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Home Opinion Obesity is a disease and drugs like Ozempic and Zepbould do help in managing weight — with caveats

Obesity is a disease and drugs like Ozempic and Zepbould do help in managing weight — with caveats

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A person stands showing his belly fat, obesityThe word “obesity” carries a stigma and it can be highly demotivating for an individual to be labelled obese or morbidly obese, terms that are widely used.

indianexpress

Jan 25, 2025 13:56 IST First published on: Jan 25, 2025 at 13:56 IST

A podcast by the ever-popular Oprah Winfrey — where she interviewed endocrinologist Dr Ania Jastreboff from Yale University — emphasised the concept of obesity as a disease. A recent Lancet commission report on obesity also said the same. Just to put the record straight, the WHO classified obesity as a disease in 1997. In fact, not only is it a disease like diabetes or hypertension, it is also the mother of most chronic diseases, requiring lifelong management.

The word “obesity” carries a stigma and it can be highly demotivating for an individual to be labelled obese or morbidly obese, terms that are widely used. A reasonable suggestion by the American Association of Endocrinologists, which we have adopted, is the acronym ABCD — Adiposity Based Chronic Disease.

Regardless of the semantics, we have to think of obesity as a chronic “neuroendocrine” disease — a disturbance of the hormone-brain axis. When we eat, the intestines send out signals (like the GLP1 hormone) to the pancreas and other parts of the body, including the brain. The brain tells us when we are satiated and should stop eating. Brain centres, under the influence of brain hormones, also control our appetite. Putting it simply, dysregulation of this hormone-brain axis leads to a mismatch between our requirements and what we eat. As a result, we eat excessively and put on weight. This axis determines the set point for weight and is different for every individual. Very often, therefore, it is not the individual’s fault that they tend to gain weight more easily than their peers, or lose less weight than others on medication.

If we think of obesity as a disease, we will have little problem in accepting that it should be treated with medication. There is no reason for feeling guilty or ashamed about the use of medication to treat obesity. It is not a sign of defeat. We need to think of obesity in the same way as we think of other chronic diseases like diabetes, blood pressure and high cholesterol. The new class of GLP1 drugs typified by semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbould) — and a whole bunch of new ones in development — at least partially treats the biological defect in the brain that causes obesity. By resetting the set point, they help us lower weight. However, as with most medications, they work only as long as they are used. Once off the drug, the weight can come back. The method for dose adjustment that I use is similar to that discussed by Dr Jastreboff. The principle is to start low and increase slowly, to reduce side effects. When target weight has been achieved or weight has plateaued at the maximum tolerated dose, I try to continue the patient on the lowest possible maintenance dose.

It is very important to set realistic targets when initiating therapy. The target cannot always be what the patient desires. A conversation about this between patient and doctor is essential. For someone who is 5’8” and weighs 120 kg, to aim for an ideal body weight of 70 kg is virtually impossible. It is important not to be driven by cosmetic considerations alone. Many individuals have body image issues — I get requests from women who are underweight but want to lose more weight for a modelling assignment or a wedding. It is also important for potential users to realise that not everyone loses huge amounts of weight.

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While obesity is a disease, it cannot be treated just by medication. One can never ignore that treating obesity involves a lot of effort on the individual’s part, and lifestyle measures remain the foundation of successful management — in the same way as for diabetes. I have some patients who tend to depend solely on medication and stop making any lifestyle effort. Such patients are bound to be long-term failures as they will gain weight rapidly whenever they try to reduce the medication dose.

There was not much discussion about side effects in the Oprah interview, but I would like to point out some. Gastro-intestinal side effects are common and usually manageable. Pancreatitis is exceedingly rare. Muscle loss that occurs due to rapid weight loss, although not a direct drug effect, is of particular concern among Indians who often have low muscle mass to start with. The recent report of the rare occurrence of eye optic neuropathy (NIAON) with the use of semaglutide tells us that continued pharmacovigilance is required. And while it is true that most patients with obesity require continued treatment, I would be cautious in recommending lifelong treatment with the new GLP1 drugs for every obese individual till more data emerges.

The writer is chairman, Endocrinology & Diabetes, Max Healthcare

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