Building A Multidisciplinary Program

Hi there, my name is Aaron Carriage Bailey. I'm a rheumatologist and obesity medicine doctor in Vancouver, Canada. I am also doing a PhD looking at the effects of GLP-1 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 program 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 maximize success of an interdisciplinary clinic.

So, you know, with the obesity imperative campaign, there's going to 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, axial spondyloarthritis. Obesity is associated with more severe or active disease and more treatment resistant disease. You know 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 randomized 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 studies like the TOGETHER PsA study. And so, a lot of benefits.

It's also important to recognize 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. Unfortunately, there's still a lot of stigma around obesity and you know 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 non-judgmental 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 complementary expertise who are 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 activity 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 a psychologist can be really beneficial.

Now, 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 behavior 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 patients interdisciplinary team they have an intake visit where they're triaged for appropriate sessions. So some people might require individualized 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 recognize 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 RheumNow.com. Thank you for your attention.