- Losing just 10% of total weight can improve health, such as reversing fatty liver disease or mild diabetes.
- Nutritional counseling can help patients lose 5% of their weight over six to 12 months.
- While there's no "magic pill," certain FDA-approved medications can help with weight loss.
- Every patient receives a customized plan for weight loss with lots of support from the entire team.
Jeremy Savage was looking forward to helping his daughter move into her freshman dormitory, but the girl pulled her mother aside to whisper some doubts. “She didn’t think I was going to be able to do it,” says Savage, 62, who lives in Fairfield. At 5 feet 11 inches and 260 pounds, his back hurt all the time and he had been having trouble walking. “She forced my wife to make a doctor’s appointment for me,” he says.
His general practitioner said he was healthy but for his weight—which was the problem. “She said it was so bad, I’d be in the hospital in a few years,” he says. “That really opened my eyes.”
Savage had gained about 60 pounds in five years. Life had been stressful, given his work as a broadcast engineer for Sirius XM and the struggles of launching his four children into adulthood. “Some were getting into trouble, and I had to get them straightened out,” he says. “It was really tough for a while.”
Savage’s doctor referred him to Wajahat Mehal, PhD, MD, director of the Yale Medicine Metabolic Health & Weight Loss Program in November 2015. “Dr. Mehal didn’t mince words,” Savage says. “He had me pick up a 20-pound jug of water. He told me, ‘You’re carrying four of those around with you all the time.’” Then Dr. Mehal talked about what Savage could do to lose those pounds.
Dr. Mehal meets individually with and tailors a customized plan for every patient. His program, which started in September 2014, offers every effective nonsurgical intervention for weight loss, including referrals to bariatric surgery.
“There are a million purported things that people say can help you with weight loss,” says Dr. Mehal—but most do not work. The Yale Medicine Metabolic Health & Weight Loss Program uses only methods that have been proved successful through rigorous scientific studies. “They all have good clinical data for efficacy,” he says. Patients can choose any or a combination of the following options:
- Nutritional counseling: Patients learn how to make better lifestyle choices—eating healthier foods and exercising more. “Patients generally lose about 5 percent of their weight over six to 12 months,” Dr. Mehal says.
- Meal replacement plan: “We take over the patient’s nutrition completely for three months,” Dr. Mehal says. A weekly meeting, led by a nutritionist, provides structure and community. “Patients learn new behavior and lifestyle skills, which will support them during weight loss and provide tools for long-term success,” Dr. Mehal explains. “The environment exposes us to high-calorie food choices 24/7,” he says. “The analogy I like to use is that we’re all living in a rock concert; we’re going to put you in a quiet room for three months.” Patients have lost 30 to 90 pounds in three months in the nutritionally complete meal-replacement program.
- Medications: The FDA has approved four oral medications for weight loss—Contrave (naltrexone HCl), Belviq (lorcaserin hydrochloride), Fastin (phentermine) and Qsymia (phentermine and topiramate). “They’re not magic pills—you can’t just take them and then eat whatever you like,” says Dr. Mehal, but the medications can help dial down appetite. “People often aren’t hungry until 1 or 2 in the afternoon,” he says. Another medication, Xenical (orlistat), reduces fat absorption. A sixth (Saxenda), delivered via injection, is a version of a natural hormone. According to Dr. Mehal, patients who choose medication typically lose about 10 percent of their weight over six months.
- Mindfulness: A mindfulness-based stress reduction class taught by a nurse practitioner helps to strengthen patients’ awareness skills so they learn to bring full attention to the process of eating. This can renew a sense of pleasure, appreciation and satisfaction with eating, so people consume fewer calories.
- Gastric balloon: An in-office procedure performed under sedation involves endoscopic (down the throat) placement of a silicone pouch in the stomach. It is filled with about 700 cc of saline, making it “about the size of a small melon,” says Dr. Mehal. It helps people feel full faster, so they eat less, and also delays the emptying of the stomach, so they’re satiated longer. Weight loss comes quickly, with a typical loss of 30 to 34 pounds in six months. The first nonsurgical weight loss device approved in the U.S., the intragastric balloon can help people who need more than diet, exercise and pharmacologic intervention but don’t want to pursue surgery.
Bariatric surgery is sometimes best
Patients who need to lose even more weight may be referred to Yale Medicine’s bariatric surgeons. This may be appropriate for those with a body mass index (BMI) over 30, if there are associated health problems, or a BMI over 40 if not. Dr. Mehal believes that bariatric surgery is the optimal approach for people with significant amounts of weight to lose. “If they are 350 pounds, and they want to be 200 pounds, that degree of weight loss is really only possible with surgery,” Dr. Mehal says.
After discussing a patient’s weight, weight loss goal and the approaches offered at Yale Medicine, Dr. Mehal asks which strategies, if any, appeal to him. “It’s not prescriptive,” he says. “We don’t tell the patients what they should do, because that doesn’t work, frankly. I tell them about their options, and give them a realistic idea of what each intervention will do. Then the patient has to decide, ‘I want to do A or B, or a combination of A and B,’” Dr. Mehal says.
Most patients are enthusiastic about giving some of them a try.
Savage immediately knew how he wanted to tackle his weight loss. “I’m a Type A personality,” he says. “I need to jump in and fully commit to something.” He chose the meal replacement plan.
Yale Medicine’s weight loss program uses the Optifast plan, which includes eight food options that patients can mix and match for a daily total of 800 calories. The choices include two soups, three shakes and three bars. Patients can also drink unlimited black coffee, diet soda or water. Savage picked his meals and got started.
“If you consume 800 calories a day, you are going to lose weight,” Savage says. “You have to, unless you cheat.” He did not. Helped along by his wife, a healthy-eating vegetarian, and his son, a college athlete, he stuck to the program.
Savage did more than just follow the strict meal rules. Along with eight others following the same plan, he was expected to attend group meetings every Tuesday with Yale Medicine nutritionist Christopher Barrett. “That’s where the behavior modification happens,” he says. “We talked about food, the reasons we overeat, how to cope with peer pressure, how to stick to a diet in social situations. I’d walk into a party with my shakes and people would make fun of me. We’d discuss those kinds of things.”
After Savage had completed 12 weeks of the program, Barrett told him he could begin the second phase of the eating plan, adding regular food back into his diet. “I told him, ‘I’m not ready yet,’” says Savage, who spent two more weeks on Optifast before slowly adding small portions of healthy foods to his diet. “You really only need a couple veggies with some protein,” he says.
Savage says he lost 72 pounds in six months. “I had to make a new hole in my belt this morning, and all of my clothes are too big!” he says. Even better, his foot and back pain disappeared.
A vast need
An estimated 300,000 people in the greater New Haven area have a BMI over 30. So far, about 200 of them have made use of Yale Medicine’s weight loss program, while an additional 600 had weight loss surgery in the last year. In response to a pressing need, the program is expanding says Dr. Mehal.
A loss of just 10 percent of body weight can bring important health benefits, including reversal of fatty liver disease or mild diabetes. Since excess weight is also associated with increased risk for some cancers, infertility, stroke, high blood pressure and heart disease, losing weight also helps protect against those problems.
“My father and mother both died in their early 60s,” Savage says. “Now, I’m thinking I might make it into my 90s.”
Savage says his luck has turned. His children are thriving, and so is he. “You feel like you’ve woken up and there’s life again. The possibilities for me are different—traveling, moving to a different location, living longer, spending time with people. It’s a very exciting time for me.”