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Prakash Chandran: Welcome to Baptist Health Radio. As the most preferred healthcare provider in Northeast Florida, we're here to help you stay informed with the latest news, views and resources for your health and wellbeing. When it comes to weight loss, the options can seem endless. And when you've tried everything, but can't seem to make progress, weight loss surgery might be your best option. But where do you even start?

Joining us today to talk about different weight loss options, including surgery is Dr. Craig Morgenthal, general surgeon with North Florida Surgeons and Medical Director of the Baptist Center for Bariatric and Reflux Surgery for Baptist Health.

This is Baptist Health Radio. My name is Prakash Chandran. So first of all, Dr Morgenthal, it's great to have you here today. Could you start by telling us a little bit about the science behind obesity?

Dr. Craig Morgenthal: Well, thanks for having me today. I appreciate it. And yes, as far as obesity, there is an epidemic in the United States with about 35 to 40% of the country obese and about two-thirds overweight or obese. So when we talk about obesity, we have to mention BMI and normal BMI, which factors in your height and your weight. Normal is 19.5 to 25. Overweight is 25 to 30. Obesity is over 30. And morbid obesity is over 35 with a medical issue like obstructive sleep apnea, type 2 diabetes or over 40.

So in 2013, the American Medical Association classified obesity as a disease, and it's a disease of increased fat mass that's associated with many medical issues. Normally, you have energy intake and expenditure balance. But with obesity, that balance is thrown off. And there's many factors that could contribute to this, including genetics, environment, fat cells. Even your gut bacteria or medications you take can lead to obesity.

And the real issue is that every part of your body is affected. Different things like type 2 diabetes as I mentioned, cardiovascular disease, obstructive sleep apnea, cancer, musculoskeletal issues. Essentially, every part of your body is affected. And when you add all that up, the average lifespan is reduced by about 10 years. So it's a big deal individually and add it up for society.

I think one point to mention just as far as COVID is that obesity increases susceptibility to COVID and to having worse outcomes, because obesity is associated with chronic inflammation, impaired immunity, respiratory issues. So there's one CDC study that showed a 12% increase in patients requiring mechanical ventilation if they were overweight and it was 108% higher risk of requiring mechanical ventilation if their BMI was over 45. So COVID, in addition to showing that patients are at higher risk, it's also leading to weight gain and worsening obesity from increased stress, more screen time and sedentary behavior. So this is a modern contemporary issue that we have to deal with.

Prakash Chandran: Absolutely. And for all of the reasons that you mentioned, I can see why it's so important to deal with it as soon as you can. Before we go to the next question, I just want to understand a little bit more about why people become obese and why some people tend to get obese faster than others. Can you maybe speak to this a little bit?

Dr. Craig Morgenthal: Well, there's certainly genetics that can play a role and what your lifestyle is and what your diet is. In the United States, for example, when you look at the foods that we eat, there might be high fructose corn syrup. People are eating fast foods. There's more sedentary behavior. There's a lot of environmental impact. I think that the key really is to prevent the weight gain. Prevention is a key for obesity because once you get to the point of morbid obesity, it's very hard to lose weight and keep it off when you try to do things like eating a healthy diet and exercising. Less than 5% of people, once they get to the point of morbid obesity, can lose the weight and keep it off.

And there's biologic reasons for that. Your body tries to push you back. Your body thinks you're starving and it's trying to prevent that. So there are studies that show that even when you are a year after you're done dieting, your hunger hormones such as ghrelin remains elevated a year after you stopped dieting. And the hormones that make you feel satisfied after you eat, they're reduced even a year after you're done. So biologically speaking, it's very challenging to be successful long-term diving. That's why prevention is the key. And that's where, for people that are morbidly obese, that bariatric surgery becomes a good option.

Prakash Chandran: And just expanding on that a little bit, why do you think it is harder for some people to lose weight versus others?

Dr. Craig Morgenthal: Yeah. I mean, everybody's different. If you put the amount of calories that you take in and the amount that you burn, I mean, it should be a balance in most people. Now, some people have hormonal issues. For example, low thyroid, hypothyroidism, that's a medically correctable situation. There are some other endocrine abnormalities. There's some medications that people take. There's various medications for blood pressure, for depression, anxiety. I mean, there's various medications, some of which can cause obesity and some may not. So that's a factor to talk with your primary care that can look at your thyroid and things like that.

Some people may have PCOS or something, so there's definitely hormones. But I think in general if you have calorie deprivation or if you're on a diet, people are going to respond to that differently. And there's really no way to predict that from one person to another. But essentially over time, if those endocrine issues are addressed, people should lose weight if they're in a calorie deficit.

Prakash Chandran: Understood. If someone is, for example, morbidly obese, let's talk about some of the options, because as you've said, statistically the likelihood of losing that weight is small, but I've heard about weight loss surgery. Talk a little bit about when that should be considered and what it is.

Dr. Craig Morgenthal: Okay. So the first thing that we want people to do and that everybody should do is try eating healthy and exercising. So we call that behavioral modification. So if you're not doing it already, you want to have three small meals a day, healthy meals, high protein, maybe low carb, healthy fats, cut out junk foods, healthy snacks if anything at all, drink zero calorie liquids, exercise regularly. You should do 150 minutes of cardiovascular type exercise a week. You also might want to do some muscle work a couple of times a week, which can also help. So that is behavioral modification, which is very important that you do that if you have bariatric surgery also, but the difference is you don't have that tool like you get with bariatric surgery.

But so anyway, you start with behavioral modification and if somebody has a BMI over 30 or BMI over 27 with medical issues, that's where medications are indicated, things like phentermine, Orlistat. These are things that you could talk with your primary care about, and they can add some additional weight loss over just behavioral modification alone. But, you know, there tends to be the possibility of some side effects. There's a chance of weight regain when you stop the medications and it may not be enough weight loss to overcome the medical issues related to obesity. So bariatric surgery is considered if your BMI is over 35 with a medical issue, type 2 diabetes, coronary artery disease, hypertension, that kind of stuff, or over 40 without any medical issues.

And then we start to talk about things like a sleeve gastrectomy, gastric bypass, which are the two most common operations now. The lap-band we did for a few years, and that kind of went out of favor. That's less than 1% of the operations that are done right now. There's also something more extreme called biliopancreatic diversion with duodenal switch, which is less than 1% of operations that are done.

So it's really the sleeve gastrectomy and gastric bypass. Sleeve gastrectomy as of 2013 was the most common operation in the United States. It's where we take off about 80% of the stomach and we make your stomach from a bag into a tube and there's restriction, meaning you can't eat as much because you have a smaller stomach. And there's also hormonal changes that kind of counteract your body's hormones that tend to make you hungrier and gain the weight back.

Gastric bypass has been around 50 or 60 years. It's a great operation. It's maybe a little bit more weight loss than the sleeve. There is a little bit higher rate of complications, so we tend to do the sleeve more, but the gastric bypass is a great operation and we tend to recommend that for patients that have type 2 diabetes that want that little extra push to push their diabetes into remission because there's no question that the gastric bypass can offer a higher chance of improvement or remission of their diabetes and a more durable remission. I don't use the word cure because it really depends on how many insulin-producing cells you have in the pancreas. So that's gastric bypass for diabetics if they want it. And for severe reflux, the gastric bypass is a better operation if somebody has severe intractable reflux, because the sleeve may be associated with reflux in some people

Prakash Chandran: Okay. So you mentioned that with the sleeve gastrectomy, you remove 80% of the stomach and you convert the bag into a tube and all of the benefits that come along with that. For the gastric bypass specifically, can you talk about the dynamics of what exactly happens during the surgery?

Dr. Craig Morgenthal: Okay. Thank you. So we make a small stomach pouch and so you eat less. And then we bypass a certain amount of the small intestine. We don't bypass the majority of the small intestine. They did that years ago and there was some downside to that. So we do about a 100 to maybe 200 centimeters of bypassing the intestines. You still have plenty of intestine left to absorb your food, but we are not absorbing all the calories that you eat. And then in addition to the restriction and the malabsorption, there's also hormonal changes with the gastric bypass..

Prakash Chandran: Okay, that's helpful. So between these two types of surgery, the sleeve gastrectomy and the gastric bypass, how does one decide which one to get?

Dr. Craig Morgenthal: So as a surgeon, I see patients in the office. We have everybody watch a webinar that they could watch at BaptistBariatrics.com. So that's the step one. Step two, we have patients come into the office where I look at their medical history, surgical history, medications, and talk with the patients. And then after that, we get testing and that we have patients see a dietician, a psychologist, and then they come back for a preop visit. So during that time, that first visit and the second visit, we'll kind of decide what's the best procedure for them depending on their medical history and everything else.

And I'm not there to kind of decide for somebody. I'm there to guide them and work with them to figure out what's best for them. I really want them to be happy with their outcome for the rest of their life, not just right now. So we're really just trying to get the best operation. And, for most people, like I said, most people choose the safety of a sleeve, but for some people, a gastric bypass is still a great operation.

Prakash Chandran: Okay. So I want to move now into the efficacy of these surgeries. How successful are these surgeries normally and how much weight can someone expect to lose?

Dr. Craig Morgenthal: Okay. So before that, I just want to say, and that's a really great question, but the key to success is that patients understand that we are giving them a tool, we're not giving them a cure. And so they have to work hard at eating healthy and exercise and that's critical. And when you come to our bariatric center, it's a center of excellence, which is important that patients go there because you know that they're going to have the resources, protocols, and outcomes to have the best operation, the best results.

We have a support structure that helps patients find successful strategies and we give professional help and support structure so that they're going to have that long-term answer. And when you do that, with the sleeve gastrectomy, for example, the average is about 50% to 60% excess weight loss. Or if somebody is 200 pounds overweight, they could look to lose about a 100 to 120 pounds. And with the gastric bypass, it's about 60% to 70% excess weight loss. So they'll lose about 120 to 140 pounds, which is pretty good.

And really, the weight is important, but what's really important is that you understand this as metabolic surgery. It's not just weight loss surgery, we're impacting those medical issues that are associated with the weight. So diabetes has about an 80% chance of improvement or going into remission, hypertension about 75%, obstructive sleep apnea goes away about 80% of the time. So this is a big deal. When you consider the concept of metabolic surgery, for diabetes, the main medical societies that treat diabetes recommend bariatric surgery if you're diabetic and your BMI is over 40, okay? And if your BMI is over 35 to 40, if your blood sugar is not well controlled, then they recommend it.

And really when you look at the success of these operations, when you look at the long-term studies that compare people that have bariatric surgery versus those that don't, and you follow those patients for five years, one study that I quote had a mortality rate of about 6% of people that did not have surgery versus less than 1% for the patients that had bariatric surgery. So what we're doing is we're changing people's lives. Bariatric surgery can be life-changing, but it could also be life-saving. It's a big deal.

Prakash Chandran: Absolutely. And still after hearing all of that, and the statistics sound very good, there's going to be people that might be a little apprehensive about going into surgery to begin with. So can you just speak to the safety of the surgeries themselves?

Dr. Craig Morgenthal: Surgery has never been safer. Over the past 20 years, there's been a revolution in surgery. We do minimally invasive surgery with small incisions. We have enhanced recovery after surgery protocols that, typically, we keep patients overnight after a sleeve or a gastric bypass, probably 95% of people go home the next day. And we have a preop class so they know exactly what to expect in the hospital when they go home, so they have the best outcome.

Complications. There are potential complications, maybe 1% chance of a major complication with a sleeve, a leak or something like that. It could be three or four in a thousand, very uncommon. But when it happens, we deal with it.

A gastric bypass has about twice or three times the rate, maybe 2% or 3% of major complications. But overall, the operations are very safe. And as I mentioned, it's really safer in the long-term. You're front-loading your risk a little bit, but for your health and wellness over the long-term, it's safer to do the operation. Typically, we keep people off work maybe a week, maybe a week off, a week light duty, no heavy lifting the first month and they recover pretty quickly.

Prakash Chandran: So before we close, I wanted to address one more thing. There definitely seems to be a stigma about weight loss surgery, especially around it being a sign of giving up for the person that is considering it. Like they should have been trying to lose weight by other means and now that they're doing this, they have given up on themselves. What might you say to those people that are feeling this way?

Dr. Craig Morgenthal: Well, I think this is a very important point because I don't want anything to get in the way of people getting what they need when they're ready. Because we mentioned that diets don't work, it's almost biologically impossible to overcome that. Yes, it can happen. It's very rare. So what people are doing, they're going to have a shorter lifespan if they don't get the intervention that's going to help them.

I think what's important is that people understand more now than before, maybe COVID has helped us to reprioritize what's important in our lives. And what's important is our health and wellness. People just want to be healthy. These are our family and friends and we want what's best for them.

So, let's not stigmatize. Let's encourage people to live their best life. And bariatric surgery is the most successful intervention that somebody could have for morbid obesity when they're ready to do the things that go along with that and follow with our program and make good healthy choices every day.

It is not easy. This is not a magic wand. It's not a cure. It is a tool. It takes hard work to every day be committed to making good choices and for doing that the rest of your life. So, please, I really want people to not stigmatize this, like I said, we want what's best for people and give them the best chance to be healthy in the long-term. And bariatric surgery can do that for the right person.

Prakash Chandran: Dr. Morgenthal, very well said, and I think a perfect place to end. I really appreciate your time today. That's Dr. Craig Morgenthal, general surgeon with North Florida Surgeons and Medical Director of the Baptist Center for Bariatric and Reflux Surgery for Baptist Health.

Thank you for listening to Baptist Health Radio. To learn more about the medical weight loss options available to you at Baptist, call (904) 202-SLIM or visit baptistjax.com/weightloss. That's Baptist J-A-X dot com slash weight loss. If you enjoyed this podcast, please share it with your friends and family, and be sure to check out the entire podcast library for topics of interest to you.

I'm Prakash Chandran. Thanks again for listening and we'll talk next time.