Slim Chance

IT WAS IN JUNE last year when Arjun Sha began consuming one of the promising new categories of weight-loss drugs that has taken the world by storm. Sha had been overweight for nearly a decade. His sedentary lifestyle, coupled with an unhealthy relationship with food, led him to weigh 125kg at one point. “I tried going to the gym, and was on diet as well, but none of it worked,” says Sha, who works for a Delhi-based tech platform. “Due to my obesity, I was on drugs for hypertension and choles­terol as well.” Sha began taking Rybelsus, the oral form of Ozempic, the injectable drug that has become synony­mous with rapid weight loss the world over in recent times, after he was introduced to it by his partner who works as a doctor.

The likes of Ozempic, originally conceived as a drug for only diabetics, work as a weight-loss drug by targeting that part of the brain that regulates appetite, ensuring that the individual consumes a lot less food than he normally does. Sha began with the lowest dose of the drug, 3mg, and began increasing its power, from 3mg to 7mg, and finally 14mg, after every few months. The results were almost instantaneous. “From day one, it cut down my hunger pangs and food cravings, which was a big issue. Prior to taking the drug, I used to devour food. Now, I was getting full after just having 3-4 chapatis. So, from 3,000-plus calories, I was only eating around 1,500 to 1,800 calories every day. It was like my relation­ship with food was changed entirely,” he says.

Within seven months, Sha lost 24kg, which was about 19 per cent of his original weight. He now didn’t even need drugs for hypertension and cholesterol. Sha had been advised to exercise while taking the drug, but he did not do that. “Had I done that, I would have lost more weight,” Sha says. “The drug promises around 15 per cent [reduction], so I was well above that. I went from 125kg to 101kg. I wanted to go below 100, but that didn’t happen so I quit the drug.” Since his weight loss had stagnated, and the costs of the drug was burning a hole in his pocket, he stopped taking it in January.

Technically, Ozempic is a diabetes drug. But in recent times, it has become something of a sensation for its weight-loss capacity. It has turned people into internet sleuths looking for telltale signs of Ozempic use, such as the “Ozempic face” (the sagging of facial skin), “Ozempic butt” (a similar sagging effect around the buttocks), and “Ozempic hair” (hair loss), even as many celebrities like Oprah Winfrey and Elon Musk have admitted to using weight-loss drugs and vouched for their effectiveness. The likes of Ozempic—and there are several more of them, includ­ing Ozempic manufacturer Novo Nordisk’s Wegovy, Eli Lilly’s Mounjaro and Zepbound, and a few more, including some in development—contain a compound known as semaglutide, which affects the areas in the brain that regulate appetite, and prompts the stomach to empty slowly, making those taking it feel satiated much faster. These drugs also activate receptors for a hormone called GLP-1, which animal studies have shown, is found in brain cells in regions crucial for motivation and re­ward. This could be one reason, experts feel, that the drug influ­ences cravings and desires. “This medicine decreases food crav­ings. So now, even if food is kept in front of you, you will just not feel like eating it,” says Dr Sweta Budyal, an endocrinologist in Mumbai’s Fortis Hospital. Interestingly, there have been reports abroad where users who enjoyed drinking alcohol have reported feeling no craving for it, and researchers are investigating wheth­er these drugs have the potential to deal with addictions. Some scientists believe that these drugs could have an impact in many other fields of medicine, and several trials are on investigating their effectiveness in dealing with chronic kidney issues, cardiac issues, Alzheimer’s, liver disease, polycystic ovary syndrome (PCOS), and even issues of the skin.

Although some doctors in India prescribe them cautiously, try­ing to wean patients off them over time, people are usually expected to take them for the rest of their lives. Stop taking them, the cravings for food return, and so do invariably all the lost kilogrammes. These drugs are also very expensive. But they might become relatively more affordable in the future, since many of their patents are com­ing to an end, and several Indian and Chinese pharma companies are known to be developing generic versions of them.

IN INDIA, Apart from a few like Rybelsus, most of the injectable forms of these drugs aren’t currently legally avail­able. But that might soon change. The subject expert commit­tee of the country’s apex drug regulator, Central Drugs Standard Control Organisation (CDSCO), recently approved the import and marketing of the drug Tirzepatide—marketed as Moun­jaro and Zepbound in the US and made by Eli Lilly—for those suffering from Type 2 diabetes. Another application for dealing purely with obesity is believed to be undergoing review by CDSCO. Based on the recommendation made by the committee, the final approval for the drugs is expected to come from the Drug Controller General of India. Eli Lilly’s CEO David Ricks had earlier told reporters it expected these drugs to hit Indian shelves by sometime next year. Many believe others like Ozempic and Wegovy will follow soon after.

I asked him what had happened, and he said, he had no time to exercise. So, I told him there was Rybelsus. And after three months, when I saw him, I was amazed. He was fitter. He had lost around 10 to 12kg, says Dr. Karishma Balani, dermatologist and director, Synova

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These injectables, while not legally permitted for sale in the country, are widely available in the black market. Many affluent Indians are stashing them in their bags on their return trips from Europe, Dubai, and elsewhere. Many pharmacies across the country sell them on the sly, often at marked-up prices. One can even find them on popular online platforms like In­diaMART. There has also been a disconcerting rise, according to experts, of counterfeit versions of these drugs flooding the market. “I used to get many people coming in every few days and enquiring about this drug,” says Dr Sharanjeet Kaur Sodhi, a bariatric nutritionist, earlier with Sir Ganga Ram Hospital in Delhi, but currently in Toronto, where she continues to tele-consult Indians dealing with obesity. “They have either heard about it online. Many Indians also travel abroad and get exposed to it there.” She is aware, she says, that several individuals procure these injectables illegally and often take them without any doctor supervision. “That is inadvisable. This is a drug at the end of the day, and you can’t just take it like that.”

Budyal, too, says patients should not be using it by them­selves. “It has to be initiated by a doctor who will do some basic work, go through the patient history, rule out those who are unfit for it. For instance, patients who have a family or personal history of medullary thyroid cancer or they have had pancreati­tis, these are contraindications [against use of the drug]. Obesity is a complex and chronic disease. You cannot just take a pill or go off it. You can’t manage it like this,” she says.

Eli Lilly’s interest in entering the Indian market isn’t surprising. India has a big problem with obesity. According to the National Family Health Survey-5 from 2019-2021, 29.8 per cent of urban men and 33.2 per cent of urban women between the ages of 15 and 49 years can be categorised as overweight or obese. This is not to speak of childhood obesity, which is also said to be growing at an alarming rate. The weight-loss market itself has begun growing rapidly in recent times. According to the research firm Pharmarack, the market has almost tripled in size since January 2022, the period when Rybelsus was launched, from `174 crore to `474 crore earlier this year. Many Indian pharma companies, from Sun Pharma, Biocon to Dr Reddy’s Labs, Lupin, and others, are developing their own versions of weight-loss drugs. The effectiveness of the drugs to lose weight, even the oral ones which are believed to be not as effective as the injectable versions, has surprised doctors. “I have seen some people losing be­tween 20 to 25kg, sometimes even 30kg,” says Sodhi, as she lists how individuals across age groups, from women in their 20s, wanting to lose weight before marriage, to some in their 20s and 30s wanting to lose weight so they can conceive without complications, and many others, both men and women, from their 20s to the 50s, just wanting to lead healthier lives, have gone on the drug under her supervision.

Dr Kiran Sethi, a celebrity skin specialist and popular figure online, runs Isya Aesthetics, a health and wellness firm in Delhi, where these drugs are prescribed in their weight management programme. Most patients who ask her for the drugs tend to be people who’ve heard about its effectiveness during their travels abroad or heard about it from friends and family who have used it overseas. The injectable forms like Ozempic and Wegovy, she says, are often sourced by expatriates or those who have travelled to countries where these medications are more readily accessible. “Within our medical weight manage­ment programme, we do prescribe semaglutides, both oral and injectable, depending on the patient’s specific needs and medical history. We have an American Board-certified endocrinologist on board who selects the appropriate form based on factors such as health status, obesity level, and the presence of co-morbidities. The oral medication has shown great efficacy—patients can lose 7-10kgs with minimal side effects. Injectable forms are also highly effective but are typically used for patients who require a more aggressive approach to weight loss,” she says. She usu­ally prescribes these drugs for a limited period, she says, aiming to wean patients off the medication once they have achieved their weight loss goals and established healthier lifestyle habits. “It is important to monitor and adjust the dosage based on the patient’s progress,” she says.

What about conditions like the “Ozempic face”, “Ozempic butt”, and “Ozempic hair”, which are sometimes witnessed among users of these drugs? “[They] result from rapid weight loss and can be avoided by ensuring a gradual weight reduction, high-protein diets, and adequate nutrient intake. Our nutrition­ists work closely with patients to provide balanced diets rich in iron, vitamins, and proteins to prevent such side effects,” she says.

In Mumbai, Dr Karishma Balani describes herself as a fan of the drug Rybelsus. A dermatologist who serves as the direc­tor of Synova, a chain of skin and beauty clinics, Balani often gets patients with complaints of acne, hair thinning, and obe­sity. Many of these patients tend to be diagnosed with PCOS, and very often, they are also obese and suffering from insulin resistance. She usually prescribes Rybelsus in such cases, she says, and it usually shows good results. But Balani doesn’t limit the knowledge of this drug to just her clinics. Sometimes, she will share the drug’s name with old friends struggling in a gym, or to their wives with weight issues. Sometime ago, she chanced upon an old friend, who works as a hair transplant surgeon, and found he had put on several kilogrammes. “I asked him what had happened, and he said, he had no time to exercise. So, I told him there was this magical thing [Rybelsus]. ‘You can try it out.’ And after three months, when I saw him, I was amazed. He was fitter. He had lost around 10 to 12kg,” she says.

Balani and other doctors caution against abusing the medicine and using it without consulting a doctor. Some experts even point out that there haven’t been long-term studies on these drugs, so we have little understanding of the risks they might carry. Budyal thinks these drugs will prove to be a game changer when it comes to dealing with obesity. “These medicines have actually opened a new vista in the world of weight management. So far, we didn’t have anything which was as effective and as safe as these medicines are. So, these, and a lot of other medicines in the similar class which are in the pipeline but seem to be even more potent, some even showing weight loss which is quite close to what bariatric surgery achieves, are quite something. If we can achieve something like that without invasive procedures like bariatric surgery, that would be a major achievement,” she says. Others like Dr Farah Ingale, the director of internal medicine in Fortis Hiranan­dani Hospital in Navi Mumbai, are more circumspect. “In terms of obesity, it can be a game changer only when it becomes affordable. Perhaps when generic versions are developed, this might hap­pen. But right now, only a select group of people can afford these drugs,” she says.

Back in January, when Sha stopped consuming the drug, like it often hap­pens, the weight started coming back on. “Just after stopping the drug, I started regaining my weight as my hunger pangs were back. I was unable to control my food cravings. In just one month, I gained 4kg leading to 105kg. I abruptly stopped the drug which is also a factor for regaining weight… I should have tapered down with a lower dose,” he says. Sha went into what he calls a panic mode, fearing he would lose all progress he had made. He began exercising, including running for an hour daily, and restricting his food consump­tion to 1,800 calories per day. Although he has stopped running now, he has been losing about one kilogramme monthly, and currently weighs 98kg. He has currently kept an aim of reducing his weight to 90kg. “I never thought I would be able to lose weight in this lifetime,” he says. “It helped me understand my body and what kind of food I should eat.”

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Lhendup G Bhutia

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