John Morton, MD, MPH, decided to become a bariatric surgeon during his surgical training after he performed weight loss surgery for a woman with diabetes. The woman had been on insulin therapy for years but came back two weeks later and no longer needed it. In that short period of time, her blood sugar levels had dramatically improved. Other patients were reporting the same thing.
“I had the good fortune of having an endocrinologist in my clinic,” Dr. Morton says. “We both looked at each other and said, ‘Wow. What's going on here?’"
That was almost 20 years ago, when doctors were just beginning to understand that bariatric surgery allowed many patients to toss not only their insulin, but their blood pressure (hypertension) medication as well. Since then, a growing body of evidence has shown weight loss—be it surgical or nonsurgical—also prolongs life, restores mobility, and lowers the risks of cancer, heart disease, liver disease, and other serious illnesses. “You start to get an idea of what a burden obesity is when you relieve patients of that burden. They were affected, literally, from head to toe,” says Dr. Morton, who is now chief of Bariatric & Minimally Invasive Surgery for Yale Medicine, as well as vice chair of Quality and division chief of Bariatric & Minimally Invasive Surgery for Yale New Haven Health System.
We sat down with Dr. Morton, who provided answers to commonly asked questions about weight and spoke about a new weight loss center he expects to launch soon.
What is a healthy weight?
A healthy weight is not just the number you see on the scale. Our fifth vital sign should be body mass index (BMI), a combination of your height and weight, and probably the simplest screening tool out there. I would think of it this way: green light, yellow light, red light. If your BMI is 18.5 to 25, that’s a green light and you’re in good shape. If your BMI is between 25 and 30, you still have an opportunity to lose that weight on your own with diet and exercise.
Once your BMI reaches 30, you’re in the red-light zone, which seems to be the tipping point where most people can’t lose weight on their own. It’s also the inflection point of increased mortality and morbidity, when people develop problems like diabetes or high blood pressure. The good news is that there are several treatment options available for people whose BMI has reached 30 or higher. These include medications and endoscopic therapy [a much less invasive approach than surgery—a doctor will insert a thin, flexible tube through your mouth and perform a procedure to reduce the amount of food that can pass through your stomach]. When you get to a BMI over 40, or a BMI over 35 combined with a serious medical problem, you qualify for weight loss surgery.
Some people think their BMI is high because of muscle mass.
I hear that from some people, but that's a pretty rare circumstance. Most of us are not Shaquille O'Neal, or someone who is heavier due to a larger frame and more muscle mass. Most of the time, the extra weight is due to extra fat tissue. And that's easy to quantify. We have tools in our clinic that allow us not only to determine your weight, but also your fat mass and your muscle mass. So, we can tell you if it's muscle mass or not.
Weight loss for people in the yellow “overweight” zone can be difficult. How do you advise those patients?
There are four pillars to weight loss: diet, exercise, sleep, and stress management, and all those things need to be addressed. A lot of dieting is around volume and volume control. So, use a salad plate instead of a dinner plate. Do simple things like drink a big glass of water before you eat, then wait 15 minutes to see if you're still hungry. A lot of times we eat not because we're hungry, but because we're thirsty, or sometimes because we're tired. If you don't sleep at least seven hours a night, you increase your risk of gaining weight. Exercise is always helpful, for your heart and for maintaining weight loss, but you need to burn 3,500 calories to lose one pound while keeping your food intake the same. As for stress management, many of us are on call 24/7 for a lot of things. But it's important to learn to deal with the stressors, so that your body doesn't feel that it needs to keep every last calorie to fight stress. Somehow, whether it's through prayer or meditation or enjoying time with your family, you’ve got to figure out how to get your stress levels down.
At the same time, we’re all dealing with weight gain triggers.
Absolutely. As far as food, sugar is probably the biggest problem, and it comes in different forms. It’s in a lot of processed food, and it plays a big role in altering our insulin levels. We’re also looking at things called obesogens, a general term for different factors that contribute to weight gain. This includes things like Bisphenol A (BPA), which was used in water bottles and the linings of cans, among other things. I did a study showing that if the BPA level in a person’s body is high before bariatric surgery, the patient will not lose as much weight. Insulin, some antidepressants, and antibiotics are obesogens.
Your stage in life can also be a trigger. People tend to gain weight in middle age, when metabolism slows down. They may be working a lot, don’t have time to prepare food, and don’t expend as much energy. We have to do a better job of counseling women who are pregnant or could become pregnant, too. You are supposed to gain 25 or 35 pounds during pregnancy, but unfortunately, the average weight gain during pregnancy is closer to 50. The best way to get that weight off afterward is to breastfeed, but many women can’t do that, and many remain overweight. Then, if you have three kids, you’re gaining more weight with each pregnancy. So that's a time to intervene.
So why doesn’t everyone take weight loss action when the scale creeps up?
The Biggest Loser Study advanced our thinking on this. Researchers tracked the people who were on that show over time and all of them ended up gaining their weight back. That showed that losing weight doesn’t have to do with motivation, because those people kept showing up on a weekly basis, even if they had to be weighed and humiliated.
So, it's not for a lack of effort. It's not psychology, it's physiology. There are hormones that determine feelings of fullness and of hunger, and these hormones are permanently altered when you diet. As the hunger hormone goes up, the satiety hormone goes down. And here’s the kicker: These hormones never go back to baseline after you diet. This is why—as you know if you’ve ever dieted—you can regain the lost weight and then some—and that “and then some” is because hormonal changes have taken place.
What else do we know about the science behind this weight gain?
Some of the cognitive changes associated with carrying extra weight and losing it are important—we’ve seen memory and executive function improve with weight loss. The area of orthopedics combined with weight loss has taken off, too, because we are learning it’s not just about physics—it’s not just that putting more weight on a joint is causing it to degenerate. There is now big recognition that obesity is a disease of inflammation, which affects everything from your immune system to your bones. With obesity, the bones don’t metabolize as well, grow well, or heal well. So, it’s more than just the weight—there are other things that are going on when you are obese.
How do you treat a weight problem, knowing these things?
Yale Medicine is creating a unique weight loss center through the new Digestive Health Service for which I am co-director that will provide the entire continuum of care for patients with obesity. We’re already doing a lot of this now. The center will include everything from diet to exercise to medications, endoscopic therapy, and surgery, all under one roof, with the patient at the center. It will foster collaboration among endoscopy, endocrinology, cardiology, psychology, dietary counseling, medications, and surgery. Cancer care took off when people started to work together, and that’s the next step for us.
The other thing that we're going to do that's unique is an intergenerational clinic. We all recognize that obesity is a family disease. Many times, we’ll treat a young adult who is carrying extra weight, and then they go home and the parents aren’t changing their habits. That’s like sending an asthmatic child home to smokers. If you don’t change your environment, the behavior is going to continue. So, we want to treat the whole family.
Does weight loss treatment really help?
It’s combination therapy, for sure. You have to examine people’s lifestyles. You have to figure out which medications can help and which current medications aren’t helping. Weight loss surgery is different, too. A lot of surgery is episodic, like gall bladder surgery—something is not working, so we take it out. But bariatric surgery is more of a longitudinal relationship. Patients still need to make lifestyle changes, and they can only do that if they are in a place where they have the support to succeed.
We’re also providing weight loss treatment to prepare people for other surgeries. For example, orthopedists do a million joint replacements annually, and a titanium joint can last 30 years. But if you’re obese, that joint only lasts 10. So, we are providing weight loss prior to joint replacement to make people stronger for surgery. Heart surgeons also know that when a patient is obese, it’s more difficult to do open heart surgery or place a stent, and the medications don’t work as well. So, obesity is a chronic disease that affects the entire the house of medicine.
How safe is surgery for weight loss?
Bariatric surgery has never been safer or more effective; for many people, it’s the solution. And it is 95% minimally invasive.
The biggest change we are seeing with surgery probably is that we are doing a lot more sleeve gastrectomies, which reduce the size of the stomach and change its shape from roughly the size of a football to the size of a small banana. The gold standard for bariatric surgery is actually Roux n Y, also known as gastric bypass, which creates a way for food to bypass the stomach. But some people prefer sleeve gastrectomies because they are less invasive. Both of these surgeries involve minimal incisions, a short hospital stay, and a quick recovery. We now have 12-year data that shows that patients who have surgery versus those who don't have a 40% reduction in mortality—that's a huge reduction.
There are some relatively new medications that can augment surgical outcomes, and if you come in for treatment earlier, they can play a bigger role. There are six medications that we can use before surgery, after surgery, or in some combination. Giving a medication to maintain the weight loss after surgery is similar to prescribing tamoxifen to prevent a breast cancer recurrence.
What are the rewards of helping people finally lose weight?
For me, it’s a real blessing. This work is technical, it’s intellectual, and, of course, it’s emotional, because who doesn’t like having grateful patients? I’ve treated approximately 4,000 patients, and the stories I hear are overwhelming. Some refer to their surgery date as a "second birthday.” I have success stories about improvement in health and in quality of life, where now they have the confidence to apply for jobs. Some people who couldn’t conceive before will start families. It’s a happy specialty. We don’t have a lot of complications at all, and we really do make people better.