Weight-loss drugs can help but they won’t solve India’s obesity crisis

The arrival of modern anti-obesity medicines has transformed obesity treatment. For the first time, drugs such as semaglutide and tirzepatide can produce weight loss approaching 15–20 per cent in many patients—results previously achievable mainly with bariatric surgery. Millions of people living with obesity, type 2 diabetes and related metabolic disorders now have genuine hope. In India, clinicians have been using these medicines for several years, with their use accelerating over the past year following the availability of tirzepatide.

Two major systematic reviews published recently in The BMJ together provide perhaps the most balanced assessment yet of these medicines. One, published only a few days ago, involving nearly 100,000 participants across 262 clinical trials, confirms their impressive efficacy and cardiovascular benefits. The second, analysing 37 studies involving more than 9,300 participants, examines what happens after treatment is stopped. Together, they remind us that while these medicines represent a major therapeutic advance, obesity treatment cannot be judged by kilograms lost alone. For India, where obesity coexists with relatively low muscle mass and limited healthcare resources, the lessons are especially important.

Quality of life: Less dramatic than expected

One of the more surprising observations in the recent BMJ review is that despite substantial weight loss, improvements in quality of life were relatively modest. Across more than 45,000 participants, none of the available medicines produced improvements that met accepted thresholds for clinical significance on standard quality-of-life scales.

This does not mean patients fail to benefit. In everyday clinical practice, many individuals experience dramatic improvements. Patients who previously struggled to walk even a few steps often regain mobility. Those with obstructive sleep apnoea frequently report refreshing sleep after years of disturbed nights. Many patients also report greater self-confidence as they lose weight. Everyday activities become easier. Nevertheless, the findings remind us that losing weight does not automatically translate into proportional improvements in overall wellbeing for every patient.

Muscle loss: An important concern for Indians

An issue of crucial importance is muscle loss. The medicines producing the greatest fat loss also result in measurable reductions in lean body mass. Tirzepatide appears to produce greater reductions in lean mass than most other therapies, while semaglutide also results in significant muscle loss. Some loss of lean tissue accompanies virtually every form of weight reduction, whether achieved through dieting, surgery or medication. However, preserving muscle is essential because it determines strength, mobility, metabolic health and healthy ageing.

This concern assumes particular importance in India. Indians typically possess lower skeletal muscle mass and strength than many Western populations, even at similar body weights. Loss of muscle mass and strength (sarcopenia) is increasingly recognised among older adults and people with diabetes. Reducing body weight without simultaneously protecting muscle may increase frailty, falls, disability and hospitalisation, particularly among older patients.

The answer is not to avoid these medicines but to prescribe them more intelligently. Every prescription for an anti-obesity medicine should be accompanied by advice on adequate protein intake, regular resistance exercise and periodic assessment of muscle strength—not merely body weight.

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The challenge of weight regain after stopping treatment

Perhaps the greatest challenge starts after successful weight loss. The second BMJ meta-analysis provides sobering evidence on what happens when treatment stops. Across 37 studies involving more than 9,300 participants, patients regained weight at an average rate of approximately 0.4 kg every month after discontinuing medication. Interestingly, those receiving newer incretin-based therapies such as semaglutide and tirzepatide regained weight even faster, with modelling indicating that most patients returned to their baseline body weight within 1.5–1.7 years. At the same time, improvements in blood sugar, blood pressure and cholesterol gradually disappeared, with most cardiometabolic benefits returning close to baseline within about 1.4 years.

These findings reinforce an increasingly accepted concept: obesity behaves much like hypertension or diabetes—a chronic, relapsing disease requiring long-term management rather than a short therapeutic course.

The cost of long-term treatment: Are generics the answer?

This raises uncomfortable questions. Can patients remain on these medicines for many years? Will they continue injections indefinitely? Can healthcare systems afford lifelong treatment? More importantly, can individual patients?

These questions become even more relevant in India. Generic semaglutide is expected to substantially reduce treatment costs and improve access. Even then, long-term therapy is likely to remain expensive for large sections of the population. As generic versions become available, ensuring consistent quality and bioequivalence will be important. Newer medicines such as tirzepatide and future dual- or triple-agonists may remain beyond the reach of many families for years. Given limited healthcare resources, these medicines should be prioritised for patients most likely to derive substantial clinical benefit rather than used indiscriminately for cosmetic weight loss. Cost-effectiveness, therefore, cannot be ignored while framing India’s obesity strategy. Every kilogram of weight lost must be considered alongside treatment duration, affordability and long-term sustainability.

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India’s obesity epidemic cannot hide behind weight-loss drugs

The latest generation of anti-obesity medicines represents one of the most important advances in metabolic medicine. They should neither be dismissed because of their limitations nor promoted as miracle solutions.

Patients with severe obesity, or obesity accompanied by major obesity-related complications such as type 2 diabetes, metabolic dysfunction-associated steatotic liver disease (MASLD), obstructive sleep apnoea or established cardiovascular disease, are likely to derive substantial benefit from these medicines. For those with milder obesity, or whose primary goal is cosmetic weight loss, careful discussion about expected benefits, possible risks, costs and the likelihood of long-term treatment becomes essential.

However, India’s obesity epidemic will not be solved by injections alone. Healthier food environments, greater physical activity, prevention beginning in childhood and better public awareness remain indispensable. Anti-obesity medicines should complement—not replace—these measures.

The latest evidence reminds us that the true goal of obesity treatment is not simply to lose weight. It is to preserve muscle, improve physical function, improve physical fitness, reduce complications, sustain a healthier body weight and ultimately help people live longer and better.

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The true measure of success is not the maximum weight lost during treatment, but whether a healthier weight, muscle strength and metabolic health can be maintained years later. For Indians, who face the dual burden of excess body fat and relatively low muscle mass, this balanced perspective may prove even more important than the excitement surrounding these remarkable new medicines.

(Dr Misra is Chairman, Fortis C Doc, Diabetes and Allied Sciences)