The Four Pillars of Weight Loss Part 4 Save

Everyone, my name is Lourdes Perjcada, I am an assistant professor in dermatology at Harvard Medical School, and I work as a clinical researcher at the Brigham and Women's Hospital in the department of dermatology. And today I'm going to be talking about sleep and obesity, the role of sleep in weight management. So today I would like to discuss an increasingly recognised component of weight regulation and cardiometabolic health that is typically not so discussed and people are not so aware of, which is sleep. We traditionally approach obesity management through nutrition, physical activity and pharmacological interventions. However, sleep is another potentially modifiable behaviour that deserves consideration.

And for our patients with rheumatologic conditions, this is particularly relevant given the frequent coexistence of sleep disturbance, pain, fatigue and increased cardiometabolic risk. Starting with epidemiological studies, there is evidence that short sleep duration, which is generally defined as less than six hours per night, has been associated in a study with eight percent higher relative risk of central obesity. Importantly, this association in this study was persistent even in studies that had excluded BMI in their adjustment models. Although these findings cannot establish causality between these associations, they do suggest that insufficient sleep may be relevant not only to overall body weight but also to abdominal adiposity. Experimental studies build on these findings.

In a randomised controlled crossover study, healthy adults who were restricted to four hours of sleep per night for two weeks showed to have consumed approximately 300 more calories compared to the control group who had adequate sleep duration. This addition in calories per day was also happening in the context of increased energy expenditure. But perhaps the most interesting finding of this study was that there was also an 11% increase in visceral fat, was measured using abdominal CT. So this suggests that insufficient sleep may influence not only weight gain but potentially also where fat excess is accumulating, which has important implications for cardiometabolic health. One limitation of these experiments, however, is that they involved fairly extreme sleep restrictions, as I mentioned before, for four hours per night for two weeks.

So there were other studies in which they modified sleep but more in the moderate side. So there's a particular study by Surrey Kat and colleagues in which they examined a more moderate sustained sleep insufficiency, including ninety five adults. So what they did was they reduced the sleep of these individuals by seventy eight minutes for six weeks and they observed that this resulted in greater body weight, increased waist circumference and also more sedentary time. Interestingly, hormones such as leptin increased alongside this weight gain, but then there were others such as ghrelin and GLP-1s that remained statistically unchanged. So these findings suggest that even modest chronic sleep insufficiency can adversely affect weight regulation through mechanisms that are more complex than we anticipated.

Then it is also important to note that the metabolic consequences of poor sleep extend beyond weight gain and energy intake. In a recent systematic review of randomised trials, they found that sleep restriction also negatively affects insulin sensitivity. Importantly, these effects were not limited to sleep duration. They also observed adverse outcomes with circadian misalignment and suppression of slow wave sleep. So this, put together, reinforces the importance of considering sleep health as a multidimensional construct.

And not only that sleep duration is the domain that is associated with these adverse cardiometabolic outcomes. And so why does insufficient sleep influence eating behaviour? Traditionally, we thought that increased hunger was happening through changes in grilling and lepting exclusively. However, in a recent review it was shown that increased hunger does not always translate into increased food intake and that people may also eat more without feeling hungrier. So the mechanisms underlying these associations still remain unclear.

And there seems to be a place also for behaviours such as food reward and the opportunity to eat more when sleep is more restricted that may be playing a role too. And all this data that I just shared with you then raises an important question. If restricting sleep promotes weight gain, can extending sleep have the opposite effect? So Tassalli and colleagues tried to address this question through a randomised trial in which they examined eighty isles with overweight who habitually slept less than six point five hours per night. And following individualised counselling, participants slept one point two hours longer per night and consumed approximately two seventy fewer calories per day compared with controls.

And this was without changing their diet or their physical activity. So this ultimately resulted in a modest short term weight reduction. These studies were further complemented by other studies that show that behavioural sleep interventions reduced caloric intake by approximately 150 calories, with some improvements also in weight and BMI, particularly among people who were obese. However, we should say that overall the results are inconsistent and that long term studies are still necessary to determine these associations. So what does this mean for our clinical practice?

I think that there are three main messages that I would like to share with you today then. First is that sleep deserves consideration when discussing obesity and cardiometabolic health, including not only sleep duration but also other domains of sleep such as sleep quality, timing, regularity. Second, that insufficient sleep may contribute to adverse metabolic outcomes through several interconnected pathways, including increased energy intake, changes in adiposity and impaired insulin sensitivity. And finally, that improving sleep may support existing weight management strategies, although it should not be considered as a standalone treatment for obesity and more evidence is needed to truly demonstrate this positive effect. So with that, I'm going to conclude this talk on obesity and sleep.

I hope that this information was useful and interesting to you. If you have additional questions about this topic, please refer to the RheumNow website for additional details. Thank you.

Thanks so much for joining us. I'm here today with Anastasia Amaro, one of our endocrinologists at Penn. I'm Alexis Agde. I'm a rheumatologist and epidemiologist at Penn. I treat psoriatic arthritis in particular, and we've been thinking a lot about obesity in psoriatic disease.

Anastasia, her specialty is obesity. So can you tell us a little about you and what your practice looks like? Then And we'll dive into our question today.

Excellent. Thank you, Alexis, for having me. I am an endocrinologist and obesity medicine specialist. I direct the Center for Nonsurgical Weight Management Center here at Penn. So we do all kinds of obesity management in people with and without rheumatological conditions, in people with cardiovascular disease and without it.

So obesity and complications of bariatric surgery if people have them.

Great. Well, so one of the questions that we as rheumatologists are always getting stuck with is how do we bring up obesity with our patients? And actually, I talk about obesity and psoriatic disease, this is one of the most common questions that I get from other rheumatologists. I'm really nervous to bring it up. Patients sometimes have a bad reaction to it.

In general, as back up before you even address that question, what do you want to tell other specialists about that are not obesity specialists about talking to patients or considering obesity in their patients?

Thank you, very good question. So I think I would like to go into briefly into two different directions. So one direction is not really involving the patient here, just a message to non obesity medicine specialties. The problem with obesity, one of the challenges we have studying obesity is that obesity has been severely undercoded. We can recognize obesity as clinicians, but we don't put it on paper.

We don't assign code to it for many different reasons. We can dive into them, but not necessarily so. But if there is no code, health studies are very difficult to conduct. It's difficult to convince third party payers to participate in patient care if obesity is not listed as the chronic disease. So I would urge and I would ask non obesity medicine specialists and primary care physicians to incorporate diagnosis of obesity in their portfolio.

Diagnosis is simple. It's E66, I think, and that's it, a couple digits after the dots. You can select non specified, that's totally fine. But that E66 will get a whole lot of information for public public health research. Please use

your problem list and make sure to diagnose it. I think that's actually a really important point is making sure that you're calling it out for the patient and the people taking care of them and you're calling it out as a problem. So you put this ICD code in, what are we telling the patient about it or how are we going to talk to Exactly. The patient about

So this is a very good question. So you put something on and patients may not be happy if you don't discuss it. So the way I address it in the first place, at the moment where I have to code for example and this is where the conversation begins. I say, well, your body mass index is thirty two and that's what is defined currently in our vocabulary is obesity. Would it be okay with you if I put it in your chart?

So overall approach to breaking ice about any new condition would be ask, tell, ask. So first, you're asking for permission. They say, okay, put it on. If they say, don't, I don't want to go there. You're done pretty much.

You cannot force things onto someone. But if they say, okay, yeah, I'm fine. It's actually I'm glad you bring this up. Then it opens up an opportunity to say something else. So that's your opportunity to make a statement.

And then of course, you know the patient. Let's say it's not a new patient for you. So you have established relationships, know their own engagements in their healthcare. So you can make a more or less scientific statement outlining the problem, saying something like excess weight is associated with difficulties treating arthritis or we have seen that weight loss has helped people with their joint pain. So something you can expand on scientifically if patients so desire.

So if you catch their attention, the next question, then the next after the statement is the next ask. Would it be okay if we discuss your weight in the context of your rheumatologic condition? So I think this is a very simple tool and if we train ourselves and each other it it, it will help us a great deal.

I love that. It's so simple. Ask, tell, ask. And yet I don't do it very much. I think I do the tell then ask, which I really like that as an opener though.

The general way I have done it is when a patient is not doing so well on therapy, I might say, can we talk about the other, I guess maybe I'm asking about it. Maybe I say, I'm going to tell you a little bit about the other things that may contribute to lack of, to this therapy not working as well as it is, or maybe let's explore some other ways that you might be, we can maybe get you feeling better. And then that's where I'll talk about anxiety, depression, obesity, other things, and say, maybe we can pull on this string a little bit and can we talk about that a little bit more? I think I probably too often do the statement rather than the question. So I think that's a really great point.

You

it, you do it. I think it's hard to kind of start from a question from like out of nowhere. It's still going to be continuation of your previous discussion, you know? It's not going be the opening paragraph of your day of your encounter. It's probably naturally coming to that.

So statement questions, statement questions.

Yeah, that's a great point. Well, I think that's actually a great thing to leave people with. So ask, tell, ask, thinking about the questions in there and kind of that opens the door for more discussion. And like you said, many patients want to talk about this and they're just waiting for the opening. Actually, one specific anecdote is you and I were just on a different meeting earlier today and one of the patients said, I was nervous to raise it with my doctor.

And to me, that kind of blew me away a little bit. I was like, What are the people you're supposed to ask? Like, so, But they don't always know that. So asking will open the door for them to be comfortable with that. And I have seen that several times in practice too.

Yeah, that's absolutely right. And so even probably if you'd like to continue in the topics of different language used in our medical and in our communication with the patients, it's probably of I find helpful is going away from standards, from, well, it would be nice to lose weight and reduce calories or increase physical activity. Nobody knows what that means and they've seen it and heard it so many times that I doubt a sentence like this would cause anything but resentment. Know, 80 specific is better than general statement. So if you have the bandwidth, if you have the extra two minutes, select something one and make a specific comment.

If there is no specific recommendation you feel comfortable about, make another scientific statement to kind of keep people engaged or have them reflect on what they do or have them do a Google search or AI search in a more strategic way after speaking with you. So yeah, kind of specific and going away from

generics. Perfect. Any last thoughts you want to leave our rheumatologists or any of our listeners with?

Rheumatologists specifically, one more thing you can do, and it could be an introductory statement in all of those conversations actually. People who used to receive steroids, you can admit that steroids may have affected their metabolism or may have affected their appetite or may have affected their weight. Therefore, do you mind if we talk about metabolism or weight? So kind of admitting that steroids have done some, well, were unnecessary evil, but they may have affected patients' metabolism. So it also takes a little, may take a little bit off that guilt sensation that it's going to be all about their discipline and routine.

It's not about discipline, it's not about willpower. We're going talk about obesity as a medical condition. We're going to talk about obesity as a disease. It's not going to be a talk about willpower.

Perfect. I think that is a great place to leave our rheumatologist. So to summarize, we talked about making sure you're making the diagnosis, code it. Number two is talk to your patients about it and use the ask, tell, ask approach. Use a scientific statement or something that's going to pull them in.

And maybe use the experiences you know they've had, like history of glucocorticoid therapy to say, we know this is hard. This is not a willpower thing. This is your metabolism. Can we talk about how this might influence your disease? So thank you so much Anastasia for joining me today and thank you to our listeners.

Thank you.