Obesity: A National Problem
The global obesity epidemic is well established, and a major cause of an international concern which was also commented upon by our prime minister Mr Modi, recently. He made a nationwide appeal to tackle this serious problem. A recent study published in the Lancet has revealed that 44 million women and 26 million men aged more than 20 are obese in India. The comparative figure of 1990 was 2.4 million women and 1.1 million men. India could be facing an obesity epidemic, alarm bells already ringing, particularly for the young. The study also found that 12.5 million children (7.3 million boys and 5.2 million girls) in the country, aged between five and 19, were grossly overweight in 2022, up from 0.4 million in 1990.
According to a recent cross-sectional study of more than 100,000 individuals conducted by the ICMR, (ICMR -INDITAB-17) the prevalence of generalised 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.
Definition
It is defined by the Obesity Society as a medical condition, often considered as disease in which excess body weight has accumulated to such an extent that it negatively affects health. People with a body mass index (BMI) over 30 Kg/m2 are by definition obese. BMI is calculated by dividing weight by the square of height. As per the WHO and ICMR obesity is defined in Indians as a BMI > 25 Kg/m2. By this definition up to 50% of our urban population could be obese. Another important criterion to be measured in these patients is the waist circumference (WC). Truncal obesity is very common in our population. A WC of > 90 cm for men and > 80 for women in our population indicates visceral obesity as compared to a level of > 108 cm for men and > 88 cm for women. This simple measurement carried out by a measuring tape around the abdomen midway between the lowermost portion of ribs and upper most portion of the hip bone is very well corelated with the possibility of getting vascular problems like heart attacks, strokes and blockages in the arteries of the legs. Besides cardiovascular problems obesity is associated with cancers, diabetes, obstructive sleep apnoea (OSA a cause of snoring), osteo arthritis of joints, fatty liver, infertility and depressive illnesses.
Obesity has several socio-economic, individual and environmental causes. Common among these are unhealthy diet, lack of exercise, rapid urbanisation, genetic susceptibility, endocrine disorders and mental disorders.
Weight losing Therapies
The traditional methods of losing weight by adopting a healthy life style by reducing calorie intake, taking plenty of fruits and vegetables, and regular burning of calories by exercise in any form are very important. The general goal is first not to further gain weight to reduce weight and most important is to maintain the lost weight. Although these measures are useful but not consistent in reducing the associated problems. What is needed is to reduce it by more than 20% at least. Moreover, there is a large percentage of persons who are not able to adhere to this for the long term or are unable to reduce significant weight by these measures alone.
Bariatric surgery which involves making changes in the digestive tract surgically is a method reserved for extreme cases of obesity where the BMI is more than 40 kg/m2 or more than 35 kg/m2 with concomitant diseases like diabetes, heart related issues which could be reduced by it. It is extremely effective and leads to a weight reduction up to 25% and is associated with reduction in vascular events, cancers and liver disorders associated with fatty liver. Being a surgical procedure, its adoption is very low in general.
Drugs for producing weight loss
This is what everybody looks for and medical research is continuing to look for the ideal drug which should at least match the results of bariatric surgery. A plethora of drugs have been tried in the past but without much success in maintaining the lowered weight. A new generation of drugs seem to be working very well and are most promising.
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. These agents except Rybelsus are still not available in India. Recently Tirzapetide from Eli Lily has been approved and should become available within a few months in our markets. It is a weekly injection. All these agents basically work by imitating an intestinal hormone that stimulates insulin production, lowering your appetite and making you feel full. These additionally act on several organs of the body and not only promote weight loss but also reduce vascular events independently. These injections produce up to 15 to 20 % wight loss in 15 months’ time with a rapid onset. A number of new agents with some additional properties are in clinical studies. The expectation is these would result in a weight loss up to 24% which makes them at least equivalent to bariatric surgery.
Obesity controlling agents are at the forefront of medical research these days. These drugs have a bright future but there is a key challenge of making them affordable and accessible to the underserved populations that carry the highest burden of disease. Lastly it should not be forgotten that these agents are adjuncts to the traditional methods of losing weight by dietary methods coupled with exercise programs.
Prof Upendra Kaul, Founder Director Gauri Kaul Foundation.
