The Four Pillars of Weight Loss Part 1 Save

Hello. Welcome to our RoomNow podcast on obesity. My name is Doctor. Philip Meese. I'm director of rheumatology research at Providence Swedish Medical Center in Seattle.

And we're here today to talk about the four pillars of obesity management, which include nutrition, physical activity, behavioral support, and medical interventions. And I'm joined by a wonderful colleague, Juliana Simonelli, who is the director of the Obesity Care Program at the University of Utah. And as we have been working to develop content for this RheumNow month focus on obesity, it's just been a delight to get to know the deep knowledge and wisdom that comes from Julianna.

Yes. Well, thank you so much, Doctor. Meese for having me here today and for to be sharing the stage where we're talking about obesity care in rheumatological conditions, and in particular with the four pillars of obesity care.

Giuliano, what is it that constitutes these pillars? If you could give us a brief outline.

Yeah, so really we're talking about nutrition, physical activity, behavior support, and medical interventions, is truly comprehensive. We're talking from medications to surgery, whatever interventions we do have available. I think it's truly focusing on the idea that is not one single treatment approach, right? That we truly have to use this comprehensive approach in caring for patients with obesity. In particular, when we're thinking of obesity and rheumatology, we have these mutual reinforcing mechanisms and overlapping inflammatory pathways for both conditions.

So, again, looking at obesity in a way that makes sense as we would treat any other chronic condition where the basis of everything that we do, it is lifestyle intervention, and then adding on layers to that as we need to be addressing the underlying physiology as well. We know from studies such as the Look Ahead trial patients who they have followed for many years, who have diet and exercise, when they do that alone, eighty five percent of those will have weight regain within a year. So again, highlighting the importance of addressing the underlying physiology of obesity, but not forgetting that we also have to intervene and make recommendations for dietary interventions, for physical activity, as well as for the behavioral health aspect of the disease.

Thank you. Well, let's focus on that first pillar, nutrition. Of course, in virtually every visit in rheumatology, our patients ask us, well, what can I do to decrease inflammation, improve pain, improve my function? What diet should I follow? And we always have difficulty with that because there's so many diets that people run into on the internet.

And of course, they're getting advice from their uncle and their sister and so on. The little bit of evidence that we have, we could say something like the Mediterranean diet has shown some ability to be associated with reduction of inflammation. But how do you go about yourself talking with patients about it and what team do you work with in this regard?

Yeah, no, I think that's a really important question and something we get asked all the time. I often have patients who come into clinic and say, what I heard online is, and in particular with Instagram and the popularity of a lot of fad diets, and we have heard that over the years. What we do know that what's most important beyond a diet itself is their ability to continue to follow a healthier eating program. So I think that's really key. So in clinic, we tend to focus on a higher protein, higher fibre, lower carb diet.

And we know that there is some data for the Mediterranean diet that is supportive to showing some decrease in inflammation. However, I see such a wide range of patients. And unfortunately, more recently, I have had so many patients that can afford really healthy foods. So really working with what we have is key. And instead of saying I'm taking it away, I say the idea is not a diet, right?

It's not like when we think of diet is like this restrictive, I'm not eating enough to then lose weight. We're really thinking let's have healthier foods that are gonna really help with our function. And in particular, now with GLP-one based therapies where overall induces satiety makes people feel fuller, so they're not eating as much. So first we recommend that they avoid skipping meals that they eat consistently and eating more during the day makes more sense. So some people go all day without eating and eat most of their meals at night.

We know based on studies, circadian rhythm studies, that as the sun goes up, our metabolism is up. As the sun goes down, our metabolism is down, much better to eat more during the day and less in the evening. So eating more consistently throughout the day makes more sense. Leaner proteins, higher fibre, and lower in high processed foods. And also avoiding liquid calories.

I think that's the easier target here. I have some patients that drink quite a bit of soda or juice. So we really work on where we can focus and then making changes at each step and each visit. We don't have to change everything at once. As I'm getting older, I'm seeing how habits are so hard to change and we cannot relate to that, and particularly eating habits.

So really making smaller changes throughout and seeing what they can incorporate that are healthier and overall focusing on how they're going to feel better. So by eating less sugar, they tend to feel better and less inflammation. And I think that tends to work really well.

Well, those are some really wise comments. Thank you very much for that. And it helps give us some perspective and language in speaking with our patients. A similar set of issues with the physical activity. Many of our patients want to know what can I do safely?

They have a bad knee, if they have an Achilles tendonitis, synthesitis problem, then they're often very fearful about doing appropriate exercise. So one of the defaults that we in rheumatology will always acknowledge is get in the swimming pool if you can, relatively non injurious to lower extremity joints, great conditioning for the whole body, but it's not very practical, especially here in the Northwest. So we do encourage regular physical exercise. You have the as with all of your patients with our obesity issue, there's a lot of stigma being in the gym, undressing in front of other people, getting in the swimming pool, or they may feel too tired or too not able to do like go out and play pickleball. What do you end up recommending and how do you recommend it?

Yeah. So, I think the first thing is acknowledging how difficult that can be for someone that is already having a lot of pain in particular difficulty with their mobility and their physical activity abilities. So acknowledging that, and then I usually tell my patients, anything is better than nothing. So even starting with chair exercises. So in our clinic, have made a handout that I give patients with bands and chair exercises that is very easy and that they can follow.

And in addition to that, I often will refer patients for physical therapy whenever they are able and that's possible. I know that sometimes co payments can be quite expensive nowadays and many of my patients say they can't afford the co payment and they would prefer not to go to PT. But if they can, I will refer them to PT? I think water exercises, water aerobics is great. One thing that I will add, and it's key as we're treating patients with the GLP-one based therapy is our concern for loss of lean muscle mass.

General, as we lose weight, about a quarter of that is to be muscle. And to prevent additional lean muscle mass loss, we have to eat enough protein and they have to do resistance training. For the resistance training with the pool therapy, there are some tools that they can use in the pool to add on resistance. And I have some patients that do that. I tell them to use weights, heavier weights on their upper body if they can.

And if they can use their legs and do lower impact, they might be able to do a stationary bike with some resistance. So key is that they have to do at least two days of some level of resistance, even if they start. And I say, do you know you could do anything for five minutes? I waste plenty of time looking through my phone and social media for a few minutes a day. So any one of us can do anything for five to ten minutes and really getting them to feel better.

Also, sometimes we focus more on the nutrition to start with, and as they lose some of the weight, it makes it easier for them to move. So just adding, being incremental in their ability to do physical activity. Also recommended some additional resources. There's free online resources on YouTube. There are some free apps, the Nike training app, it's a good one.

There's some other paid apps that are not, they're about $28 a month. So like the Peloton app is another really good option. And it gives you many, many, you can pick many different options there. So those are all really I tell them this is key for success and key for them to keep on those medications is that they really need to do a resistance training. Cardiovascular is also really important and that we can maybe do with, like you said, with swimming or stationary bike, impact for that.

Terrific advice. Now for the third and a very important pillar is behavioral support and dealing with the emotional issues that beset individuals who have both rheumatic disease on the one hand and then obesity on the other. That's a double whammy. Already we know that patients with psoriatic arthritis, psoriasis, rheumatoid arthritis, lupus, they have already higher rates of depression and potential suicidality than in the general population. And then if you add to that obesity, then it's just really amazingly a big issue.

We have the advantage in rheumatology of having sometimes extremely long term relationships with our patients. Some of the patients in my practice I've been with for thirty years. So, we share intimate moments. We share intimate conversation. So, we are in a good position along with perhaps a psychologist or psychiatrist that might be helpful to us or a chaplain to provide and to talk about and provide emotional support.

How get into this? How is it with your patients?

Yeah, no, I think this is a very, again, another very important issue. We know that obesity increases the risk of depression while depression also increased the risk of developing obesity. Is this bidirectional similar to what we see with rheumatological conditions? And having that relationship. And I think approaching the patients in a nonjudgmental way is really key, in particular when you have had this long relationships with the patient.

Most often the patients that have obesity come into the office saying, have experienced a lot of stigma and obesity bias as they are seeking care. I have patients that say, I come for knee pain and all they tell me is that I need to lose weight. Like I didn't know that if it was that easy, I would have done it. So really coming from a nonjudgmental way, I usually first, and I think at least they're coming to see me obesity management and weight loss. But in the rheumatological office, I think first asking permission, we do have better tools now to care for obesity, and we are here to help and support you along the way.

Is that okay that we talk about this and try to address some of those issues? So I think first asking permission to talk about it is key and then telling them, why are you concerned? Because this might impact your treatment response, might lead to worse health outcomes, and I'm concerned. And this is how I can help you. And I think presenting that way it's very important.

I think other factors that we do see that from a behavioral health perspective that can impact overall outcomes both for weight loss, but I think for the rheumatological conditions in thinking of inflammation in general, sleep is a key one. Patients, I think with, right, oftentimes during they have pain, fatigue, have problems falling asleep, staying asleep. So in patients with obesity are also at higher risk of developing obstructive sleep apnea. So every patient that comes into our clinic, do screen them for obstructive sleep apnea doing a stop bank questionnaire, which is a really easy questionnaire. They answer and I just put it on my note.

And if they're intermediate to higher risk, I will refer them to do a sleep study. In addition to that, obviously giving recommendations and keeping a consistent schedule, all the behavior things that we do know and to recommend not being on screens right before bed. Even in my house now, have lamps instead of over light lights, because we know that the light can impact on how awake we are and can really interfere with our circadian rhythm. And why that's important is because we have plenty of data and plenty of research now showing that even one bad night of sleep that can lead to abnormal, additional weight gain. There was one study that looked at healthy individuals that if they slept less than six hours, just a few times per week, they gain as much as two pounds per week.

I know, so they say equivalent, a bad night of sleep is equivalent of eating a big mac, right? So this idea how important sleep is in behavior, but we know it is also important for pain control, for mood. Really working with patients in this other pillar, it's very important.

You bet. Thought you were gonna comment on teenager's screen time, but Oh

my gosh. No, I mean, it's a constant battle at my house. So he's like, why can I not be playing video games late at night? So yes, yes. We turn off the internet at a certain time at night.

Oh my gosh.

So we have no access and then I don't have access either.

So then we come to the fourth pillar, which is just sweeping through medicine in general, but certainly in rheumatology practice, when I asked the question of audiences a year ago, how many of you all are prescribing GLP-one receptor agonists? Maybe 10% of the audience would raise their hands. More recently, as I've been asking that question, it's more like 50. And it's either that they are prescribing or that they are now more actively talking with patients about doing so and then getting them their internist or someone like you to prescribe for them. But you have a lot to say about medications.

Let's teach us about how important these newer medications as well as some of the older ones are in adjunctive care of our patients.

Yeah. So as I started saying, we should be treating obesity as we're treating any other chronic disease, that we are addressing the under we're implementing lifestyle interventions. However, we have to address the underlying physiology of the disease. And the way I think about it as humans, we have evolved to protect against energy deprivation, right? So we survive in times of famine and war, and now we live in this obesogenic environment where we have access to very high caloric foods 20 fourseven, we have stress, we have lights, we have renal, all the things we did talk about, little decrease in movement.

We're sedentary, we're doing many things over Zoom now. You combine and then we have the genetics on top of that, and then you combine all those factors that lead to abnormal weight gain, but making it really hard to lose weight. Any of us that have ever tried to lose any weight or what we hear from our patients, they can say, you know, I lose around five to 10 pounds just to regain the weight. And this is really hard, I feel really hungry because we do have mechanisms. As soon as we start to lose weight, we have mechanisms that push our weight back up because our body likes to be in a steady state.

We increase leptin, we decrease some of the thyroid hormones, some of the metabolic hormones in general, leading to the weight regain. So the medications address the underlying physiology. All the medications we currently have, I mean, the majority except for one, do act on the appetite centers of the brain where they induce including some older medications, the oral medications that we had in the market for the last several years, and the newer GLP-one based therapies that we do see to be very effective now, they all work in the appetite centers of the brain where it induces satiety, leads, patients can start eating, but then it makes them feel fuller. And overall, in some of them do decrease a little bit of appetite. And the other mechanisms in particular with the GLP-1s, what they do in particular in the beginning may slow down gastric motility and again, leading to the sensation of fullness and satiety.

That being said then leads to patients eating less, so then leads to a caloric deficit, and therefore they're losing weight. And to reinforce everything that we said is that with the medications, we have to make recommendations for appropriate nutrition because they're feeling fuller. I said, you know, you're feeling fuller, so we have to get the biggest bang for a buck. So we have to eat more protein, more fiber because the fiber also will help with motility. Oftentimes the side effects from medications, as we know, can be nausea and sometimes constipation, occasionally diarrhea, but the fiber can help with that too.

And protein can help in preventing loss of lean muscle. And then in addition to that, then doing the resistance training, like I mentioned, minimum of twice a week, ideally more if they can, in addition to every other recommendation, all the other recommendations that we're giving in managing their side effect. My suggestion is usually to start low and go as low, depending on patient's tolerance. And we do bring patients back in our clinic. Unfortunately, how busy we are, we often bring them back on average of every two to three months.

So we're seeing them quite a few times during the year to make sure that they are doing well. They have additional amounts of weight loss greater than 10 pounds per month, we also add on Ursadio to prevent gallstones. So again, is this idea that we truly have, right, we're not addressing only that there's no like this magic pill that we give once or the injections that we're giving and then forget about our patients, we really have to follow them along the way. My nurse manager, we're talking this morning in particular with all the of the wild wild West here in the West, I'm sure it's in other parts of the country too, with med spas and some other things. She said a very wise quote today, she's like, anyone can prescribe a medication for weight loss, and some patients will lose some weight.

However, it really takes a team, a multidisciplinary team to provide the adequate kind of care where we are improving their health and overall improving their quality of life. And I truly believe in that. And I think this is a journey. We don't need to address everything at one visit, which makes it hard in particular when you're dealing with many other issues, many other medications. I think starting the conversation and then bringing the patient back.

And once they're ready to make that change, then go to other professionals too. Use registered dietitians whenever available. Nowadays, there's a lot of resources online, behavior health, if there is possibility. They have all kinds of discounted places online too. So nowadays with telehealth, that also helps and hopefully it also helps with patient access.

Very wise comment from your nurse manager, very holistic. So one of the things that's exciting to us as rheumatologists is especially with the publication of the Together PSA study wherein even at four weeks into that study where combined combination of an IL-seventeen inhibitor and tirzepatide, was a significant difference in ACR responses even with minimal weight loss. So it raises the question, are these drugs immunomodulatory in nature? And some evidence for that comes from translational data where we see not only reductions in leptin and pro inflammatory adipokine, but also our traditional pro inflammatory cytokines like IL-six, TNF and so forth. So we're now getting into a fascinating new area where between this effects in PSA, psoriasis, knee osteoarthritis, broad potential benefits.

But I'm glad you raised the point about fighting against sarcopenia. This is something that is important for people to recognize, to have resistance training along with their use of these medicines.

Yeah, no, I think those are excellent points. And I think it's an amazing, exciting era to be an obesity medicine specialist, knowing when I started and I had less than a, you know, I had a few, few medications to treat patients with and now having very effective medications, but also figuring out how it can affect the inflammatory pathways and how that's leading to better outcomes, better treatment outcomes, in particular with the rheumatological conditions, I think is a very, very exciting era to be treating patients with obesity. However, again, it does take time and it's a journey. And remembering that not everybody is going to respond the same, that there is a response curve. Where the majority of people respond by having a certain percentage of weight loss.

And we have some that are non responders and some that are super responders. And remembering those other ends of the curve that, and we might need to change medications, might need to add on, and we might need to figure out what else is going on with our patient before we blame, you know, automatically say, well, maybe you're not doing what I'm telling you to do. But But remembering that does not work the same for everyone. And there's a lot of other factors that we're trying to figure it out. But we are in the right path for the treatment of obesity and rheumatological conditions.

I'm thrilled to be part of it.

Doctor. And Juliana, we are truly delighted to have you as a member of our broader rheumatology team. I hope this may be your first certification that I consider you an honorary rheumatologist.

That's amazing.

So Thank with that, we went on behalf of RheumNow and this month's focus on obesity and rheumatic disease. Thank you for listening.

Yes, thank you.