What Are the Four Pillars of Obesity Management?

Hello. Welcome to our RheumNow podcast on obesity. My name is Dr. Philip Mease. 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 Simonetti, 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 Juliana.

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

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

Yeah. So really we are talking about nutrition, physical activity, behavioral support, and medical interventions, which 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 it 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 mutually 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 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, 85% 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 are 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, you know, and we have heard that over the years. What we do know is 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 fiber, lower carb diet, and we know that there is some data for the Mediterranean diet that is supportive and has shown some decrease in inflammation. However, I see such a wide range of patients, and unfortunately more recently I have had so many patients that cannot 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 diets as this restrictive "I'm not eating enough to then lose weight." We're really thinking, let's have healthier foods that are going to really help with our function.

And in particular, now with GLP-1-based therapies, which overall induce satiety and make 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. Some people go all day without eating and eat most of their meals at night. We know based on 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 fiber, and lower in highly processed foods. And also avoiding liquid calories. I think that's the easier, you know, the easier target here. I have some patients that drink quite a bit of soda or juice. So we really work on where they can, you know, where we can focus and then making changes at each step and each visit. We don't have to change everything at once. That's, you know, as I'm getting older, I'm seeing how habits are so hard to change and we can all 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. There's a similar set of issues with physical activity. Many of our patients want to know what can I do safely? If they have a bad knee, if they have an Achilles tendonitis or enthesitis 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. As with all of your patients with their 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 not able to 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, you know, anything is better than nothing. So even starting with chair exercises. In our clinic I 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, that 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-1-based therapy, is our concern for loss of lean muscle mass in general as we lose weight. About a quarter of that is going 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 resistance. And I have some patients that do that. I tell them to use weights, maybe 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, you know, you could do anything for five minutes, right? 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 5 to 10 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 being incremental in their ability to do physical activity. Also, I recommend some additional resources. There are free online resources on YouTube. There are some free apps — the Nike Training app is a good one. There are some other paid apps that are about $28 a month, like the Peloton app, which is another really good option and gives you 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 — they really need to do resistance training. Cardiovascular is also really important and that we can maybe do with, like you said, swimming or stationary bike, lower 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 30 years. So we share intimate moments. We share intimate conversation. So we are in a good position along with perhaps a psychologist or a psychiatrist that might be helpful to us, or a chaplain, to talk about and provide emotional support.

Um, how do you 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 increases the risk of developing obesity. This is bidirectional, similar to what we see with rheumatological conditions.

And having that relationship, and I think approaching the patients in a non-judgmental way, is really key, in particular when you have had this long relationship with the patient. Most often the patients that have obesity come into the office saying, you know, they have experienced a lot of stigma and obesity bias as they are seeking care. Right? 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 — if it was that easy I would have done it," right?

So really coming from a non-judgmental way — I usually first, you know, and I think at least they're coming to see me for obesity management and weight loss. But in the rheumatological office I think first asking permission: say, you know, "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 you are concerned — right, because this might impact your treatment response, it might lead to worse health outcomes, and I'm concerned, and this is how I can help you. And I think presenting that way is very important.

I think other factors that we do see from a behavioral health perspective that can impact overall outcomes — both for weight loss but also for rheumatological conditions, thinking of inflammation in general — is sleep. Sleep is a key one. Patients with pain and fatigue often have problems falling asleep and staying asleep. And patients with obesity are also at higher risk of developing obstructive sleep apnea. So every patient that comes into our clinic we do screen them for obstructive sleep apnea using a STOP-BANG questionnaire, which is a really easy questionnaire they answer, and I just put it in 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 to recommend — not being on screens right before bed. Even in my house now I have lamps instead of overhead lights, because we know that the light can impact 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 can lead to additional weight gain. There was one study that looked at healthy individuals — if they slept less than six hours just a few times per week, they gained as much as 2 pounds per week. Yeah, I know. So they say a bad night of sleep is equivalent to eating a Big Mac, right? So this idea of how important sleep is in behavior — but we know this is also important for pain control, for mood. So really working with patients on this other pillar is very important.

You bet. I thought you were going to comment on your teenager's screen time, but — oh my gosh. No, I mean it's a constant battle at my house. He's like, "Why can I not be playing video games late at night?" So 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. [laughter]

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-1 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, but 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. We are addressing the underlying — you know, we're implementing lifestyle interventions, however we have to address the underlying physiology of the disease. And you know 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 24/7, we have stress, we have lights, we have — you know, all the things we did talk about — a decrease in movement. We're sedentary, we're doing many things over Zoom now. 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 5 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 — 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've had on the market for the last several years, and the newer GLP-1-based therapies that we do see to be very effective. Now they work in the appetite centers of the brain where it induces satiety — patients can start eating and it makes them feel fuller. And overall, some of them do decrease a little bit of appetite. The other mechanism, in particular with the GLP-1s, is that in particular in the beginning they may slow down gastric motility, again leading to a sensation of fullness and satiety. That being said, it 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 — with the medications, we have to make recommendations for appropriate nutrition because they're feeling fuller. I say, you know, you're feeling fuller, so we have to get the biggest bang for our buck. We have to eat more protein, more fiber, because the fiber also will help with motility. Often times 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, doing the resistance training like I mentioned — minimum of twice a week, ideally more if they can — in addition to all the other recommendations that we're giving in managing their side effects. My suggestion is usually to start low and go slow depending on the patient's tolerance. And we do bring patients back in our clinic — unfortunately, as busy as we are, we often bring them back on average 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. If they have additional amounts of weight loss greater than 10 lbs per month, we also add on ursodiol to prevent gallstones.

So again, this is the idea that we truly have, right — we're not addressing only... there's no 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 and I were talking this morning, in particular about all the — kind of the wild wild west here in the West, and I'm sure it's in other parts of the country too — with med spas and some other things. And she said a very wise quote today. She said, 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 you know this is a journey right 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 you know go to other um uh professionals too I use registered dietitians whenever available um nowadays there's a lot of resources online um behavioral health if there is a possibility you know they have all kinds of discounted places online too. So nowadays with telehealth that also helps and hopefully um also helps with patient access. Very wise comment from your nurse manager very holistic. Yeah.

So one of the things that's exciting to us as rheumatologists is uh especially with the publication of the TOGETHER PsA study uh wherein uh even at four weeks into that study where combination of an IL-17 inhibitor and tirzepatide uh uh there was a significant difference in uh ACR responses even uh with minimal weight loss. So it it raises the question are these drugs uh immunomodulatory uh in in nature and uh some evidence for that comes from translational data where we see not only reductions in leptin uh and adipose pro-inflammatory adipokines but also our traditional pro-inflammatory cytokines like IL-6 uh TNF and so forth. So um we're now getting into a fascinating new area where um uh between these effects in PsA, psoriasis, knee osteoarthritis, uh uh broad broad potential benefits, but I'm glad you raised the point about uh fighting against um sarcopenia. This is something that is important for people to recognize to to have resistance training along with their um uh their use of these medicines.

Yeah. No, I think those are excellent points and and I think it's a very it's an an amazing exciting era to be, you know, 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 um affect the inflammatory pathways and how that's leading to better um you know 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 you know and it's a journey, right? And and in remembering that not everybody is going to respond the same. Um that there is a response curve, right? We we have where the majority of people respond by having a certain percentage of weight loss and we have some they're non-responders and some they're super responders. And remembering those those other ends of the curve that um and we might need to change medications, we 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 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 a in the right path of um in you know in the right path for for the treatment of obesity and rheumatological conditions and I'm I'm thrilled to be part of it.

And Juliana we are truly delighted to have you as a member of our our broader rheumatology team and uh I hope uh this may be your first certification that I consider you an honorary rheumatologist. Oh that's amazing. Thank you. [laughter] So, so with that we want and on behalf of RheumNow and this month's focus on obesity and rheumatic disease, thank you for listening. Yes, thank you.