Conquer Your Weight

Dr. Sarah Stombaugh: This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight Podcast, episode number 64. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone, and thank you so much for joining me today. I am excited to bring you a special guest for our episode, but before I do, I want to take a minute to invite you to join my medical practice. If you have been listening to my podcast for a while and thinking, oh my gosh, I wonder, is this the right fit for me? Am I a good candidate for these type of medications? I really wish I had someone to advise me on the right type of nutrition or exercise or whatever it is. If you wish that you had someone supporting you in your weight loss journey, I would love to be that person. Even if you're just questioning, I wonder if this could be a good fit, go ahead and reach out. I do a free 30 minute meet and greet visit on Zoom with any potential patient to learn about their goals and how I can best support them. And honestly, if it's not a great fit, no big deal, I will send you in the direction of another physician or another program that I think may be a good fit for you. So if you are interested in working together, go on over to www.sarahstombaughmd.com. That's S-A-R-A-H-S-T-O-M-B-A-U-G-H-M-D.com. You can find that webpage also in my show notes. Go on over to the individual visits page, fill out the form there, and our team will be in touch with you in order to get you set up with that free meet and greet. Visit to learn if my practice is a great fit for you. And now for today's episode. All right, welcome. Today, I am so excited, I have a guest with me, Dr. Isabelle Amigues. She is a rheumatologist and a good friend, and I'm so excited to talk with her about the role of arthritis, inflammatory arthritis, how diet plays a role, how some of these medications play a role. We were talking because about a month ago now, a really interesting paper came out talking about some of these new medications, the GLP-1 receptor agonist and how they can play a role. And so we are going to talk about that and all of the good rheumatological stuff today. So Dr. Amigues, thank you so much for being here today. Dr. Isabelle Amigues: Yes, and thank you so much for having me. Such a pleasure. Yes, Dr. Sarah Stombaugh: I'm so excited. Tell us a little bit about yourself. Dr. Isabelle Amigues: Yeah, absolutely. So I'm a rheumatologist, so I'm French, cannot hide it. I have the accent. So I did rheumatology, actually, I did everything in France and Paris and in Leon in France. And for love, I moved to the US, but it wasn't that easy. I had to do all of the training again. The good thing is that it's pretty much free in France, so it was okay. I did the residency and fellowship again and New York City. I finished with fellowship at Columbia University, and I love rheumatology so much that it was really just a pleasure. In fact, I even extended it a little bit. I wanted to do more research. And then I moved to Denver, Colorado that I love. And I was faculty practice in National Jewish, which is a faculty and researcher center. Did a lot of lung associated with rheumatologic disorder stuff. And then at 40, so almost five years ago now, I got diagnosed with stage four breast cancer, and I've done very well, continued to do so, and I really can thank the medicine, the western medicine for it, but I also discovered a whole new way to approach conditions that included eastern medicine such as Qigong and energy healing, meditation, visualization and things like that. And it was so powerful to me. So at first I thought, oh, this is placebo, right? Even if it's placebo, it doesn't matter. I want the placebo on my side, so I will take the 30% because usually placebo is 30%. But then I started looking into it and saw actually a lot of good studies on all of those. And so I started to integrate it into my practice and then realized that the type of practice I had with the faculty practice I was in didn't allow me to fully be this new rheumatologist that I had become thanks to this health crisis. And so I open the first direct care slash concierge rheumatology practice in Denver, Colorado a little over a year ago. And gosh, I love it. I think it's the most incredibly satisfying practice I've ever had. And it's funny, I thought maybe I would miss doing research and things like that, but actually I want to. And I think there will be a time in my life where I will do research again, but for now I am just enjoying taking care of patients, loving them, just making sure that they're doing well and offering the best of me to my patients. So that's what I do and I'm very happy. And I think it's cool to have this background of both a researcher as well as a clinician, and now really putting it all to the core of what clinical care is. Dr. Sarah Stombaugh: I love that. Your story is so amazing. Everything from your training and to your cancer and being able to be in a place where both, I mean you had double the training, right? Just simply because you did double the length of time really of any other physician out there, which is really pretty impressive. And your commitment to the field to do it. Again, we know a lot of physicians, my listeners may not know, but it's really common in medicine that people who've been practicing in another country when they come to America, they think, oh gosh, maybe I'll be a fill in the blank. And they change their specialty. So I love that rheumatology was so special to you that you continue to do that again. And we know that eastern medicine, it's been around for millennia, and so we know that there are so many benefits of it. So the fact that you've been able to use that in your personal journey and sharing that with your patients, I absolutely love that. So thank you for sharing with us. I would love to hear from you, I have patients all the time who are dealing with arthritis. Sometimes it is osteoarthritis, sometimes it is inflammatory arthritis. And I feel like there's not always good messaging about what is the difference between those things, both in terms of diagnosis and even treatment. So I'd love to hear from you about what those two different things are. Dr. Isabelle Amigues: Yeah, thank you so much for this question because it's really something that I try to put out. So I have my own rheumatology YouTube channel, and that's something I feel like I keep repeating over and over again because inflammatory arthritis carries so much more issues than osteoarthritis. So osteoarthritis is what we call mechanical joint pain, mechanical in the sense of it's the mechanics of the joint. That's an issue that's primarily an issue because as time goes, we are thinking that everything is inflammatory related, but for now, osteoarthritis has a genetic component and basically an overused component. And so if you're repeating [phone] use, we are seeing, for example, a lot of osteoarthritis because people are using their phone all of the time. If you're a worker like in the streets, you might have developed, if you're using some of those tools that are vibrating on the street, you might develop some type of osteoarthritis in places that usually we don't see and so on. And then there's also this genetic component and that type of pain is very different that the inflammatory arthritis. But before we go into this, the inflammatory arthritis is an arthritis that's associated, and that causes and is due to inflammation. Mostly it causes inflammation. And the problem with inflammation is that it can destroy your joint. So not great because then you can lose function, but it's actually more than that. Usually there is inflammation in your whole body. You may not necessarily see it, but you have it and you may have more cardiovascular disease, heart failure, hypertension, you may have lung disease, you may have skin conditions and fatigue, et cetera. And for me, one of the studies that I was involved actually as a first order was so cool because it was at Columbia University and we were looking at the heart of patients with rheumatoid arthritis who had no cardiovascular disease. And what we saw is the patients who had the higher activity of their disease, so their disease was more severe, we found that they also had more inflammation in the heart. There is no reason to have inflammation in the heart. But then even better, we saw that it decreased, that inflammation in the heart decreased as we treated the rheumatoid arthritis. And so I think that that's very, very cool. And so that really shows a difference between inflammatory arthritis and the mechanical arthritis. Now, in terms of how we distinguish it, and I think that that's very important for the people who are listening, there's three or four main questions that are really important and that can really help you reassure yourself saying, okay, this is not inflammatory or tell you have a call to action of please go and see a rheumatologist. One is that inflammatory arthritis is worse in the morning. That's number one. So is it worse in the morning or is it more like at the end of the day, if it's in the morning, if you wake up with pain, that's a problem, right? Then do you have morning stiffness? So do you feel stiff as if you had to wait until all the oil engine in your joints are working and that if it takes more than half an hour, we say that that's morning stiffness, that's consequential, so that is associated with inflammatory arthritis. And then do you have any swelling of the joint, not the bony swelling, but where if you touch it, it's like a cushy feeling that's inflammatory, and then does it get better with exercise? That's inflammatory. So I think the free question that the patients can ask that you all auditors can ask, is your pain worse in the morning? Is it associated with more than 30 minutes of morning stiffness? And third, is it better when you exercise? If you respond one to any of those questions, I would recommend you see a rheumatologist because you may have an inflammatory arthritis. So I think hopefully this helps each of those have a full hours lecture. Dr. Sarah Stombaugh: I appreciate that because a lot of times you hear people talking about arthritis, but it's not always clear what is meant. And it's very common when patients come into my clinic that they're dealing with osteoarthritis commonly of the lower legs, of the knees is very common, of the hips, and it's common because we're bearing our weight on those. And we know of course, that losing weight can make a really major difference in the improvement of those symptoms. But what we also know is that losing weight can improve the symptoms of inflammatory arthritis. So I'd love to hear a little bit for you, what does it mean to have inflammation? What is the role of obesity, or excess adipose tissue, that excess fat tissue, how does that contribute to the inflammation in our body and then specifically in inflammatory arthritis? Dr. Isabelle Amigues: What a good question. And one that has been looked at and continues to be looked at a scientific level with research and metabolic syndrome or overweight is affecting one-third of the population or even more. Dr. Sarah Stombaugh: Two-thirds. Dr. Isabelle Amigues: Two-thirds, right. Like what I was saying. I was like, no, it's more but two-thirds is so much. Dr. Sarah Stombaugh: Well, it's about one-third overweight and one-third obesity. And so when we combine it, it's significant. Almost 70% or a little more than 70% of our population has overweight or obesity. Dr. Isabelle Amigues: So there's a lot of conditions that are associated with it. And basically, so we know that adipose tissue is pro-inflammatory, that we know that in cardiovascular disease, we actually know this also in cancer patients. So for example, breast cancer, one of the things that I don't want to happen to me is recurrence. So I look very much at what can I do to prevent that? And it turns out that there's a study that shows that overweight, so not even just obesity, but overweight is associated with more recurrence. You're like, okay. And it's because we think now that cancer is a pro-inflammatory state. So now coming to the rheumatology perspective, and we were not sure, we had some ideas that, for example, a lot of psoriatic arthritis patients, it's a certain type of inflammatory arthritis, they tend to be overweight and obese, and we all had seen that with improvement of their weight, they would be better, but there was no study per se. And then we started doing studies and we started seeing that there is a direct correlation between fat tissue or adipose tissue, and number one, developing psoriatic arthritis or rheumatoid arthritis or inflammatory arthritis in general. And number two, with layers. So the activities, so how severe those inflammatory arthritis are is related to how much fat you have in your body. And so very often what I would tell my patient is that it's not about how much you weigh, it's how much muscle tissue you have versus how much fat tissue you have. And so if everything is muscle or good, even if you weighed very little, but all you have is just adipose tissue, that's still a problem. And so there's such a correlation. You can actually look at the tissue, the fat tissue, and see that it's inflammatory. It's really, really cool. The studies that are looked at right now are very, very interesting when it comes to inflammation and adipose tissue. I don't know if I answered your question. I was going to go somewhere else after that, but yeah, that's the first piece. Adipose tissue or fat tissue is pro-inflammatory and causes rheumatoid arthritis causes psoriatic arthritis. Those we know probably causes other inflammatory arthritis to be honest. And it's associated with more severe disease, in both cases like rheumatoid arthritis and psoriatic arthritis. Dr. Sarah Stombaugh: And so what do we do about that besides the obvious of lose weight, how can we best support our patients in doing that? Dr. Isabelle Amigues: So up until very recently, personally, my goal is always remission, especially in rheumatoid arthritis and in psoriatic arthritis, and we have a whole set of what we need to do called the treat to target. So you start with maybe a DMARD and then a medication or a medication, and then you go to a biologic, which is you go very directed against inflammation. And really, honestly, in a lot of patients it works superbly and we get to full remission like that. And that's great. And some patients, I had this hint right there where I remember when I think it was the GLP-1 agonist, and I had a patient that had diabetes and that had no, she was obese and she had psoriatic arthritis. And I remember thinking, I've tried so many treatments for you and you haven't achieved remission, you're much better, but you haven't achieved remission. And I remember telling her, and it was at the beginning of all of those drugs, and I was like, I think you would benefit from trying. And I think it was Trulicity maybe at the time, and I was like, I think you should try Trulicity and see how that works for you. She had diabetes, so got approved right away, started it. So there's a time where it wasn't so known, so not everyone knew about it. So she started it, she had it and she loses 30 pounds. But in the process, and sorry, and in the process, not only does she lose 30 pounds and she also gets perfect remission of her psoriatic arthritis. We had not changed anything else. That is the only thing that did. And so the reason I share this is that when you have inflammatory arthritis, you have pain. So it's very hard to say, oh, just exercise. And we all know it's not easy to lose weight, especially if you have insulin resistance like after menopause or if you have diabetes. It's not easy to lose weight. And I'm so upset every time someone is like, oh, just lose weight. And they're like, okay, yeah, sure. Tell me how. Dr. Sarah Stombaugh: Yeah, like I haven't been trying that. Dr. Isabelle Amigues: Yeah, it's kind of ridiculous. And it's always the woman that get that. I feel like in men, we don't usually say that. We don't hear that as often, but woman is like, oh, you should just lose weight. And I'm like, wait, what? Tell me how. Really that's important. So then comes, and I think that that's what you were referring to, this article in nature, which I think is just a review, a small review article to show that all of those drugs, and this is where I get so excited because you could say, okay, well, we're decreasing the adipose tissue, we're decreasing the weight. So because you're decreasing the weight, you're decreasing the adipose tissue when you use GLP-1 agonist and semaglutide and so on, and that's great. And that by itself is going to decrease the inflammation that's associated with my patients with inflammatory arthritis. Now, do they have their own anti-inflammatory mechanism is a question. And that is very cool. I can remember my patient, she loses 30 pounds and she also gets into remission. So that's just one example. I've got some other ones since, but then I think it's really cool to say, well, what if the first step in treatment of a patient that's obese would be to lose weight and to help them with that? I think we say that first you lose weight, then you exercise. I think it keeps changing, but it's what at first you lose weight, then you can keep exercising. You can start exercising because having less weight allows you to have more energy and to work out. But I think it's really just this approach of can I help your inflammatory arthritis from both side? And really it's the third side, the side of I'm helping the inflammation directly with the drugs that I know in rheumatology. The second side is helping the inflammation by decreasing your weight and also helping maybe the inflammation by those new drugs as well. And then the third side is this empowerment of the patient of lifestyle changes and then more exercise and a better diet. And if you want, we can talk about anti-inflammatory diet, but really this holistic approach of it's not just one thing because we're so complex, it's really just attacking and it's not attacking, but managing. Dr. Sarah Stombaugh: That's really comprehensive. And I think that's because that's exactly it, right? When we think about our bodies are so complex, it's never going to be, let's just do this one thing and it changes everything. These medications, whether we're talking about for the treatment of obesity or for the treatment or support of inflammatory arthritis, they're just part of the picture. And when we can think about the other medications for arthritis, thinking about the dietary changes, the exercise changes, what is the comprehensive lifestyle that involves, and yeah, I would love to hear that from you because we often hear inflammatory or I want to follow an anti-inflammatory diet, and what does that really mean? Dr. Isabelle Amigues: Well, yeah, that's such another excellent question. I will say that I didn't understand it either, and I thought anti-inflammatory diet and Mediterranean diet and whole food plant-based diet was all three different diets. And then you start looking into it and you're like, no, no, no, no, no, they're actually almost the same. So a whole food plant diet is just the same than a Mediterranean diet just without the fish or the meat because you're trying to not have any animal protein and anti-inflammatory diet and a Mediterranean diet, if you look at it, it's literally the same. So then I can speak about the inflammatory diet. The inflammatory diet is basically the SAD diet, standard American diet. It's really sad because it's basically what my kids want, burger, bread, processed food, sugar. And the truth is that we are made to like this. It's not our fault. We like sugar. When we were made as the first human, if there was sugar, you wanted to pile that up because you didn't necessarily have access to the sugar in a long, you didn't have access to the blueberries or whatever, raspberry or strawberry the whole year. So you wanted to pile that up so that you would have access to reserve during a time where there was not as much food. The problem is that now we have enough food, and so then they create inflammation because they are piling up and they do create more fat, and then ultimately that's inflammatory. And then on top of that, there are some nutrition choices that are not nutritive and are pro-inflammatory. And that is usually processed food, sugary food, and red meat mostly. And it is proven that it is pro-inflammatory. It is proven that people who eat this have more chance of having rheumatoid arthritis, and it's proven that it can cause flare. And in fact, I have so many times my friends, my patients would tell me that they would develop flare if they eat sugary stuff. And so then an anti-inflammatory diet or the Mediterranean diet is pretty much a diet that's choosing to stay away from this. And I will give you a really cool example. So I'm French. My family comes from the south of France. So Mediterranean, they are coming from Corsica. And when I was a kid, I would hang out at the cemetery. It is not creepy, it's not sad. Imagine the sun, the view on the sea and you're by the mountain. It's actually beautiful. My grandma would go and take care of the tomb and she would meet other people because it's a very surprisingly very social plates, at least it was. I don't know that it's still a social place now, but then you have me as a kid and my brother and my sister, and we're small and we start just playing in the cemetery. And again, beautiful sun like blue sky. So it's fun. The cool thing was for me, I was learning how to do subscription. And a very cool thing was to start realizing that a lot of people were lived to be 98, 100, 96. And I mean we're talking when I was young, less than 10 years old. So that's thirty-five years ago. And when those people had died much before, and it turns out we know that they eat a very specific diet because what do they have? They have access to a little bit of meat, and that would be the type of meat that you would eat only during the big holidays. So Easter or Christmas, something like that. I can just think of what my grandma would make to know what an anti-inflammatory diet or Mediterranean diet is. So they would eat a little bit of fish, very little. They would eat very little amount of meat. They would eat a little bit of fish, but not that much. And really what they were eating was salads, like products of the garden and salads and chickpeas and tomatoes that add so much taste and olive oil because that's Mediterranean area where you can do olive oil. And there was a little bit of bread, even though here, I don't know, the bread in this country is definitely processed differently than in France, but you would have one piece of bread, right? It is not like the whole bread. And so then you're thinking, okay, well, so a Mediterranean diet is a diet where you enjoy your food. It has a lot of taste and you have moderation in meat and moderation even in fish. And really it's more whole food plant based. That is an anti-inflammatory diet, and that works if you do it, you feel better if you do it, you have less joint pain, you have more energy, and it's proven in so many countries and in so many places, and that's what we should all strive for. So yeah, that's the anti-inflammatory diet. Dr. Sarah Stombaugh: I love you sharing that. Dr. Isabelle Amigues: I went on the tangent of the cemeteries... Dr. Sarah Stombaugh: No, I love it because I think one of the things I say to my patients sometimes is, would your grandmother recognize that food? And so if your grandmother has no idea what you're eating, it is not real food. If it's not made of real ingredients combined together, my grandmother would recognize a chocolate chip cookie. She would not recognize even a protein bar for example. What is this food that we or food-like item that we are putting into our bodies? Dr. Isabelle Amigues: And I always go back, I'm someone who really likes, I like fairness. I don't like when things are unfair. And one of the thing that really I cringe is the fact once you know that the reason people are tending to all of those really bad food because we all know it's bad, and I would say the other day I had not eaten and where did I gravitate towards? There was a smoothie and then I was like, wow, this smoothie is really good. And then you realize that there's 23 grams added sugar. And so then it's realizing that if we like something more than the spinach, it's probably because there's added sugar because that's their way of selling. And so then we realized that and we're like, okay, do I want to be manipulated by the system or do I want to do my own choice? And it's not necessarily, I think I personally try to give myself some grace and I definitely give my patients grace. It's funny how we're always harder on ourself when it comes to food because it's not easy. Everything is made so that we eat the processed food because it costs us money to make and it's highly addictive, and so you're going to eat more of it. Dr. Sarah Stombaugh: I always say that is someone's full-time job. There are food engineers who their entire job is to work on what is the texture and the flavor and the mouthfeel, and there are people who get paid lots of money by every single corporation in order to make that Oreo. An Oreo is perfectly designed to be crunchy and then creamy and then crunchy and got the tiniest bit of salt balance the sweet. That is a full-time job. That is many people's full-time job is to create and craft the Oreo. And so when you think about that for all of these highly processed foods, it's like of course they are designed to be really addictive. And what I think is really fun though is that some of these real foods can be really, really, really delicious also, and I think that's part of it too, is learning how to prepare them and how they can be enjoyable. Because I used to hate broccoli, for example. I thought it was blech, and it took a really serious dedication of, okay, it turns out I don't like broccoli when it's over steamed in a microwave, but when I roast it or when I saute it or when I do these different things, it's actually much more enjoyable. Dr. Isabelle Amigues: Yeah, that's exactly it. That's exactly it. Discovering the pleasure in eating food at a different level and it takes a food education. It is not easy, but it's so powerful because then it empowers everyone to make choices. I love bread, and so I started doing my own bread with flour that comes from France, and yeah, I felt less side effects from it because otherwise I feel pretty bloated if I eat bread from here. And that is kind of cool. I was like, oh, I'm empowered to make my own bread. It's cool. Dr. Sarah Stombaugh: Yeah, I love that. Well, and thinking about each of our journeys, it's going to be different. And there's these general principles that we can apply to anyone and looking at, even if you're desiring like, oh my gosh, I wish I could eat these healthy foods. And it's so challenging. That's where it's been really neat to see some of these medications, the role that they play in the food chatter in supporting the healthy decisions that we're already making. And you probably know Semaglutide just got FDA-approved last week for cardiovascular risk reduction, so not for diabetes, not for weight. And so we're starting to see it and it's fun to think, are we going to see it for inflammatory arthritis and for these other conditions because our weight is really just the result of so many things in our life. And so thank you for coming on to share that. Let me ask you, as we wrap up, is there anything that you'd like to share with our listeners? Dr. Isabelle Amigues: Yeah, I mean, I think we touched about so many things when it comes to food and inflammatory arthritis, but I do have a podcast and I do have a podcast on UnabridgedMD where I really would love to have you on. And then I also have a rheumatology YouTube videos where it's called Rheumatology 101 by Dr. Isabel Amigues, but really rheumatology 101, and you should be able to see it because it's really important to educate patients and to educate ourself really in this landscape that's ever changing. There's so much and there's data that there is people who are scientific and there's other people who are not scientific and what's real, what's not, and is there any data and so on. So love educating and so always happy. And then of course, if anyone has a rheumatologic condition, I'm happy to take care of them if they are interested. On the social media and everything, my practice is called on UnabridgedMD for the non edited version of the physician and the patient. Dr. Sarah Stombaugh: I love that. And we will share all of your links in the podcast notes so my listeners can check you out there. Thank you, Dr. Amigues, so much for doing us today. We really appreciate it. Dr. Isabelle Amigues: Thank you.