More than half of adults in New York City are overweight or suffer from the disease of obesity, according to the New York State Department of Health. And the prevalence in the Bronx is highest among all the boroughs.
Dr. Sriram Machineni, an international leader in the field, is hoping to change that. He was recently recruited to create and head a weight management program at Montefiore Einstein — the first such program at the institution to treat adults with obesity and related conditions. The Fleischer Institute Medical Weight Center will serve both the residents of the Bronx and surrounding areas, including Westchester, and will be housed at the Einstein campus at the Fleischer Institute for Diabetes and Metabolism. Some services will be available at the Montefiore Einstein Advanced Care (MEAC) facility in Elmsford, NY.
Dr. Machineni comes to Montefiore Einstein from the University of North Carolina at Chapel Hill where he was an assistant professor in the division of endocrinology and metabolism, and director of the UNC Medical Weight Clinic.
He recently spoke with us about his vision for the Medical Weight Center.
What makes Montefiore Einstein’s weight management program different from those at other medical institutions in New York City?
Many programs in the city are not able to support populations who are medically underserved, like our patients in the Bronx where obesity rates are high. These programs are very expensive and sometimes involve meal replacement plans, which can cost upwards of $500-$600 per month. And new medications can cost upwards of $900 per month if not covered by insurance. The programs are often short-term, which is not optimal for a disease that requires life-long management.
Our program is designed to help everyone reach a healthier weight and maintain it long-term.
What will the Medical Weight Center offer patients and what is the criteria for receiving care?
Our program is tailored to the individual and includes medical assessments, nutrition and psychological counseling, and treatment with effective and lower-cost medications covered by insurance.
We spend a lot of time with patients discussing general health and nutrition and work with them to develop strategies for increasing physical activity, improving sleep hygiene, managing stress, and many other components that affect weight loss and metabolic health.
The criteria for patients include a BMI for adults that is 35 and higher without underlying medical problems related to weight, such as diabetes, high blood pressure, joint pain, or trouble walking, and adults with a BMI of 27 and higher who have medical complications and co-morbidities associated with obesity. We also see patients with post-bariatric surgery complications, such as weight gain, low blood sugar, and malabsorption issues.
Take us through a patient’s first visit.
Before the patient comes in for their first appointment, they receive a questionnaire designed to assess different aspects of their lifestyle, such as a history of weight fluctuations, eating patterns, sleep patterns, stress-related eating issues, and physical activity. It takes about 20 minutes to complete and patients send it back to us before their appointment.
At the first visit, we collect additional history and conduct a physical exam including measuring the neck and abdominal circumferences.
We then spend an hour with them where we do a detailed analysis of what has occurred with their weight over the past few years, the effects of medications they may be taking on their weight, and other contributing factors to weight gain. We perform a different assessment for patients who have undergone bariatric surgery (weight before surgery, weight loss after surgery, and the medical issues they are experiencing).
At the end of the evaluation, we make recommendations. We start with diet and advise patients on how to follow a Mediterranean diet, which has the most evidence for long-term health. There are no specific calorie restrictions. We want patients to get accustomed to the quality of the diet – unprocessed foods with ample fruits and vegetables – and not simply focus on calories. This will be the foundation of our program. If needed, our dietitian provides more guidance on how to make the right food choices, navigate a grocery store, prepare healthy meals, etc.
We also do evaluations for emotional and stress eating and if patients are struggling, refer them to our psychologist for counseling in either a group or one-on-one setting. This behavioral eating program, what we call appetite awareness training, covers how to recognize the difference between hunger and cravings or stress-based eating. We offer guidance and provide resources on setting up and maintaining a regular exercise program, ways to improve sleep hygiene, how to meditate to manage stress, and other lifestyle interventions.
When patients return for a second visit, usually after one to three months, we look at what is and isn’t working and adjust the recommendations accordingly.
How will the program be staffed?
Initially, there will be an obesity medicine specialist, advanced practitioner, dietitian, and part-time psychologist, and eventually more providers including residents and fellows for training. The physician trainees will provide clinical care and assist with our research efforts. There will also be a clinical research coordinator and a research nurse as the volumes of patients and research studies pick up.
What kind of research will you be doing?
We will be studying pharmaceutical interventions on weight loss but being that I just joined Montefiore Einstein a few weeks ago, we need time to create a clinical trials program, find pharmaceutical companies to work with, and set up an overall infrastructure.
Prior to coming to Montefiore Einstein, I was the principal investigator on several studies measuring the effectiveness of medications on weight loss, including three on tirzepatide, a promising drug that could be approved for the treatment for obesity within the next year or so and will most likely be a game changer in the medical treatment of obesity.
What’s the environment like for anti-obesity drugs?
There has been a lot of excitement about drugs that have been shown to promote weight loss – and not just among clinicians. These drugs were initially approved by the FDA to treat type 2 diabetes, but doctors – and the public – have discovered that they have positive effects on weight loss. People without diabetes and not necessarily at high risk, are clamoring to get them – so much so that there have been shortages for those who need these medications to treat their type 2 diabetes.
However, there is Wegovy™ (semaglutide), which was recently approved for the treatment of obesity and tirzepatide, which I mentioned earlier, just received a fast-track designation from the FDA and could be available as early as the end of 2023 for the treatment of adults with obesity.
Other semaglutide medications, Ozempic™ and Rybelsus™ are not approved for weight loss but are in great demand by the public who are aware of its benefits. The biguanide medication metformin (Glucophage™, Riomet™), an older drug approved for the treatment of type 2 diabetes, is also being used in some patients but is not as effective as the newer drugs. There are other agents that may be used including regimens that contain phentermine, topiramate, bupropion, and naltrexone.
How effective are these new medications?
They have been shown to be very effective — and life-changing — which is why the public, having seen success stories on social media, want them. One-third of patients taking Wegovy™ lose over 20% of their body weight compared to 5-10% for the one-third taking metformin.
I use metformin as a first-line treatment for most of my patients and reassess from there. A big issue for our patients will be the cost of these new drugs, which are generally not well covered by insurance. A way to overcome the high cost of new medications is to use combinations of generic and less expensive medications to bring some of the benefits to patients.
How do the new medications work?
The new medications work on the brain, not the stomach. They increase satiety and reduce appetite. So, when someone is eating, they feel full faster with smaller amounts of food, and, in general, do not feel as hungry as they do before starting the medication.
Some of the medications could have an additional benefit of increasing metabolism or energy.
Wegovy™ works on a receptor for a hormone called glucagon-like peptide-1 (GLP-1), which is found in the body and acts on the brain to control appetite. It mimics GLP-1’s effects on the brain so that patients are able to better manage their appetite and reduce their food intake.
Tirzepatide has dual action. It works on the GLP-1 receptor as well as another receptor for GIP, which makes it better tolerated by reducing side effects like nausea and vomiting more commonly caused by GLP-1 agonists. In addition to regulating appetite, tirzepatide also appears to have a small impact on energy expenditure. More studies are needed on the mechanism by which that works.
A lot of overeating is tied to emotional factors. Many of us eat when we are not hungry due to boredom, loneliness, and stress. How will you be addressing this?
There are three components at play when it comes to weight management: homeostatic eating, which is based on real hunger; hedonic (emotional) eating, which causes overeating in the absence of hunger, and energy expenditure.
The new medications work on homeostatic eating and/or energy expenditure but there is still the issue of hedonic eating. Some of these medications impact emotional eating to some extent, but not fully. There are other medications we use, such as topiramate, which may help. So, we have specific strategies, including counseling by our psychologist, that we can use if someone has cravings or emotional eating issues without associated hunger.
In some cases, will these medications replace the need for weight loss surgeries or will they be used in concert?
The advent of the new generation of medications has been causing social media influencers and mainstream media to launch into hyperboles about how “bariatric surgery is finished.” This is far from the truth. We need all the treatments that we already have and more to find what works for each individual. The way forward is to integrate these treatments and use them in combination to produce the best results for individual patients. I have frequently used anti-obesity medications in people who did poorly with surgery to bring about the best metabolic and weight reduction outcomes for the individual patients.
What got you interested in this area of medicine?
After finishing my residency in internal medicine, I was a primary care provider in Buffalo, NY, for five years and saw that many of the illnesses that I managed in clinic were tied to obesity. When I was asked to speak about managing obesity for Grand Rounds, I realized that there was not a good understanding about treating obesity. There was a lot of focus on short-term diets without much follow through and long-term support. So, there was not much data on medically treating obesity, but there was a fair amount of data on bariatric surgery.
I became very interested in understanding more about obesity and started attending conferences where I got to listen to some great speakers who had a vision of how we could use new approaches and rethink the paradigm of treating obesity. I was able to eventually train with one of these visionaries during my fellowship in obesity medicine at Harvard to get an in-depth understanding of the biology of obesity and design novel strategies to approach the treatment. We have come a long way since 2006, when I started looking into this: we had only two approved medications for obesity, both of which were not good for different reasons. Now our primary goal should be to make these amazing new medications affordable to patients that need them the most.
The main thing is that we don’t want people to think of the Fleischer Institute Medical Weight Center as a weight loss center because this is much more than weight. It’s about managing overall health. Weight is one part of that.
Posted on: Friday, December 16, 2022