Introducing Weight Loss

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 patient.

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. 40% of the US population, a 100 million people are obese with a BMI of greater than 30. If you include overweight, it's over 70% of the population. Um, you are familiar with and very effective at managing comorbidity in rheumatology, but do you really have a plan for obesity? Most of us don't. Um, but yet we know obesity causes disease. It worsens disease. It handcuffs treatment responses and it leads to overall poorer outcomes. And 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-1 therapies uh and bariatric surgery. It's going to 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 you would say, yeah, I discuss it with my patients, but you know, nobody follows my advice. You know, they come — I mean, 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, you know, 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,
but yeah, there's a problem with weight loss diet and exercise. It seems very frustrating.

But I, you know, 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 um 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 uh 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 um you know yelling at them or you know telling them that you know why this is horrible and whatnot. You need to feed into the patient's own motivations with you know supportive information with a supportive plan. When the patient perceives that you're not judging them um 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 uh what physicians do um maybe a third of physician visits don't uh — will discuss — 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 um are underutilizing referral tools and it's not just for GLP-1 therapy or weight loss clinics or endocrine clinics but we're talking about behavioral uh programs, weight you know Weight Watchers um bariatric surgery you know 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 uh looking down the road. Of course, all this is driven by good conversation and trust. Um the pillars of these
discussions are often called the five A's or the four A's. I'm going to describe that for you briefly before I tell you my three minute script.

The six A's begin with ask — you know, where are you? What do you want to do? Do you want to discuss obesity or not? And then if they express interest, because you're showing in a non-judgmental way that you're open to this discussion, then the second A is assess the patient's risk factors and readiness for change. You know, ask for permission to do certain things — to, you know, check their weight, check at every visit, 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. Maybe 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, shared decision making. And after that it's assist in what kind of treatments, what kind of goals, and then lastly it's arrange for accountability — meaningful follow-up on a regular basis, so that they know 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." Like, eat less — you know, be more specific, give them a specific diet. So being specific, being intentional, and being supportive is what will work, with you leading the way.

So 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 3 or 4 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. Um, and that would be a great way to relieve pain.

So then you, you know, 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? You know, 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.

So 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 maybe why your disease is not well controlled right now. Losing weight isn't necessarily about 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.

Um, 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, you know, different diets um 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, you know, why not see a specialist for this medical problem you have? There are specialists who specialize in being overweight and/or obese. They're endocrinologists but there are other medical
specialists who 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 uh and tolerable in many patients that can lead to you know 10% 20% 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 sort of 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 uh 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&Ms, um 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 6 months permanently.

Another thing that they can do is they can track their food intake because you're going to 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 and 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. Um reduce their calories to 1,400 to 2,000 calories a day and to increase their exercise. But they 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.

You know, um I'm a fat guy. I've always been a fat guy and that's why I used to play lineman in football and linebacker and um but I got up to over 340 pounds and I was there for many many years. My
excuse was I had horrible knees. My excuse was I had horrible knees and that I couldn't exercise. And 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 10 minutes or 15 minutes. My first goal was five minutes and I did it and I came back and I did it two days later. And then over the course of six months my, you know, five minutes on a treadmill became, you know, 20 or 30 minutes on a treadmill or 20 minutes on a treadmill, 20 minutes on the um the bicycle and 20 minutes on the elliptical. I could get 60 minutes of high intensity aerobic activity.

You know what? I lost weight and I had my knees replaced at 290 pounds and I did well for a while. Um, but then I got serious again about the exercise and I got all the way down to 235. So I lost over 100 pounds, but you know, I was doing it alone and other than exercise and crossing some things off my my you know, no more potato chips, no more um uh cream cheese, you know, that kind of thing. Um, I got up to 270 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, you know, I'm much healthier. I'm still um I don't know what my BMI is, but I'm down to 215 to 220 and um and I exercise, you know, 3 to 5 days a week. I do 20 to 50 miles on a bicycle and but I needed a plan and you know I and 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. 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 followup that's sooner rather than later. When they know that you're interested and you're invested and that you're cheering for them, they're more
you're cheering for 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.