For People with Obesity, Enara Offers Surgical Outcomes Without Surgery

A small Silicon Valley clinic is making huge waves in the world of obesity medicine.

With the goal of achieving "surgical weight loss without the surgery," internist Rami Bailony, MD founded Enara Health Group in January 2016. Located in San Mateo, CA, Enara offers an oasis of support for patients seeking to lose weight sustainably. In just two years, Bailony's integrative approach has already generated impressive results: Enara patients drop, on average, 11% of their body weight. That's double the percentages seen in most "successful" weight loss programs.

"Taking a look at the Diabetes Prevention Program--a program which a lot of digital healthRamiBailonyRami Bailony, MD, Founder, Enara Health Group companies are looking to scale--what was the average weight loss at 10 years? Two percent!" says Bailony, who trained at the University of California San Francisco.

When working with patients, his clinical objective is to get as many as possible to lose 15%. "When you get to 15% weight loss, your life changes in all kinds of positive ways that don't happen when you only get 3% or 5%."

It's an ambitious goal, especially for a non-invasive, non-surgical modality. But Bailony and his interdisciplinary team are already able to help some patients get to that range. He anticipates that with a few more years of testing and refinement, Enara's program will be able to routinely deliver such outcomes.

A Light in the Dark

A key ingredient of Bailony's program is its high level of personal engagement. "It's critical to approach patients not only scientifically, but also personally," he urged. This philosophy underlies every service Enara provides, from its collaborative team of holistic practitioners to the intuitive health technologies that patients use to track their activities.

In developing Enara, Bailony drew on his previous work with diabetic patients as a fellow at Stanford University's Medicine X program, where he noticed a distinct difference between individuals with type 1 versus type 2 diabetes.

Unlike type 1 patients, those with type 2 expressed far more guilt about having diabetes, and in particular, about being overweight. They blamed themselves for having what many people perceive to be a "lifestyle disease."

While it is true that lifestyle factors do play a role in the etiology of diabetes, the "lifestyle" label often carries implicit blame and shame.

The type 2 patients tended to "see themselves as failures, to see it as their fault for being overweight," Bailony observed. In many cases, that sense of culpability is a major roadblock to healthy, constructive weight loss efforts.

Enara, an Arabic word meaning "to illuminate," conveys the clinic's core intention: to shine a gentle light on the dark, self-defeating emotions that so often accompany obesity, and to illuminate a path toward better health.

Enara is committed to de-stigmatizing obesity, and creating a "guilt-free zone" where patients experience less shame around their weight. One aspect of the treatment strategy involves having patients rewrite the stories they so commonly tell themselves.

"Obesity is the leprosy of the 21st century," Bailony says. It is a tremendous challenge to deconstruct the overwhelmingly negative associations most Americans have about overweight people. Physicians are sometimes the worst offenders in this regard.

The Weight of Blame

"Docs internally blame obese people for their conditions, all the time. I know. I did it. And I was obese myself," Dr. Bailony said at a Stanford Medicine X conference last year. He noted that at one point, his BMI over 30.

"We continue to hand out wellness programs, wearables, and gym memberships as if losing weight was easy, and keeping it off is even easier. Yet there are so many patients who do everything "right" and still gain weight. This creates a vicious cycle of internalized failure, guilt, and a cascade of mental health problems."

"When you get to 15% weight loss, your life changes in all kinds of positive ways that don't happen when you only get 3% or 5%."

Body-positive movements have slowly started to gain traction, but many overweight patients still endure and internalize the huge stigmas our culture attaches to weight. This self-criticism is rarely a motivator for health improvement. On the contrary, it almost always becomes an impediment.

Bailony says clinicians need to grasp what metabolic research has revealed over the last 15 years: that weight is the result of a very complex interaction between genetic, metabolic, microbiomic, environmental, behavioral and psychosocial factors. He also stresses the significant influence of hormones. Mounting evidence points to appetite-modulating hormones as key factors in determining weight loss outcomes. Of the dozen different hormones that regulate appetite, just one increases our desire to eat, while the remaining eleven suppress it. "You could talk to patients about improving their diet, but if they're on medications that increase their appetite, it won’t work," he explained.

The bottom line is that no one thing causes obesity. No one "character flaw" is to blame, and no single intervention will resolve it. One of Enara's main goals is to help people get off what Bailony calls "the hamster wheel of frustration."

Enara healthThe clinic's initial three-month program starts with an individual consultation that includes a thorough discussion of eating habits, behavioral patterns, stress, sleep and other factors influencing metabolism including emotional states, hormones, and medications. In addition to a standard medical history and physical exam, the first visit also incorporates basic labs to capture important weight-related biomarkers like cholesterol, A1C, and markers of inflammation, which are then checked again every three months. 

Enara clinicians draw heavily on cognitive behavioral and addiction treatment models, and they encourage patients to take an in-depth look at their eating behaviors. "It’s not just about immediate weight loss," Bailony stresses to his patients. "They need to see it as long-term weight maintenance."

If that all sounds a little squishy and subjective, consider that the best "objective" drug therapies for obesity are only marginally effective, and can sometimes be dangerous. Today, there are six FDA-approved obesity drugs, and many primary care doctors dispense them readily. But they seldom deliver healthy, lasting, and sustainable weight loss on their own. The medications, Bailony cautions, "are only as good as the behavioral program behind them."

A drug regimen without comprehensive lifestyle support is, in Bailony's opinion, "a waste of money."

Part of the problem is in the way physicians view weight and weight loss. "Some doctors don't appreciate how much support is really required to lose weight," he told Holistic Primary Care. "The medical community commonly thinks that diet change is easy, and many physicians are skeptical that obesity should even be considered a disease." But any honest clinician knows that telling patients to eat healthfully and exercise regularly will rarely give lasting results--even if a patient wishes to follow the advice.

Bariatric surgery has definitely proven successful in both reducing weight and keeping it off. It is typically far more effective than medication alone, often resulting in weight loss in the range of 29% of total body mass.

But a number of factors like high costs and long wait times render this option inaccessible for many individuals who need it. Further, a patient's life post-surgery also requires major lifestyle changes and considerable support, meaning that the surgery doesn't work in a vacuum; it too requires a comprehensive lifestyle support program for optimal outcomes.

Surgical Results Without Surgery

Bailony said he began studying the statistics on bariatric surgery and wondered if it would it be possible to create an effective non-invasive model that generated similar long-term results. He set the ambitious goal of assisting patients in achieving 15-25% sustained weight loss over a five year period.

He and the Enara team are well on their way toward reaching that target.

Enara's practitioners bring a very different understanding to the process of weight reduction, and they are not wedded to any particular clinical tool. Rather, they try to optimize the benefits of a whole spectrum of therapies and lifestyle shifts. This often includes medication, though part of Enara's goals are to keep meds to a minimum.

This may mean, for instance, that an individual who comes into the program taking four of five drugs for diabetes and hypertension may add on one obesity drug initially, but with the ultimate goal of dropping the first four later on.

Juan Ojeda, Jr., a recent Enara patient, exemplifies Bailony's medication-light approach. "I was on insulin for a long time," said Ojeda. Before visiting Enara, "I had seen so many general practitioners, but they do so much, see so many patients, that it was always just prescribe, prescribe, prescribe."

"After a metabolic test, Dr. Bailony looked at my vitals, figured out what wasn't working and what we could do. The first thing he said to me was, 'I'm going to get you off insulin because it's killing you.' He switched up my meds and put me back on metformin. Within a couple months, I was off insulin completely, and I cut my blood sugar in half. Dr. Bailony told me, 'I’m helping you help yourself,'" Ojeda added. "I learned that when it comes to wanting to really better yourself, it all starts with you."

Further differentiating the Enara experience is its practitioners' deep personal understanding of the weight loss struggle. Bailony and his team members have completed the program themselves, and this direct experience informs how they communicate with patients.

"They speak from their own experience, not with a voice that says 'this is how yours should be,'" said Enara patient Liz Mandel. "As a patient, you can take from that and have it inform your own experience." Mandel described the "incredibly positive and supportive" atmosphere of the clinic and its staff.

The support also comes with demands. Mandel recalls that Bailony "was real and honest about the need to eat right, to eat less, and to have realistic goals. He was honest about the difficulty at the beginning of the program. His credibility stood up, and that is very important."

For Mandel, the sense of partnership with Enara's practitioners is what keeps her connected to the program. "It's about working with your patient and making them part of a team, supporting them, talking to them, and getting to know them. A lot of providers don't do that.”

Tech-Enabled Teamwork

Beside Dr. Bailony, the Enara team includes a physician's assistant, a personal trainer, and several dietitians. The RDs meet weekly with new patients during the first 12 weeks. They also offer shopping appointments, during which they visit grocery stores with patients to teach about different foods, and help them make healthy meal choices. All of Enara's practitioners collaborate on a combined medical and behavioral nutrition plan tailored to each patient.

"Obesity is the leprosy of the 21st century."

Enara makes heavy use of a variety of technologies to help patients track their daily weight-related activities. These digital systems allow Enara's entire practitioner team to quickly and easily engage with patients at any time.

Each day, for example, patients take photos of the meals they eat, and upload them to an Enara app. Between visits, the medical team can review patients' daily photo logs, sending personalized comments and tips directly related to their food choices and eating patterns. Enara practitioners also share educational videos and motivational ideas outside the office setting.

The Silicon Valley tools are a help, but it is really Enara's supportive, blame-free atmosphere that makes the difference over time.  "They are drawn to the culture here," Bailony said, emphasizing that a patient's ongoing relationship with the clinical team is what ultimately helps to overcome the biology of obesity.

"In so many ways, this has changed my life," Mandel told Holistic Primary Care, describing her experience with the meal-tracking app. Though she'd tried keeping food logs in the past, she found them difficult to maintain. "The pictures made it super simple. With my busy schedule, I didn’t have to go into the clinic once a week, but I could use FaceTime and communicate via the app."

"I received regular support -- but it was on my terms, as opposed to me having to fit into the program," she added. "It integrated into my life so it was very present and regular. Now, I don’t need to submit daily pictures anymore. I have so much experience, I know the difference between a healthy meal versus an indulgence."

Mandel is currently in Enara's maintenance phase. She visits the clinic monthly and meets virtually once a week with Dr. Bailony.

During Enara's pilot period, Bailony says he engaged patients who strongly preferred a long distance telehealth model. But after several months, most of them came to value the face-to-face clinic visits, even if they had to travel some distance to reach Enara's San Mateo location.

Cost-Effective & Transformative

The Enara approach is definitely a long-term solution, not a quick fix. He hopes patients will remain connected to the clinic for at least five years after their initial visits. He's off to a good start on that front; 70% of his initial patients are still engaged with the clinic today, after two years.

From a fiscal viewpoint, Enara's model aims to deliver excellent clinical outcomes at prices that are within reach of uninsured people, while also appealing to insurers. The program bundles a comprehensive array of tests, clinical services, medications, tech tools, and ongoing consultations into a package for which insured patients pay a monthly fee of $35 (or $30 per month if paid as a lump sum annual fee) for the basic plan, or $80 per month for a plan that includes an Apple watch ($65 per month if paid annually). Enara works with most major California insurers, which reimburse for the costs not covered by the patient's out-of-pocket payments.

For people without insurance, Enara charges $175 per month.

In addition to helping transform patients' lives, Bailony and his colleagues want to transform medical care for people with metabolic disorders like diabetes and obesity.

In many ways, he says, obesity medicine today is where HIV care was in the earliest days of the AIDS crisis: the condition is highly stigmatized and many view it as  "punishment" for "wrong" living; pharmaceutical options are limited; and few clinics or care models are specifically designed to meet the true complexities of the disorder.

Bailony predicts that obesity care will follow a similar trajectory as HIV medicine, as clinicians and researchers gain a better understanding of both the physiology of obesity and its psychosocial drivers, and as more effective treatment options--both prescription and nutritional--become available.

The need for this shift cannot be overstated. Obesity now outpaces smoking as the leading risk factor for cancer. In October, the CDC released a report indicating that overweight and obesity are associated with higher risk for 13 types of cancer. Combined, these cancers account for about 40% of all cancers in the United States.

As practitioners like Bailony tip the scales towards a more comprehensive weight loss model, the problem slowly becomes more solvable.

When asked about the most significant change he’s experienced since becoming an Enara patient, Ojeda mentioned not the 60 pounds he’s dropped, but rather the tremendous shift that’s occurred in the way he thinks about weight. “I lost more weight in my mind that was pushing me down, making me think that I couldn’t do anything about it.”

Under Bailony’s guidance, Ojeda learned the paramount importance of a positive mindset. “It’s way more mental than physical,” he said. “I had it totally wrong almost all my life. As simple as it sounds, for me, it was a mental conquering. I had to learn that it’s mind over matter.”

With the right combination of mindfulness, medication, and personalized support, Bailony aims to guide many future patients down a similar path towards vibrant health and sustainable weight reduction.
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