it better? The problem is that when you look at what physicians do, maybe a third of physician visits only a third will discuss obesity when obesity is a big problem, meaning two thirds you're avoiding the conversation, and that might be for the reasons I just said.

But when it does occur, it increases the odds of a serious attempt and weight loss success by at least two, if not threefold. The other thing is physicians are underutilizing referral tools, and it's not just for GLP-one therapy or weight loss clinics or endocrine clinics, but we're talking about behavioral programs, weight watchers, bariatric surgery, all the things that they could use to get on that path to losing weight. What you need to do is have a structured program, a script, and lead the accountability, which is really you cheering for them when they achieve success, and underscore for them what the success will look like looking down the road. Of course, all this is driven by good conversation and trust. The pillars of these discussions are often called the five As or the four As, and I'm gonna describe that for you briefly before I tell you my three minute script.

The six As begin with ask. Where are you? What do you want to do? Do you want to discuss obesity or not? Then if they express interest because you're showing in a nonjudgmental way that you're open to this discussion, then second A, assess the patient's risk factors and readiness for change.

Ask for permission to do certain things, to check their weight, check at every visit, to do their waist circumference, which is an important tool. Look for other comorbidities, social determinants of health, and then really set up goals that are meaningful to them, not just meaningful to you. It's not always about the scale, it's about what's meaningful to the patient. The next A is advise on what their options are, advise on what... Maybe you start with advising about the hazards of obesity as far as their health, and then advise on what their options are.

Next is agree on what the goals are, set goals together, that's shared decision making, and after that it's assist in what kind of treatments, what kind of goals. And then lastly, it's arranged for accountability, meaningful follow-up on a regular basis that they know that they're going to talk to you at the next visit about the goals we talked about at the last visit. So here is my three minute script, and I want to start by saying the big mistake that most of us make is either in not initiating the conversation by asking the first question, and that's supported by really not knowing what to ask or not knowing what to say. And the second big mistake is not being specific. Yeah, you should eat less and exercise more.

How many times have you said that, and every person that's heard that says, Well, that was no help. Eat less, be more specific, give them a specific diet. Being specific, being intentional, and being supportive is what will work with you leading the way. Here's a script that I wrote out. I do this often off the top of my head.

I'm going to publish this on RheumNow this month so that you can refer to it, but you might begin with, at the end of your visit, reserving three or four minutes for one other thing. You know what else can really affect your disease, your arthritis? And that's your weight. I know you know that, but is it okay if we talk about this for a few minutes? So then you say, Well, it's not just the weight and the scale that I'm worried about, but I do know what you have already realized, that being overweight makes it really difficult to be active, that you don't do things that you once did.

Because you do less, you get weaker. Because you get weaker, you do even less. Because you do less, you get weaker, and that leads to more pain when you finally do something. It's a downward spiral. I try to teach my patients to get strong, and that would be a great way to relieve pain.

So then you ask them, have you thought about losing weight? What would be a good weight for you? How much weight loss would make a real big difference for you? Your ideal weight would be, and you can talk about that, but ask them what their ideal weight is. Ask them, What have you tried?

What didn't work? What held you back? How did this fail ultimately? Because people who have been in this situation have usually tried several things and failed several times. Then you make the big statement that this is not just about the scale and their waist size or their dress size, you say that extra weight increases inflammation.

It increases the mechanical stress on your joints, both lead to more pain and more disability, and may be why your disease is not well controlled right now. Losing weight isn't necessarily how you look. It's about improving your pain, lessening disease activity, improving the labs that tell us you have inflammation in your body, and improving how well your medicines work. Yes, when you're obese, the medicines don't work as well as when you're not obese. I know it sounds funny, but it's really true.

And when you talk about what they've done in the past, you want to remind them, without being judgmental, that going alone is not the way to go. You know that that has failed. You tried this. You've tried different diets, that may have worked temporarily but didn't work in the long run. So you know going alone is difficult, whether we're talking about diet or exercise.

We do know from experience and research that when you do it with someone else, either with a pal, a friend, someone in the same boat as you, or joining a group, whether it's diet or exercise, you're far more successful than if you do it alone. Secondly, why not see a specialist for this medical problem you have? There are specialists who specialize in being overweight and or obese. There are endocrinologists, but there are other medical specialists who do this as a specialty and that's all they do. You can see a surgeon about bariatric surgery, which helps you to lose weight.

You can see a weight loss specialist who can talk to you about the medicine approaches, which are new and revolutionary and tolerable in many patients that can lead to ten percent, twenty percent, even 30% weight loss, and it can be permanent. So why not see a specialist? This is where you, the rheumatologist, need to say, I'm someone who can do this, or I'm not someone who can do this, and I can refer you to someone who can do this. And again, through shared decision making, you make that decision better. But if you're a rheumatologist and you want to guide weight loss with your patients, you need to have a weight loss clinic.

There's a minority of rheumatologists, and we'll be having them this month, talk about their experience in running weight loss clinics as part of a rheumatology clinic. But they're the minority, but there needs to be the commitment as far as education, personnel, plans, knowledge of the options, for their patients. So you then need to be specific, specific about diet and exercise. I like to advise my patients to, one thing I always say is write down the 20 foods that you eat that you know are going to kill you. Write down the 20.

Twinkies, M and M's, Cadbury bars, whatever it is, and then cross off 10 of them and see if you can live without 10 of them. I mean live without them permanently, not just for Lent or the next six months, permanently. Another thing that they can do is they can track their food intake because you're going tell them eat less, exercise more. They should download MyFitnessPal, and there's probably 10 other programs like that where they can track their activity in calories burned and track their food intake by writing down what they had at a specific restaurant that they went to. It's very effective.

I advise my patients to do that 20 down to 10 foods that'll kill you list, reduce their calories to 1,400 to 2,000 calories a day, and to increase their exercise. But to do these things, they have to be motivated. If they're not motivated, if they're not ready, then it's not yet there. I'm a fat guy. I've always been a fat guy, and that's why I used to play linemen in football and linebacker, but I got up to over three forty pounds, and I was there for many, many years.

My excuse was I had horrible knees and that I couldn't exercise. When it comes to advising exercise, my own story was I'm a jock, I can exercise, and then I'd exercise and I would be disabled for days because I overdid it. I had to start really low and go slow. I had to start on a treadmill, holding on with my arms for dear life to unload my knees and not try to do ten minutes or fifteen minutes. My first goal was five minutes, and I did it.

I came back, and I did it two days later. Then over the course of six months, my five minutes on a treadmill became thirty minutes on a treadmill or twenty minutes on a treadmill, twenty minutes on the bicycle, and twenty minutes on the elliptical. I could get sixty minutes of high intensity aerobic activity. You know what? I lost weight, and I had my knees replaced to two ninety pounds, and I did well for a while, but then I got serious again about the exercise.

I got all the way down to two thirty five, so I lost over 100 pounds, but I was doing it alone. Other than exercise and crossing some things off my no more potato chips, no more cream cheese, that kind of thing, I got up to two seventy again. It wasn't until I started seeing my primary care and she was my motivator. And she sent me to the sleep guy who told me, You got sleep apnea and you need to lose weight and do these other things. And then they sent me to a nutritionist who took me shopping and told me what to buy in the grocery store.

So now with the help of professionals and a plan, I'm much healthier. I don't know what my BMI is, but I'm down to two fifteen to two twenty, and I exercise three, five days a week. I do 20 to 50 miles on a bicycle, but I needed a plan. I tell this story to my patients because I want them to know that I'm in the same boat with them. So if you can share, then I think it leads to trust, and trust leads to them signing on to your plan.

Write down your plan. It's for the patient. They should walk out clutching your plan. I do it on yellow sticky notes and tell them, stick it on the refrigerator. They need to have a to do list, and by next visit, I need you to do A, B, and C.

They need to set goals that they can agree to, you need to provide the rules, and you need to be the source of hope. Last step is to arrange for follow-up that sooner rather than later, when they know that you're interested and you're invested and that you're cheering from them, they're more likely to lose weight that will benefit them, their arthritis, and make your management of their disease easier. Tune in for more of these four pillars of weight loss videos here on RheumNow.

Hi there. My name is Aaron Kheraj Bailey. I'm a rheumatologist and obesity medicine doctor in Vancouver, Canada. I am also doing a PhD looking at the effects of GLP-one receptor agonists in inflammatory arthritis. I'm doing that at Arthritis Research Canada and the University of British Columbia.

Today I'll be talking about building an interdisciplinary programme where we look to co manage obesity and arthritis together. This is something that I've been working on for the last little while and I'm happy to share some of the insights. So a few goals. First, I want to talk about why I think co managing arthritis and obesity together is important. The second thing I want to do is talk about some of the unique needs that a person with obesity and arthritis may face, and how a team based model of care might be able to meet those needs.

I'll end by talking about some potential strategies that can maximise success of an interdisciplinary clinic. So, you know, with the Obesity Imperative Campaign, there's going be a lot of talk about why obesity matters in different forms of arthritis, so I'll keep it brief. The first is for people with different forms of arthritis, like osteoarthritis, psoriatic arthritis, rheumatoid arthritis, axSpA. Obesity is associated with more severe or active disease and more treatment resistant disease. The leading cause of death for people with these different forms of arthritis is also cardiovascular disease, and we know that obesity is an important treatable cardiovascular risk factor.

And when obesity is treated, not only do cardiovascular outcomes tend to improve, but we're seeing from some more recent randomised data as well as observational data, particularly for osteoarthritis and psoriatic arthritis, other outcomes tend to improve as well for people with arthritis. They tend to experience less pain, they have improvements in function, we're seeing some improvements in disease activity with some recent psoriatic arthritis study that put together a PSA study, and so a lot of benefits. It's also important to recognise that arthritis can affect obesity. So this relationship can be bidirectional and complex, and I found it helpful to view it through a biopsychosocial lens. So there are biological factors such as the chronic inflammation generated from both conditions that can increase cardiovascular risk.

Both conditions can also amplify pain, can also affect sleep, physical function. And when we think about this from a psychosocial perspective, both conditions on their own are also associated with higher rates of depression and anxiety, and together that can be a major mental health stressor for somebody. Societally, unfortunately, there's still a lot of stigma around obesity and there's also some stigma around the use of some of these effective newer anti obesity medications. And I think it's important that when somebody comes to receive care for managing obesity, for example, we provide that care in a compassionate nonjudgmental way. And I think that's where the role of an interdisciplinary clinic comes in.

So what I envision is a clinic with a number of professionals with complimentary expertise for providing safe care rooted in motivational interviewing principles. So I imagine a nurse who can perform some of the screening and counseling, one or more clinicians depending on their training who can assess rheumatic disease activity, obesity severity and complications and make recommendations around investigations and management, a movement specialist like a physiotherapist or kinesiologist who can provide tailored physical activity assessment and prescription. You know, we know that when people lose weight, no matter how they lose weight, there is some expected muscle and bone loss that's going to happen. And for a high risk population, such as those with inflammatory arthritis, we want to try and reduce the risk of the development of sarcopenia or osteopenia with weight loss. And so introducing tailored feasible physical activities such as resistance training is really important, and a kinesiologist or physiotherapist could help with that.

In terms of nutrition, a dietitian can be helpful in providing tailored culturally appropriate nutrition assessment and planning. And then for those who need a little bit of extra psychosocial support, having access to a social worker or psychologist can be really beneficial. Now, you may be asking I mean, you may be saying, This sounds wonderful. I wish all my patients could see all of these different healthcare providers, and how do we make this practical or how do we actually facilitate flow through a clinic like this to help the most number of people possible while still providing good quality care? So, from the literature in obesity management, early success tends to predict long term success, and it looks like regular healthcare contacts, that's a facilitator for effective behaviour change.

So again, we want to try and build a model where people can be seen frequently, early on, and they're supported closely during those initial phases of therapy. Now, in order to do that, what I propose and what I'm working on building is kind of a two channel approach. So first patient's interdisciplinary team, they have an intake visit where they're triaged for a session. So some people might require individualised care and that's okay, but there will be a number of patients who could benefit from group therapy. And then those individuals would join a small group, say 10 ish people, and that group will then move through the program together.

Let's say it's a six month program where they're being seen about once a month. And so when they come in for a visit, maybe the group is split in half. Half starts with the physiotherapist, half starts with the dietitian, they switch, they move to the clinician and so on. And that way, not only are more patients seen and can move through the program, but also now these patients start to recognise that they're not alone, they're going through similar stuff to other people, they have similar questions to other people, they can learn from those around them, and they can start to build this sense of community, they feel supported by those around them, and that hopefully will promote an element of self efficacy. So in short, I hope I've illustrated that I think co managing arthritis and obesity together is important.

They affect each other in somewhat of a bidirectional way. And I think an interdisciplinary clinic and this model of care can provide effective evidence based care in a non judgmental way, addressing the biopsychosocial aspects of health. If you want more info about this, please visit roomnow.com. Thank you for your attention.