Obesity- Our Burning Public Health Issue

A recent study published in the prestigious medical journal Lancet has revealed that 44 million women and 26 million men aged more than 20 years are obese in India currently. The comparative figure of 1990 was 2.4 million women and 1.1 million men. India could be facing an obesity epidemic with alarm bells 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 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.

Obesity is defined by the Obesity Society as a medical condition, often considered as a 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.

It is a major cause of disability and is associated with several diseases, especially cardiovascular diseases (heart attacks, strokes and heart failure), Type 2 diabetes, obstructive sleep apnoea (OSA), certain types of cancers and osteo-arthritis.

Obesity has several socio-economic, individual and environmental causes. Common among these are unhealthy diet, lack of exercise, rapid urbanization, 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, plenty of fruits and vegetables and regular burning of calories by exercise in any form are very important. However, 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 and this surgery has significant morbidity too.

Drugs for producing Weight Loss;

This is what everybody looks for and medical research is continuing to look for the ideal drug which at least match the results of bariatric surgery. 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.

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. These agents except Rybelsus are still not available in India. Recently Tirzapetide from Eli Lily has been approved and should become available soon. 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. Injections Semaglutide and Tirzepatide have been approved by the US FDA as a safe weight losing drug. These injections produce up to 15 to 20 % wight loss in 15 months’ time with a rapid onset.

Oral Rybelsus (Semaglutide) has been available in India in three strengths 3, 7 and 14 mgs for the management of obese diabetics and is also being used as an off-label agent for weight reduction.  It is a path breaking technology of converting a peptide into a pill. The downside is that a very few patients tolerate the recommended 14 mgs dose and the weight loss is not comparable to the injectable variety. More data needs to come regarding its efficacy whereas its injectable version is a proven entity. Another agent Survodutide , a glucagon receptor and GLP1  agonist is in phase III studies and a number of oral agents with a dual mode of action (GLP analogues and GIP) orforglipron and triple mode of action (GLP analogue, GIP and glucagon receptors) retatrutride are in the pipeline with an estimated 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.

The author is Founder Director Gauri Kaul Foundation

NOTE: All the medicines should be taken only under the supervision of your doctor.