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Evidence and algorithms can only take us so far. The decisions we make with patients depend on our ability to communicate complex, sometimes uncertain, and emotionally loaded information in a way that builds trust and supports shared decision making. Weight is one of the most sensitive topics in clinical practice, and in PSA it is also one of the most clinically consequential. Let's go to a case and meet Ayesha. She is 44, has PSA well controlled on an IL-17 inhibitor, and has a BMI of 34, up from 29 at diagnosis. She has gained 6 kg over the past year. Her rheumatologist wants to discuss weight management. Ayesha has previously expressed frustration and distress when weight has been raised by her doctors. Let's take a look at polling question number 6. How confident are you in initiating a weight management discussion with a PSA patient who has previously reacted negatively to this topic? A very confident, I have a structured approach. B somewhat confident, I raise it but find it uncomfortable. C. Limited confidence. I often avoid it or defer to others. Or D, not confident. I rarely raise weight in this context. Thank you for these responses. Now on to Doctor Morola. How do you approach a conversation with Aesa, a patient who has been hurt by previous clinical encounters around weight? How do you raise this clinically necessary topic in a way that maintains trust and keeps her engaged in her own care? I'm happy to take a stab at this. I, I will tell you, um, off the bat, I was, I was impacted recently by a comment that was made by a patient at one of our, uh, uh, national meetings, the IDIOA meeting, during outcome measures meeting. And in that case, um, it was a woman who has struggled with her weight, has inflammatory disease, and in fact, was saying, you know, just the opposite, that she wishes. Physicians and providers weren't so afraid to bring it up or weren't embarrassed to bring it up. And so I think, I, I just say I think that there are patients on both sides of this spectrum, those who are waiting for us to bring it up and others who may be uncomfortable by it. So I'd say don't, don't assume by walking in the room that patients are automatically don't want to talk about it, they may be very eager to talk about it. Um, so I'll start with that, but I, you know, I think there is some learning from the literature, you know, about how to prompt. Um, these conversations. So, first of all is, you know, what's called the permission-based opening, right? So thinking a little bit about, you know, um, asking if it's OK to discuss, you know, weight, uh, and, uh, uh, you know, rather than. Leading with it, um, you know, it may, uh, you know, or pointing out, uh, you know, pointing out the need or the potential benefit, uh, you know, without first opening that conversation, um, framing it as being disease relevant, I think is increasingly, not only, um, uh, you know, relevant, but, but true. I mean, I think we're, we're learning from all of these, um, studies, the one we're talking about today, that, you know, that the, that. We can tie it back to more than just, you know, the, the, the old conversation about weight loss, right? It's about tying it to symptoms, uh, tying it to inflammation, tying it to the comorbidities of disease, uh, rather than just being, uh, you know, some sort of lifestyle failure or personal responsibility issue. It's, it's bidirectional, right? That the weight is contributing to the inflammation burden. The inflammation burden is probably contributing back to. The weight, the ability to be active, and, you know, and framing it in that way and taking away some of the, the, the, the, the burden, uh, and, and the guilt from the patient, I think is really very helpful, um. You know, I know um we have uh some content, you know, we're sharing around non-stigmatizing language, you know, looking about what to avoid, what, you know, what would be preferred language. I think getting comfortable with those, uh, can be helpful, um, you know, in this particular case, acknowledging, um, Ayesha that, you know, that she's had this negative experience in the past, but then moving it beyond again, the lifestyle. Um, failure and, and, and quickly moving it into the understanding of the, of the pathobiology at a, at a patient appropriate level, um, I think is, is really important. Also, we're in a new era where that conversation's very different than talking about. And I think this is key. It's not about what you're eating or how many, you know, how many blocks you're walking, we still have to have those conversations, that's still the healthy conversation, but we have other interventions, and I think that that also is facilitating because it wasn't just, you know, hide the cookies, it's, you know, let's talk about. Um, that, and, you know, we have some ways, uh, to help you because I can tell you in my house that hiding the cookies is not, is not working well for some, some of the folks on this call right now. So, uh, anyway, and by the way, last thing I'll say, you know, we looked in, you know, and speaking of Together PSA I mentioned this earlier, but in the arm that, that was, that included. You know, first of all, these are patients in a, in a clinical trial setting where we know they adhere better. They were given individualized counseling for healthy diet and exercise. You know, this is a moment to de-guilt people even in that context, we saw very little weight loss and very little impact in that arm, which to me again underscores that that's not a frequently highly impactful intervention in in these patients. Uh, this slide addresses the whole issue of talking about weight and, and use of language when we're communicating with our patients. Several phrases that you should avoid because they are stigmatizing. You need to lose weight. It makes your PSA worse. Your BMI is a problem we need to address. Have you tried dieting or exercising more? Obesity is limiting how well your treatment can work. Preferred statements might be the following. And these include asking permission for communication. Would it be OK to talk about how much your metabolic health connects to your PSA? Some of what's driving your symptoms may be coming from inflammation linked to body weight. Can we explore that together? What has your experience been managing your weight in the past? I want to understand what's worked out and what hasn't. There are options now that can help with both your joint disease and your metabolic health. Would you like to hear about them? So some key principles frame weight as a disease relevant metabolic factor, not a lifestyle failure. Do get permission before raising these sensitive issues. Uh, Disease framing is important, as you're discussing management options. Doctor Gottlieb, what are realistic expectations to set for Aesha if she starts a GLP-1 receptor agonist alongside her IL-17 inhibitor? How do you communicate the uncertainty around timeline and magnitude of benefit without undermining her motivation or eroding trust? To be frank, I don't approach it that way at all. First. Of all, I often with a patient on the first time that I see them, remember their skin can be bad. They can't, they can't do a lot of daily tasks of living. I had a patient crying, saying I can't make the peanut butter and jelly sandwiches for my children because my hands hurt so much. This is not the time. I, I think that the, the first thing to do is, is to Get them better. At least get them better somewhat, and, and sometimes you could, many people clear without the benefit of the GLP-1 receptor uh uh agonist. So the first thing I do is get them better, OK? And, and then I bring up, uh, um, it could be the second visit, but I'll bring up, you know, that people with psoriatic arthritis, especially, Those even with psoriasis alone have an increased risk of mortality due to cardiac, I go, I, I go through the litany. I mean, a cardiovascular issues, stroke. I also talk about sleep apnea. I also talk about um weight on the joints and uh. And then I say, I'm gonna make the outsides and your joints much better. I want the insides to look as good as the outside. And so, and then I bring up the subject about uh weight loss that we have medications that can really help with weight loss and I think it would make your psoriatic arthritis even better, your skin even better, and cut down on those comorbidities that could shorten your life. And that's how I bring it up. I don't talk about uncertainties and all that. No, I don't. Thank you both. Ayesha's case reminds us that communication is not a soft skill. It is a clinical competency with direct implications for treatment, uptake, adherence, and outcomes.