Combating Obesity

 Obesity is becoming a global epidemic in both children and adults. It is associated with numerous health issues like heart diseases, diabetes, high blood pressure, cancers, sleeping disorders like snoring (Obstructive sleep apnoea) etc. In fact, obesity is an independent risk factor for cardiovascular diseases and these risks have also been documented from childhood. In general, obese people have a lower life expectancy. Internationally, a body mass index (Calculated by computing height and weight) over 25 kg/m² is considered overweight and more than 30 is defined as obesity.

Obesity can be broadly classified into four main types based on BMI and associated health risks: Class I, Class II, Class III, and Class IV. Class I (BMI 30-34.9 kg/m²) is considered low-risk, Class II (BMI 35-39.9 kg/m²) is moderate-risk, Class III (BMI 40-49.9 kg/m²) is high-risk, and Class IV (BMI 50+ kg/m²) is very high-risk. Obesity in India has reached epidemic proportions in the 21st century, with morbid obesity affecting 5% of the country’s population. India is following a trend of other developing countries that are steadily becoming more obese. Unhealthy, processed food has become much more accessible following India’s continued integration in global food markets.

This, combined with rising middle-class incomes, is increasing the average caloric intake per individual among middle class and high-income households. Obesity is a major risk factor for cardiovascular disease which is the commonest cause of death in our milieu. According to a recent cross-sectional study of more than 100,000 individuals conducted by the ICMR, (ICMR -INDITAB-17) the prevalence of generalized obesity was 28.6% and abdominal obesity 39.5%. In a published study lead by the author in 6 districts of Kashmir valley its prevalence in the rural population was 26% in men and 30% in women.

Being a life style problem the best way to handle is its recognition in childhood and early adulthood and institution of preventive measures of diet and exercise. All this is however not able to control this epidemic and its prevalence is going on increasing. Pharmaceutical industry has been constantly trying to innovate several groups of drugs acting through several mechanisms. A plethora of drugs came in like Amphetamines, Fenfluramines, Sibutramine, Rimonabant and Orlistat, most of the drugs proved unsafe and resulted in serious problems and have been withdrawn with the exception of Orlistat which consumed three times a day acts by preventing absorption of fat. Besides its side effects like abdominal cramps, passing gas and oily stools the weight loss achieved is very modest, at best 5% over 12 weeks when combined with dietary measures with enough exercise. For these reasons and very modest weight reduction it also never became popular.

A New Generation of Weight Reducing Drug: Semaglutide (Ozempac, Wegovy, Rybelsus) and Tirzepatide (Mounjaro) are already in the international market.

This class of drugs is commonly called glucagon-like peptides (GLP-1 agonists). Tirzepatide, has additional gastric inhibitory peptide (GIP) property effect making it a dual action agent. These were developed for the management of diabetes and it was noted that the regular administration would lead to significant up to 20 % weight reduction. Ozempac / Wegovy and Mounjaro are injectable agents, while Rybelsus is an oral agent. The oral agent even in highest available dose of 14 mgs every day which is difficult to tolerate by most does, not reduce weight more than 5 to 10%.

Recently Tirzapetide from Eli Lily has been approved and is available in Indian markets freely. After a long and keenly awaited period This drug is available in Indian markets. My experience with this agent however has been there since 2020 in clinical trials. It is an approved drug for managing high risk obese diabetics, obese patients with OSA (a disorder characterized by snoring during sleep and feeling sleepy during the day). And also, for very obese people where lifestyle and diet are inadequate measures.

This injection has to be given once a week to start with and increased to 5 mgs weekly subcutaneously. Higher doses up to 15 mgs have been used in trials but are associated with high withdrawal rates and not released as yet. Results of this GLP1 and GLA analogue agent are spectacular. I have patients who have lost up to 20 kgs of weight on this drug. Side effects like nausea and abdominal discomfort are seen in some but resolve with the passage of time. It is expensive and one 2.5 mgs injection costs Rs 3500 and 5 mgs one Rs 4,375.

The cost in USA however is much higher with 5 mgs injection costing around Rs 25,000. We are now waiting for injection Semaglutide (Ozempic) from Nova Nordisk to hit the market soon. It has same efficacy and I have enough experience in clinical trials with its use. Its launch should lead to competition between the two pharmaceutical giants from Norway in Europe and Indianapolis, Indiana USA.

Obesity needs to be recognized early and the best is to prevent it from childhood. Counselling by teachers and parents should go a long way in curbing this serious malady which is the root cause of several disease. For those who still develop it there is a new hope in the form of new safe and effective drugs.

 Prof Upendra Kaul, Founder Gauri Kaul Foundation