More than the Meds: Obesity Care in Rheumatology

Hello everyone. Welcome to Tuesday night rheumatology. It is obesity month in September on RheumNow. The whole month's been dedicated to education on advances in obesity management, and especially as it pertains to the practice of rheumatology, but as you can imagine, obesity is very cross-disciplinary. Our title for this month was the obesity imperative. And I think that we chose that — we have an advisory group, Alex has been a part of the advisory group — and we chose that because we felt there was a certain degree of urgency with regard to this subject and that we all have to deal with it but we all may not have the plan that we need.

Today in our weekly RheumNow meeting, our editor said that if you are designing a treatment plan for your patient without discussing obesity as part of your treatment plan, you've really missed the boat. And that's kind of what this whole month has been about. So I want to first thank our sponsor for the month, Lilly. They've been a sponsor for most of the content that you've seen, and thank you very much for that.

Tonight our final installment of Tuesday night rheumatology is called More Than Meds, where we want to hear from four experts about how they do it, how they approach the problem, how they handle these issues with their patients. I wanted to ask each of you in the audience to be active in this and ask as many questions as you like. You can do that by clicking on the Q&A button on your Zoom screen and we'll answer your questions as you throw them at us. If I'm not answering it right away, I'm going to get to it because it's two slides down the line. So don't get antsy on us.

We're joined tonight by four experts who are actively practicing in obesity management. I'm going to ask everyone to introduce themselves as we start. So I'm Jack Cush in Dallas, Texas. Guada. I'm Guada Rispicio. I'm with arthritis and rheumatism. I'm in the DC area. I am actually obesity certified since 2022. Alexis. Alexis Ogdie, a rheumatologist and epidemiologist at the University of Pennsylvania in Philly. Stacy. Hi, good evening. My name is Stacy Ireland, nurse practitioner with the comprehensive weight management program at the University of Utah in Salt Lake City. Excellent. And Dr. Wells, Alvin Wells. I'm the director of rheumatology at the American Medical Group in Destin, Florida.

Okay. So we've got all guns on hand. We are ready to go. I want to again remind everyone that please put your questions in the Q&A box. We'll be monitoring that.

As is the case with all of our Tuesday night rheumatology sessions, we inform the program by sending out a one-time email to rheumatologists and fellows. And you can see that just yesterday morning we sent out a survey and overnight received 216 responses — two-thirds from the US, 84% from rheumatologists, 9% from nurse practitioners and physician associates, about 6% other MDs — that's endocrinologists, dermatologists, primary care — and about 3% rheumatology fellows. So we posed these questions to them because I wanted our panel to discuss these issues and then see what their peers think as they discuss them.

You know, the hardest thing is that obesity conversation. I did a video called the three-minute script that says you got to do this. It only takes a few minutes. You got to hit on a few salient points. And they're depending on you. And while it's futile and often doesn't work, you know, when you do surveys of why people lost all that weight, usually one of the main reasons is because a doctor was the one who started the conversation. So your role is really important.

So again, I asked this of everyone, and I think most people got it right by saying ask permission — 37%. 44% said N/A, which means that you're turning your back on this problem. You have missed the boat. And if I could make you feel bad about it, I would. But I'm going to ask the panel as to how they approach this.

Alexis, you just did a really good video that's posted as part of our therapeutic update series — top right box on the RheumNow website. In the email you click on that, there's seven videos on four pillars of obesity management, and this is not about drugs, this is about how you get into the discussion. Alexis, tell us about your conversation, your video.

Yeah, so I was talking with Anastasia Amara, who is an endocrinologist, and I was telling her about my trouble bringing this up because I think a lot of rheumatologists have had the experience of talking to a patient about obesity and the patient gets mad at us, and then we become more sensitive about it, and then maybe we don't do enough of going back and talking to every patient about it. My place to talk to patients about this is as I'm going through the plan. So we went through everything today. Things are not going as well as
we want. You're on this therapy, but it's not working as well as we want it to be working. What else could be getting in the way? And then I have not always asked permission first, which I think I've learned is the right way to do it. And that's what Anastasia will take us through in that video. A lot of times I've said, "There are some other things that could be contributing to you not responding as well as we want you to respond or you're not getting to the level of disease activity we want you to get to. Can I talk to you about some of these other things that might be getting in the way?" So, that's one of the ways of asking the question. So you kind of set up they're not doing great and you can ask can I tell you about some of the other things that may be going getting in the way in this little video take a look at it because Anastasia goes through a variety of different scenarios where you can ask the question in a variety of different ways to kind of get into that discussion.

Then you tell them a small nugget of information like um you know we know that weight is associated with not getting to minimal disease activity on therapy or not getting to your best place and it also probably shortens the life of a drug. So if we could work on the weight we could get um you know get you to improve disease activity. Can I tell you some can I um ask you some more questions about that or would you like me would you like to hear some options about managing your weight? So there's a lot of different ways to kind of get into that. I'm not I'm still not the best at it, but the fact that we're doing something about it, like you said, Jack, it's so important just to even talk about the subject.

Yeah. So I want to ask um Alvin and Guada um before we get to the obesity expert um and obesity clinic um and both of you guys have obesity clinics. Is this a hard conversation to start? And and how do you start, Alvin?

So it's yes and no. I I tell you uh the people who the conversation is easy to people who don't need a weight loss drug. You know, I got a wedding. I want to lose 10 pounds. And that's a different conversation. I am a little bit different. So, I don't ask permission, Jack. So, I my approach is I I'm in the exam room. The patient's on the exam table. I have my stool lower than them. I'm looking up at them. I'm going through a plan just like Dr. Augie said, but then I say, "Hey, with everything going on, how has your weight been? Has it been the same? Has it gone up or gone down?" And then that allows them to open up the conversation. So in 2010, I went to took a course and learned how to do obesity. I came back and started doing my whole obesity clinic. Uh go out. I didn't get certified, but we started doing prescribing these drugs and but also we actually put together the meal plans, exercise programs, and all these different things for them. And that kind of just snowballed into where we are today. So, I let the patient bring up the conversation, but just like what Alexis does, I piggyback that on the treatment that I want to give them.

So, Guad, what is the I mean, you can start the conversation, but if you've got no ammo in in in in the gun, can you really get into this fight?

Yeah. I mean, so as as everyone's mentioned, right, so majority of the time, you want to ask permission, but majority of the time, the patients are already asking that question, what else can I do? So this is one of the things that you give them basically a little bit more empowerment. So especially with the medications we have now we tell the patient now we have more options than just calorie in calorie out. Now I can help you with this. We have a registered dietitian on board. We have our exercise physiologist physical therapist. So we can kind of like what Alvin said we have these basically lifestyle modifications in addition to medications that would hopefully allow the patient to lead to minimal disease activity. So by putting the big picture, I think a lot of our patients have been receptive to that one. And so the way our practice works is actually my other colleagues, the other rheumatologists actually refer to some of us that are obesity certified in the practice.

Yeah. So Stacy, you work and have worked a while in an obesity specialty clinic from the endocrine side of things. I would imagine people are coming to you specifically for this reason. And so starting the conversation isn't I would think is not as hard. But is it still hard no matter where you start from?

You're right. I do have an advantage coming from a weight management program. Patients expect me to talk about weight. I I start all of my visits, especially my new visits off with motivation. So what is your motivation to be here today before even saying why do you want to lose weight? And that way I allow the patient to guide the conversation where they are at with with talking about weight. Are they ready to talk about medications? I have quite a few patients that
say, "I didn't even know this existed. I didn't even know this was a real area of medicine and I'm grateful it is." Or I have multiple patients that come to me referred by other providers saying, "Apparently there is a weight management clinic. Can we talk about weight?" So I think it will always be difficult. Weight is an extremely sensitive area. There's still stigma that exists and despite obesity affecting millions of people worldwide there's still that stigma that exists. But how I've changed my practice is asking patients what is your motivation to be here today? And that allows me to guide the conversation next of are we ready to talk about medications or go a different direction.

You know, someone on my — actually Shannon on our team — I asked her a question about motivation, motivation to learn and whatever. I love this question. I want to say two things and I want anyone to respond to this. Number one, real motivation sometimes doesn't come until people hit rock bottom. What is the factor that throws them over the edge and says yes I will now. And then when I asked Shannon this question about motivation and education, she said the problem with motivation isn't that they don't have motivation, it's that they don't have momentum. Momentum is you give them something, there's a reward, they want to come back for more. So how do you address motivation and momentum especially in your follow-up visits? Anybody want to tackle that?

Actually, we just finished a study on this. So we'll be presenting at ACR, at least a part of that study. It was called the So Well study, and we use motivational interviewing at two different time points. It was delivered by nurse practitioners between MD visits to kind of get at one topic. And so I actually stuck in the chat an informatory website that was generated by Laura Coates and GRAPPA to help with this in psoriatic arthritis. But the idea is to come up with some short wins. So it's just like anything else. You want to be able to say what can be done soon that can actually turn something around and how can you put that in the patient's frame of mind in a way that they come up with it. So actually as a part of the study, the nurse practitioner could not come up with the thing for the patient. The patient had to come up with it and they could ask clarifying questions or try to get deeper, but the patient had to say why they wanted to do it and put that in their own words and write it down and then also say what are the two or three steps that they can do that we can then follow up on.

The punchline of the study was that patients really need a lot of follow-ups. So it's not just our next follow-up in 3 months or 6 months. They kind of need some short-term thing. So it might be — even though no one wants more messages — can you send me a message in two weeks that tells me that you did this or something like that? So there's some accountability and you reply back and you say great job, keep going or something like that. I think that still needs to be worked out. But that was a key piece: short-term follow-up has to happen to really solidify that.

Jack, when you mentioned momentum, you brought back my days of physics and made me think of another term, inertia. And in some patients in the clinic, they just need that little inertia, that little bit of a push. And the push could be, hey, I need you to exercise three days a week, 15 minutes, and double that on the weekends. It could be a prescription. It could be something along those lines. But once you get over that inertia, that's where the momentum starts. And just like what Alexa said, then in two weeks, let's do a follow-up visit just to talk about where you are.

Let me ask — you've got a psoriatic arthritis patient that's doing okay, almost low disease activity, and they're all on aggressive therapy and maybe you make a change. What's your follow-up visit frequency on those people? Q3 months, Q6 months. Is it any different if they have obesity? Guada.

So the patients that are usually on my obesity medication, I do follow them every month until they're on maintenance dose and then I separate a rheumatologic visit. So usually every 3 months, and the majority of the time it changes their medication because after 6 months when they're on maintenance, it allows them to either come off some of their PRN medications or if they're on multiple therapy, sometimes we end up coming off some of them. So I think it's very empowering for the patient. And again, obviously just seeing the short wins — it's very motivational for them to continue with the medications.

Um, Stacy, you talked about the stigma and some of the negativism. How do you get over that negative part especially, and to create that relationship that the patient really
needs? We are very fortunate that our clinic was designed as a comprehensive weight management clinic. So when patients first enter our clinic, we have a weight appropriate scale. We have weight appropriate chairs, exam tables, and without even saying anything, I think we have created an environment that is more comfortable for patients living with obesity.

Our medical assistants and nurses are trained in using patient first language. And so I think it really has started with how we have created our clinic from a structural component and what our medical assistants and nurses are trained in as well. We do a lot of — by we I mean our clinic does a lot of advocacy work as well for patients with obesity through training other primary care providers. We were holding like other conferences and so just modeling patient first language and how to manage patients with obesity I think has at least helped decrease that stigma within the medical community.

The prevalence of weight management medications has brought up this conversation more. So I'm hoping with time stigma continues to decrease as we recognize that obesity is a chronic condition. And I know one of the participants mentioned in the Q&A section how important it is to build that relationship with patients. And so, um, I apologize, my little one is talking in the background, so I apologize everyone.

But talking about building a relationship with their patients, building that sense of trust — and let me pull that up. I believe they made a great point and that it's not your fault you are obese. And so talking about how complex weight is and how many factors go into obesity hopefully helps decrease the stigma between the patient and the provider.

Yeah. This week — last week I wrote about a report from the Endocrine Society. It's a statement about where the science is in obesity and thoughts about obesity. I think you should just read like maybe the first two paragraphs of that. It'll really change your mind. Especially, you know, explaining why someone has obesity and how they're going to deal with it.

Our next question is should rheumatologists have an obesity clinic? You know, Stacy has one, Alvin does, Guada does, Alexis — Penn has an obesity clinic that rheumatologists participate in. We refer patients to. Okay. So I like that because now — that's kind of how I manage as well. And we want to talk about those relationships.

But the way that the audience answers, 43% said no, refer, not my job. That's probably okay. But I want to remind everybody about 15–20 years ago I started lecturing on comorbidity in RA and everyone in rheumatology — every rheumatologist said yeah it's a big problem, you know, the diabetes, the hypertension, the obesity, yeah, but I ain't doing it, I'm too busy, I got all these drugs, I got no time, I'm not getting enough pay, I ain't doing it — smoking, vaccinations, lipids, are you kidding me, that's some primary care stuff. Well, I can tell you that has changed dramatically in the last two decades. You are taking responsibility for comorbidity management.

And many of you — the green triangle there — 20% say yes we should do it, 26% say maybe select practices, and 10% say I don't know. So I'm going to ask each of you: should you advocate that your peers start up or be involved in an obesity management clinic, or is it enough to know a lot and refer? Alvin?

So, yeah. So I was really pleased when I looked at the panel and I was seeing Stacy was going to be on. So I told you back in 2010 I had my first two PAs and one of them was a trainer and she said, "No, I really want to get into weight loss." And that put the fire in me. And then I saw the business opportunity. I said, I can carve out a whole section just where I could do weight loss. And we had patients coming in. It was a cash service. We prescribed drugs. We had the whole process going. And they would come in once a month like Guada does. And that would be my message to my colleagues. It might not be you, but it might be somebody like Guada in the group that's going to be the one learning how to do obesity, learning how to put these tools together.

It's just like you're saying, Jack. It's not just prescribing a drug. They want to know about the meal plans. Do I need some vitamin B6? Do I need all these other things? Give me some exercise plans — stuff like that. All those different things.

And going back, I know many of you know I used to work at Abbott before they became AbbVie. And we learned that with Humira the drug didn't work as well when people were overweight. And that's where we began to have this conversation even back as early as 2002, 2003. So this is where the whole process began. But I think the take-home message here is you're going to need the help. We can't do it all. That's where AI comes in.
or you might have a dedicated uh provider like Guad that would help you out with this clinics. Yeah. Guad, how do you handle this? So, there are actually four physicians and two PAs under our wellness and weight loss center. Um, so I started doing it on my own trying to kind of get my feet wet with my patients basically when I became obesity certified. I think it was just one of those things I would always refer to endocrinology and then they'll say, "Oh, no, you'll have to talk to your primary care." So, I just felt like kind of like what you said, right? I need to just take a little bit of action because some patients you know disease activity it's not movement if not it's not moving and so I took the initiative to take the obesity certification and then I started doing obesity management on my own patients for about a couple of years so we just started our wellness and weight loss center with arthritis and rheumatism so I do two half days the other physicians do half days too so we there's basically one half day every week for um among seven of us and uh we have a registered dietician. So we have all these we have the physical therapist. Um but I think just having a dedicated number of physicians uh who are interested I think that's enough for our practice. I mean obviously would welcome more because sometimes you know all the follow-ups monthly, right? It takes up a lot of our follow-up appointments and we're running out of our room follow-ups. So um with my practice because there's about 30 clinicians. So we're hoping that at least 10 of us will be involved in wellness cuz like you said it's a lot of our patients basically they majority of the time they benefit from obesity management as well.

Guadica, could you address the uh question of what is obesity certification? Oh so obesity certification this is actually a uh different certifying board. So any board certified physician um can sit for obesity exams. So you take basically um they have CME courses, they have you know review courses and so it's kind of like our ABIM. So you sit for uh basically a computerized exam. It is every 10 years you do CME uh journal basically every every year for maintenance of certification.

That's a And does do you think everybody that's going to be in your wellness clinic need to have the certification or can they be under your tutelage and come along at their own pace? I mean our our two PAs are under me but there are two of us. One is studying to take um the obesity certification. Dr. Albogdaddy is studying for the integrative medicine. So some of us are doing lifestyle medicine integrative medicine and obesity certification. Um, but I think we're just trying to again get as much basically help for our patients, right? Because there are some patients who don't want to be on medications and they just want lifestyle modifications.

So, Alexis, you have you you work at a center where number one, you're doing research in this area. You're teaching in this area. You have a great referral um operation that and and colleagues that you work with. Um how are you are you representative of all the rheumatologists at Penn are they uh as connected are they using when do they use what are they where are they failing yeah that's a great question so I am also different in that I do prescribe um medications like GLP-1 uh agonists as well because it saves my patient another visit and then they have to they have to schedule it they have to go through everything so I do try to start those prescriptions. Sometimes they still need to see our weight management clinic in order to get it approved or if there's a hangup, but I at least get the ball rolling. I start the conversation so that there's at least a cleaner handoff in the case of the need to see someone else.

Um, so actually we did do a study about lipids, you know, bringing up cardiovascular risk to see what the group of rheumatologists are doing. I think at that time it was about two years ago. uh most rheumatologists in our practice were checking lipids or you know assessing cardiovascular risk referring as needed and I think we're pretty well connected with both our preventive cardiology group and our weight management clinic. The problem is still that we don't have enough visits for weight management at Penn. So they still have a really long wait. So I think it's great to have a referral network. It does not solve all the problems. And if I could do what Guada was doing, this is like where my goals have been is to try to establish a more wellness focused practice. We have just such a huge access problem for our rheumatology patients in and of itself. But this is what people need is that well-rounded care. And if I can provide parts of that in my rheumatology care, I'm at least getting the ball a little further. But uh because these patients have so many other physicians sometimes, so it's great to be able to keep as much of it in one place as possible. Can I add
a pearl? Um, so what I do in my practice every day, the last hour of my clinic is all virtual. So from 4:00 to 5:00 pm, I'm only seeing virtual patients. There's no clinic patient in the clinic. And half of those patients that I'm seeing are all my weight loss clinic patients. They need to check in with their scale, making sure they're not having nausea on their drugs, etc., etc. So I find that's been a good little pearl to kind of use so that you can follow those patients up and then three months later they can come in for a visit to do their PSA, the RA or whatever we're doing like that as well. But the virtual visits have been a great advantage in this particular area. And that's where we use our APCs too is doing the virtual visits for this as well.

Exactly. You know, the best doctor is the one who gives a damn. And if you're having follow-up visits like that on frequent intervals, you are their favorite physician.

Um, Stacy, from your perspective, uh, I imagine you're taking this onslaught of referrals and a wait list and whatnot. Um, any advice as to how we should be referring patients or who exactly should be referred?

I think Alexis brings up a great point that access is an issue. It has been an issue. It will probably continue to be an issue. As Guad mentioned, hoping more providers are interested in adding weight management onto their clinic or or becoming ABOM certified is is helpful. Um, we have a strong partnership with sleep medicine, cardiology, uh, and and primary care and family medicine. So a few of our providers split their time between sleep medicine and and dabble in weight management. And then we have a connection with another APC that is in cardiology and as well as two other providers that split their time between family medicine and and our our clinic.

So, I think having those relationships, uh, as Alexis mentioned, has helped get the ball rolling. I find that a lot of providers are becoming more interested in talking about weight management medications. They're becoming more comfortable with prescribing them. Insurance and prior authorizations will continue to be difficult and a barrier. And then they send patients over to us to continue managing the medication.

Like Guad's clinic, we are set up with multiple registered dietitians, an exercise physiologist, bariatric psychologists and and the connection with sleep medicine and as well as cardiology. So we can offer patients that truly comprehensive approach to to weight management. And so I tell providers if you feel comfortable starting the medication, I I'm okay with with other providers starting the medication. Uh, please reach out when it's time or it's appropriate to get the patient over specifically to to weight management and at times we are the ones that are helping with the prior authorization process because it it's a lot of time.

In the surveys that we've done with rheumatologists um in the three prior weeks, um, they have all yelled um and and objected to either cost, prior authorizations, and management of GI side effects. Anybody — I'm gonna ask each of you to take a stab, give me a pearl at any one of those things that would help uh our audience that are dealing with the issue of cost, prior auths, or GI management. Alexis, you want to start?

Yeah, I think um so GI management — there are so many great uh resources online now but definitely tell your patients about exercising and muscle mass, uh, tell your patients about high protein, lots of water, healthy eating. You can find example diets online. Um, and I I can't remember this resource, but maybe we'll be able to find some and put some in here, but some of the bigger organizations have put out statements on this that are really easy to read and download for your patients. So, I have done that. So, I'll leave it with that and pass to the next person.

Got it. Uh, we have a designated prior auth team. Uh, unfortunately, this is how it is these days. Um, so as everyone's aware, there's a Medicare bridge program. It was a very long tedious process in the beginning, but it helps our Medicare patients. It's $50 for those whose coverage would not have been covered. Um, but the pearl that I heard is you cannot use obstructive sleep apnea. So, it's BMI greater than 35 — so that goes through with no issue — or BMI of 27 and pre-diabetes. So, if they have those, then you just use those. And I always remind um the other practitioners, always use the highest weight, not the current weight. So, it's whatever they started with. So if their BMI was 40, you keep using 40.

Alvin, do you have a pearl? Same type of thing. So we — first of all, we get samples of all these drugs. I get patients, they get started on a month's supply of any of the drugs. We have them all, the pills, injections. We do all of that. We give them the copay cards. We connect them with the pharmaceutical support programs. Uh, we don't have a dedicated person. That's what we rely on. Our specialties,
their goal is when I write the script and send it in, they get the drug approved because when I see that patient back in a month, I'm expecting them to be on the drug. But leveraging these programs that the companies have and again we've been using more in our Medicare patient because of the program Guad mentioned for $50 for most of our patients has really been a big win. That is a big plus.

And Stacy, do you have a pearl? If you are putting in a prior authorization, make sure you put it in correctly the first time. If, like Guad mentioned, if the wrong BMI is used, if the wrong A1C is listed, it can almost blacklist the patient from getting a prior authorization through the second time. So, do it correctly the first time.

As far as a GI pearl, I agree with what Alexis said, high protein. I tell patients that trying to start the day off with at least 30 grams, 30 to 40 grams of protein if possible, but at least 30 grams at breakfast can help with that nausea that tends to hit patients in the morning and it just starts the day off on a strong foot that they're not trying to play catchup with their protein intake throughout the day.

Yeah. Uh, a few tidbits, um, just from our notes — in a prior survey we found out that our rheumatologists, you in the audience, 34% of you are prescribing GLP-1 agents in therapies. Um, 48% say no, not me, not yet, and 18% are referring for such therapy. Uh, the resource that Alexis was alluding to is the American Diabetes Association, which has a great education program for patients on diet as they go through this. So that, I think, is helpful.

Um, let's go on to the next question. Uh, what is the most essential resource for delivering obesity care in your rheumatology clinic? Um, does this mean that they need to have a dietitian on site or that you need to have someone in your rolodex that you can refer to that knows how to manage this? Stacy, what do you recommend?

I strongly recommend having dietary access if they are associated with your clinic. That is key to patients really being successful on these medications. And as I mentioned, prioritizing higher forms of protein while on these medications. If it allows the patient to stay on this medication because we are doing a better job of managing GI side effects, then it's a win-win for everyone.

I think as we continue with these medications, I tell patients my concern is for muscle mass loss. And so having that dietary component — the dietary side, the protein side — hopefully coupled with physical activity is important. And if we look at the research that was done with both the STEP and the SURMOUNT trials for semaglutide and tirzepatide, they did include a dietary component. And so for these medications to be successful, to see the percentage of weight loss we see, there needs to be that dietary support.

So, um, Alexis, I want to ask about that second answer there, endocrine co-management. I'm a little envious of your relationship with the endocrinologist at the university. And that's how you handle referrals. I want to know, what's your advice on establishing that bridge?

I think it's getting to know the person in that role. And it's funny, I talked to Anastasia all the time now, but I didn't know her maybe two years ago. So, until these options, these therapies came about and we needed to manage them and then having more complex patients taking them and needing to start having conversations, just reaching out and establishing that link and saying, can I be a referral source for you, and can you educate me about who you want to see versus who I should just try to prescribe for by myself? We've done this in the past with cardiology as well and we have this nice derm rheum collaboration like this. So, it's really great. I think everybody gets to see the patients they want to see and it's a really great way to practice.

Guad, is this practical in your situation? You got a big multispecialty group, 25 docs, you know, there's four MDs and how many — four APPs that are dealing with this. Is there a need for you to align with the endocrinologist?

Uh, majority of the time if they're type two diabetic that's when I send them there. Otherwise we usually take over if it's pre-diabetes. Um, it's also been very difficult because some endocrinologists only want to manage, you know, X, and they don't want to do weight loss. So if they're diabetic they want to deal with diabetes, they don't want to do obesity medicine. So where I practice it's not as cohesive as in the academic settings.

Alvin, how about you? So, yeah, before I came to Destin, I was director of our HMR program, the healthy meal replacement program. That was a very popular program until COVID came around and it kind of shut that program down. Currently, I have — now there's six clinicians, um, four uh
physicians and two a dietitian, so we actually in charge of managing those things. But I have an endocrinologist on speed dial almost like what Alexis does. The challenging part Jack, just like us, the endocrinologists are booking out six, eight, nine months. I mean they are just overwhelmed with lipids and everything else and it really a challenge to get them in, and now with everybody wanting the GLP-1 and all these other drugs. So but having them on hand, if I got somebody who's a BMI you know 40, 50, we get them under control working with bariatric surgeons and all the plastic surgery doing brachioplasty, all those different things. So we have a whole team approach in my clinic here in Destin.

What I've learned this month in putting out a lot of content about obesity is I'm surprised at the amount of resources around the problem. So yeah, you may not have a dietitian. You may not have you know an exercise physiologist or enough people to really do all the things that need to be done when delivering 360 care around obesity. But there's so many resources that you can have, as you know Alvin and Guada have developed in their practices, that this is — I want you to read this, I want you to take this, I want you to sign up for that. I think that that's a great thing.

Um, Stacy, is there — is that just the way it's done in endocrine and obesity, or is there a concerted effort in this area? I call it phone a friend. So I also have friends that specifically work in endocrinology and, like that has been mentioned, what patients are appropriate to refer. Most of our endocrinologists like to manage our patients with type two diabetes, specifically type one, and then it is a partnership that I may manage the GLP side, the weight, the nutrition side, and we almost co-manage the medications together. Providers are great at sending myself messages about when we're making dose changes, especially if you are booking out six months. I would hate for a patient to stay at an ineffective dose for six months because they cannot see me. But if they're seeing their endocrinologist and they're managing their hypothyroidism and they make that dose change, that's what this is all about. It's collaboration and keeping the communication lines open.

Excellent. One other — oh, maybe actually I will wait for this next part because it'll fit even better here. So continue. So we've talked a lot about medication management, having a clinic approach, the patient, having medicine and new tools, but you know what about non-pharmacologic management? Where does the evidence lie? Where are the big gains to be had? And where's the strongest evidence? The right answer here is intensive lifestyle programs, as opposed to go to the gym or join Weight Watchers or Overeaters Anonymous or whatever. How do you guys approach non-pharmacologic management, Alexis?

Well, I was going to start by talking about our Dietary Interventions in Psoriatic Arthritis or DIPS study that we presented at ACR and EULAR this year. One of the things that we found was that we randomized patients to either a Mediterranean diet where they got supplemented with olive oil and nuts, or a DASH diet where there's tons of resources and it's easy — there's cookbooks and things like that online — and then a single handout about what is a healthy diet and a visit to a nutritionist, one visit to a nutritionist. And the other two arms had a pretty intensive followup. But it turned out in the motivated patient that one visit to a nutritionist was just as good, both in terms of weight loss but also in terms of improvement of disease activity, which was fascinating. We thought it was just going to be this control, but the control turned out to be very active. So yes, we want to do the intensive part, but doing anything in the motivated patient can be helpful too. And then I often do refer to Weight Watchers or other things like that when we don't have access to an intensive program otherwise.

Stacy, what is the approach for lifestyle management in your clinic? Where does it get used? Where does it have its greatest use? We have another subset of weight management that's called the New U program at the University of Utah that is intensive lifestyle. And so they meet specifically with exercise physiologists, physical therapists, and dietitians. And so they are covering the lifestyle part. It complements very well with our program as we're handling the pharmacological side, if patients are interested. Like Alexis mentioned, doing something can be incredibly beneficial. And so we have patients that start with the New U program and then they will continue the New U program and add on our weight management specific program. And typically that is adding in medications as well. But all of our patients through our comprehensive weight
management program do meet with the exercise physiologist and the registered dietitians and then they have the option to meet with our bariatric psychologist if need be. Like Alexa said, if patients like Weight Watchers, I know Weight Watchers about two years ago revamped their app and it's very user friendly. Patients are responding really well to the app. They like that connection. I don't mind if patients continue to use the Weight Watchers app for the dietary side along with what we are doing on the medication side.

Is there any value as there used to be in keeping food diaries and calorie counting and those traditional things? I think that depends on the patient. I have patients that really like data. They use that data to guide their decision the next day. We make so many nutrition choices every single day. I mean, some studies have quoted you make around 200 to 300 food decisions per day. So if tracking is helpful to patients, I encourage it. It is not a requirement to be a part of our program. I do not ask patients to send me their food journals. The dietitians will review food journals with patients if that works well for the patient.

So I do think there is room for tracking and they've looked at studies of what are characteristics of patients that maintain their weight loss. It's seeing a weight management specific provider once a year. It's probably helpful to do it more than once a year, but staying active, even though it's not exercise or that increased heart rate, just some level of steps. And then food tracking as well. I also primarily use it to track protein. I find patients think they're eating sufficient protein and fiber, but when we start tracking the protein, we have improvements to make.

So Alvin, you mentioned that you got into this over 10 years ago. I would imagine lifestyle management had to be a big part of your program back then. Is that still the case today now that you have all these incretin therapies and bariatric surgery? Yes, that's the key. I tell people, you know, you're not going to be able to sit on the couch, you know, have a pill or take a shot and still eating beer and pizza. You know, you still got to do all these other things that we talk about.

And Jack, just to touch on a question that came up. So what do you think about if a patient got to a point where they're not responding to the GLP-1s and intolerability. So guess what, we add other drugs. I have patients on a low dose of the GLP-1s then we're adding some phentermine or some topiramate, whatever we do to get them under control. So not everybody needs to go to the max dose of all these different drugs. They need a little bit there and you're adding some other things on top of that. And the take-home message is that these are just the tip of the iceberg. They still got to exercise and we also forget, Jack, to talk about sleep. If a patient is not sleeping well at night, they will not lose the weight. So I do sleep medicine as well. So it's a whole comprehensive approach to get those patients under control.

Right. GL, any suggestions about this aspect of obesity management? We usually also recommend getting a baseline body composition scan. So we do use our DEXA. So that allows us to have a little bit more data because sometimes patients come in with, you know, this is my goal weight. I want to weigh 110 lbs and we have to kind of go through, you know, our body composition changes as we get older and now with all your comorbid conditions, right, so it allows us to have a little bit more data for them to kind of look at just aside from BMI. So that is one, and then as everyone's mentioned, basically the dietitian mainly to focus on how much protein, how much fiber per day, because everyone always thinks they're eating enough protein and then you put it down and it's actually less than what's recommended.

So glad you mentioned again — DEXA, can you clarify for the audience who may not be aware of this that DEXA can be used to quantify muscle mass and fat mass? Correct. And then also how else can you measure muscle mass if not by DEXA? That's the only one we're using. So I know some people they come in with data from usually the gyms — I forget what they're called — impedance devices. Yeah, yeah, that's what my primary care does. She yelled at me for losing 2% to 3% muscle mass and I said, "But I'm biking more." And she says, "Well, that's just biking. You need to do more than that, buddy."

Okay, so let's go on. We have a few more questions. What is the minimum BMI for using an anti-obesity drug without a comorbidity? Per guidelines, the right answer is 27 is the BMI without comorbidities. But do you have to be a certain BMI to get on these therapies? Stacy, that's a great question. I think if you would have asked me a year ago, I would have said yes. There was more of this idea — as patients we were getting down into lower BMIs, we talked
about titrating patients off of these medications maybe more than a year ago. Honestly, I think now we are seeing the additional benefits and I'm specifically talking about the GLP medications, not necessarily all of the anti-obesity medications, but specifically the GLP and GIP medications. The benefits extend past simple weight loss. With GLP, we are seeing the 20% MACE reduction. That's major adverse cardiovascular effects reduction. We are seeing the decrease or improvement in inflammation. So using it in the rheumatology space and so I do think there's more room to talk about these medications at lower BMIs especially as patients start at higher BMIs hopefully we are getting them down to lower BMIs because we are good at our jobs right and keeping patients on these medications starting patients at lower BMIs is I think a gray area and Dr. Wells probably can speak more to this since he's been in this space for a longer time than I have. So he's seen the transition of lifestyle management now incorporating GLP medications. But I do think there is room for conversation of should we be starting patients on GLP medications at lower BMIs. We may titrate it differently and that's okay and that's appropriate. That's patient centered care. Not every single patient needs to be at the max dose of semaglutide and tirzepatide.

Though of the incretin therapies they don't all have the same indications and there are many new indications for which the BMI grade 30 is not appropriate such as sleep apnea, cardiovascular prevention, and now NASH or MASLD, and if we ever get an indication for psoriatic disease, so how are we going to handle this?

Alan, Alvin, yeah I mean it's going to be a comprehensive approach. I can tell you as rheumatologists we're so stressed already. Alexis alluded to that. Booking out so far — it's going to be APPs. We're going to have to have the support staff to be able to kind of manage these kinds of patients. I think there's no wrong BMI. Jack, but the thing I worry about — the lower that BMI, I'm more worried about them losing more protein. So you got a lady 65 years old, her BMI is 24 and she wants to lose weight so she can play pickleball here in Florida. But I say, "Hey, if you lose any more weight, you're going to lose protein." And so we talk about how to maximize that. So I think it's all going to be about the resources. How do we kind of put things in there and leverage it, but we're just going to see the demand grow and grow because of the popularity, but also because of the efficacy of all these agents.

Yeah. You know, we've had a few questions from the audience about compounding and online pharmacies. We addressed that last week. It's a gigantic issue and basically two years ago or more there was a shortage of incretin therapies and through the 503B program these drugs are approved so a compounding pharmacy could make their own and a bunch of compounding pharmacies did this. And a lot of what's sold online — the numbers are up to seven million Americans are taking these drugs from online and compounding sources. And the problem with that is that they have been shown to be highly inaccurate and highly risky.

How are you guys — Guada, how are you handling compounding, especially when they're seeing Serena Williams and Charles Barkley promoting this stuff?

This is a very complicated question. Yes. The majority of the time if they're able to afford it I do send them to Eli Lilly and Novo Nordisk. I do have a few patients that want me to prescribe compounding and sometimes they ask me to take over because they cannot afford the trade name. What I've done in the past is write for the higher dose and I asked for a vial and I asked them if we can just — it's technically not microdosing, it's just I'm trying to have them use it a little longer. And I know Alvin is nodding because this is another trick with tirzepatide. But unfortunately with the regimens and we're able to get some samples for the oral ones, but again for some patients they don't respond at the lower dose so that's all I can give them.

Alexis, have you come up against this? Yeah. Well, not as much the compounding actually. Just one question on that part about the tirzepatide and getting the vial. I was told that if the patient doesn't get what they're prescribed every month and they're on Lilly Direct, they will be kicked out of the program. So if you get the 15 milligram vial and they don't pick it up for a month because they have enough, they will not be able to get back into that program. I don't know if Stacy has had that or — I think it's 45 days. 45 days. Yeah. And so some patients — yes. So some of them I tell them you may have some extra but this is what'll allow you to stay on this regimen. True. Yeah. We were going to
do that to try to decrease costs like go to every other month and that didn't work. But yeah, I think the compounding I just describe it as you know the nature made vitamins on the you know the wall like we can't really we don't really know exactly what's in there. So it is a risk. Understandably some people want to take that risk because they can't get the more expensive medicine.

All right. So Jack, I was guilty two years ago we were doing this in the clinic because we're able to do that right because of the shortage but now we had to dial that back and I'm only using the brand name drugs now. I have a lot of people coming in already on these compounded drugs, but that's their game. They're using GoodRx and all these other mechanisms, but they're not getting it from me. This is soon due for a legal decision. If you follow this, this grace period was sort of up as of like the end of August, I believe. And there may be legislation that will cut off the availability of these drugs through compounding pharmacies. We'll see.

We asked the audience about contraindications. The right answer here is the MEN2 syndrome. Anybody want to address other reasons why you won't use or why you'll stop the use of a GLP-1 or incretin therapy? One of my patients had very low muscle mass to begin with and so the physician, my endocrinology counterpart, was really nervous about having that patient on a GLP-1 because she already had such low muscle mass because she was moving so little because of her inflammatory arthritis. So that was one where we kind of caught in a catch-22. But the main one, the other one is pancreatitis. If someone has had a history of pancreatitis you may consider being very cautious about that because some of these can cause pancreatitis.

Daisy, what about with a history of gallbladder disease? Do you avoid incretin therapies or is that you just have to watch closer? I guess watch closely. It's very similar to small bowel obstructions because of the gastroparesis. So similar reason with gallbladder disease. The gastroparesis allows the bile to thicken, create that sludge, increases risk of gallstones. You combine that with rapid weight loss, also another reason or another increased chance of gallstones. So I tell patients warning signs to watch out for, to message in, let myself know, let the primary care provider know, when is it appropriate to go to the emergency department. But these are not reasons I would not put a patient on a GLP medication. And going back to the small bowel obstructions, it depends on how many obstructions they've had and if we know the cause of the obstruction. But that is something I keep on my radar. I will titrate up slower than I typically would and always educate the patient on precautions.

Okay. Jack, two side effects that we see are not contraindications, but the hair loss and some of the visual changes. So we're still trying to look at the data and see what the long-term studies look like, but those are two things that are coming up on the radar screen right now. Yeah, they keep popping up, but it's hard to put a hard number on it, and it's certainly in that, you know, less than five, less than 10% frequency that people want to know about, but you know, is that going to stop you from using this?

Just to give the audience some reference numbers, mean weight loss at 72 weeks if you're on tirzepatide 15 milligrams a week — the right answer here was 21%. Most rheumatologists got that right. Is that the expectation now? What drug do you like to use? Is there one that's better than the others? If we're just looking at weight loss as the outcome, if cost is not an issue and the patient is willing to pay out of pocket, I do go for tirzepatide more, just because some of the side effects are more tolerable than semaglutide.

And how do you get to the right dose, Stacy, of tirzepatide? That's based on the patient. Lilly put out an email in a newsletter a few weeks ago and it was bold and said not every single patient needs to be at the 15 milligram — titrate based on the patient. What is our goal? I think one of the panel said a few moments ago a concern for the muscle mass loss, and if our goal is 110 pounds to play pickleball that is different than looking at metabolic improvement. So that's why we routinely get labs throughout patients' experience on these medications. We repeat like pre-albumin, we do DEXA scans as well to use other non-scale victories and non-scale benefits of this medication, determine what is the most effective dose. And from a research perspective, 7.5 and higher are therapeutic doses, so it's very appropriate for most patients to be on a dose of 7.5 or higher. But I tell patients we don't have to rush to the 15 milligram dose. I prefer
to keep patients at the lowest most effective dose and I know I have other doses that I can increase them to if their weight loss starts to plateau or they start to experience weight regain because we do see that metabolic shift with weight loss and so we can increase the dose as needed throughout their journey on this medication and eventually they may end up and stay at the 15 milligram dose for weight maintenance.

So I want to end with this question about what happens when we stop or when we're done with our goal. We asked this question if they stop semaglutide how much weight do they regain? Studies show up to two-thirds of their weight if you stop all-in therapy. So what is your goal when the patients achieve their goal? They've tolerated the drug. They've gotten to a weight that they like and that they're functional with. Maybe it's helping their underlying disease or future risks. Do you want to transition them just to lifestyle? Do you want to micro dose? Do you want to stretch out doses? Let's just go down the line. Alvin, how do you approach this?

So, yeah, we see this after people have been on for a period of time. They regain. I'm asking the question, what have they changed? Are they still exercising? Are they sleeping right? Are they doing meal or portion control? It's all those different things. I said, "Yes, you can go to the Waffle House and have your pancakes and syrup, but you can't do that every single day. You know, you treat yourself and you do this." So you give them something to motivate them and kind of go along, but if they don't want to go back on GLP-1 or creatine, so what we do is add back some older drugs, but it is a long-term treatment just like chronic disease, RA, PsA, whatever else it is. The obesity is a chronic disease that we now all appreciate, right?

G, how do you handle this? So at the first visit, I do emphasize that this is for chronic weight management. And that basically when they stop, they will regain most of the weight back. And as Alvin said, so we emphasize diet and exercise. Just because you've lost the weight doesn't mean that — and you're not doing much — doesn't mean that it'll stay like this. So we want to preserve the muscle mass, right? So by not exercising, by not lifting weight, strengthening exercises — they may continue to lose weight, but they're losing more muscle mass rather than visceral fat. So just emphasizing that I think at the beginning is very important because it has happened to probably 1% of my patient population and then they come back basically six months later and they're like, "Well, I didn't have any cravings before," but that's because you were on the drug. So they're trying to minimize the effect of the drug. And so again, just trying to review — these medications are here basically for the food noise, to suppress your cravings, but at the same time to help with your metabolism, because they want to think that it's all coming from their own. So it is a chronic weight management.

I want to underscore that term that came up a few times, food noise. This is something our patients really have to deal with. This is something these drugs are pretty good at, but it is always going to be there.

So, Alexis? No, I was just going to — I don't have much more to add except to further emphasize that the lifestyle changes start with the drug too, or they start before the drug and then the drug is just to help. But continuing those lifestyle changes are so important throughout.

Yes. Stacy, you get final say. Is it wrong for patients to space out their injection so they can stay on this longer and tolerate the drug better, especially after they achieve their goals? In theory, yes. Because this medication was not necessarily studied to be taken every other week, every few weeks. In practice, do I have some patients that are spacing out their injection every 13 days instead of every seven days? I do. And if it allows them financially to stay on the medication and side effects are well tolerated, I do think there is some validity to that practice. But if we are looking at how these drugs were designed and what their half-life is, it needs to be every single week. If patients are experiencing weight regain, even weight fluctuation of a few pounds on the week they're not taking this medication, then we're not doing as much good as we could for the patient. So do we need to switch them to a different medication that is more cost affordable, or can we support them in a better way with at least the lifestyle component?

I want to ask each of you to speak to this 43% in the rheumatology audience who said that we should not be managing obesity. What have you learned that you might change their minds? Alexis, would you want to start there? I think the impact — if so
the TOGETHER PsA study — I'm, you know, biased, but I think it was really a big change in what we see for the opportunities to improve disease activity beyond switching therapies. So I think the fact that getting weight down with these medications can really improve how someone feels, and now I've seen it over and over and over again. It's such an important tool that we have, and I think that's part of caring for the rheumatic disease. So I think we have to be educated about it and do it.

I think it's very gratifying seeing our practice thrive with our patients basically responding to our dedicated obesity clinics. I know I was the first one that started this and I was the only one, and so it's very, again, gratifying to see the rest of — or majority of — my colleagues basically refer to our obesity clinic. So I think they're seeing it in the patient population. So we're just hoping that a lot more rheumatology colleagues will consider practicing obesity medicine, because that is one aspect of care that we can provide our rheumatology patients.

Alvin, the marketing slogan for the New York State Lottery is "you got to be in it to win it." How can you turn that into a marketing slogan here? Yeah, very easy. I tell people, you know, you got to do it. It's going to be a nice revenue stream. We have a cash component to our weight loss practice. And here's a take-home message, Jack. If they're not doing it, somebody else will. And then why not me? Exactly.

Yeah, Stacy. It's incredibly important that we continue to work together. There are not enough obesity medicine programs, obesity-trained providers to provide adequate care to the number of people that need and deserve access to the care. So continuing to work as a team is crucial in weight management. I tell patients, I may not solve all of your problems, but I feel confident in saying that some weight loss is probably not going to hurt the situation.

And a quick plug for the APPs. Right now there is not a certification specifically for NPs and PAs, but the American Academy of Nurse Practitioners — so AANP — and the Physician Assistant and Physician Associate Academy — sorry, I may have the acronym incorrect — but they partnered to create a certificate program for APPs. And so I would strongly encourage all of your NPs and PAs to take a look at that certification. They're currently revamping it. I believe it will be out starting in 2027. It's self-paced and it's a great opportunity for your APPs to learn more about weight management, these medications, feel more comfortable having these conversations, titrating the medications, managing side effects, and as Dr. Wells said — or as Dr. Cush said — if you're not doing it, someone else is doing it. So let's do it well for our patients.

Stacy, earlier on in the program you said ABOM certification. Is that what you're referring to here? So ABOM — it's the American Board of Obesity Medicine. That I believe is what Dr. Gudakwas — uh, has associated as the obesity medicine certificate. It's not available though for APPs. That's good to know — someday. Yeah. No, it's good to know that they have their own track and that we should be encouraging it.

I want to thank our panelists for a really expert discussion, great insights, great advice for those of us who will be dealing with this going forward. Thanks for watching the series. I want to encourage you to go to the RheumNow site or email, click on the therapeutic update, the four pillars of weight loss. All those videos — they're pretty short, they're worth watching, they'll help you get started. Good night, everyone. Thank you. Good night.