"Since weight loss caught the headlines, these medicines became branded as just weight-loss drugs."
November is Diabetes Awareness Month. Dr Ambrish Mithal, group chairman, endocrinology and diabetes, Max Healthcare, Delhi, tells Srirupa Ray how GLP-1 medicines are changing the face of diabetes and chronic disease management, why weight loss varies, and how nutrition, strength training and medical supervision remain central to treatmentGLP-1 drugs inspire both excitement and fear. What makes them such a significant discovery? This class of drugs has been used to treat diabetes for about 20 years. What brought it into the public eye was the degree of weight loss achieved with newer medicines. Semaglutide produced weight loss of around 15% or more in clinical trials. Tirzepatide, which acts on another hormone pathway, crossed 20%. That broke a barrier we had never crossed with medicines before. We now had tools that could control diabetes and produce substantial weight loss, with associated health benefits. They have changed how we look at obesity and several related chronic conditions. The excitement among scientists and doctors is understandable, but patients need to understand both the possibilities and the limitations.Are people seeking cosmetic weight loss crowding out the real conversation about health benefits? Since weight loss caught the headlines, these medicines became branded as just weight-loss drugs. Half my day is spent explaining to people seeking prescriptions that they do not need them; the other half is spent persuading suitable candidates who are reluctant. Someone with diabetes, excess weight and heart or kidney complications may say, “I don’t want a weight-loss medicine.” But the potential benefits of GLP-1 drugs extend beyond weight. If someone meets the medical criteria and is also motivated by appearance, that is fine. Improved confidence and social participation matter. But taking these drugs purely to lose a few kilos before a social event is not recommended. Every prescription requires a favourable balance of benefit and risk.How do they work, and what benefits extend beyond the weighing scale? GLP-1 is a hormone released from the gut. It helps stimulate insulin secretion, suppresses glucagon, slows stomach emptying and acts on the brain to reduce appetite and increase fullness. There is evidence of heart benefits and slower progression of kidney disease. Fatty liver disease improves, while weight reduction can help conditions such as sleep apnea and osteoarthritis. Reducing visceral fat — the fat around internal organs — is important because it contributes to inflammation and metabolic problems. However, we are also learning about effects that may extend beyond fat reduction. Research into neurological conditions is ongoing; those possibilities should not be confused with established treatment benefits.Patients talk about reduced ‘food noise’. What changes in their relationship with food? Many describe a reduction in cravings. The urge to raid the refrigerator at night or have cake while working late may diminish. Others say they previously thought constantly about their next meal, even while travelling or doing unrelated things. With treatment, foods they once found irresistible — jalebi, gulab jamun, kachori — may no longer seem so attractive. The thought of rewarding oneself with food changes, though not identically in everyone. A small number also report changes in enjoyment beyond food. These experiences need discussion and follow-up. Patients should tell their doctor about the changes they notice, rather than assuming that everything is an inevitable part of treatment.Does everyone lose a lot of weight? How should patients set expectations? Responses vary enormously. Some people lose weight quickly; others begin losing only after several months. A small proportion responds poorly or loses very little, even though their diabetes control may improve. In our experience, supported by broader observations, people with diabetes generally lose less weight than those without diabetes. We have also seen better responses among women and younger patients, although individual outcomes remain difficult to predict. Expectations must be realistic from the first consultation. If you weigh 140 kg, these medicines will not necessarily bring you to 70 kg. A substantial reduction can still leave you well above that target. Early progress should not create the expectation that weight will keep falling indefinitely.Can patients stop once they reach their target, or is treatment lifelong? Many people need long-term treatment, particularly when managing diabetes, severe obesity or related complications. We should not rush to withdraw a medicine that is helping simply because someone has improved. In my practice, once weight loss plateaus or treatment goals are reached, we discuss whether a lower maintenance dose is appropriate. Some patients need higher doses; some may eventually stop. Any reduction requires monitoring for weight regain or worsening metabolic control. Taking a drug briefly, stopping it and restarting before another social event is not well studied. Weight commonly returns after withdrawal. Patients should discuss affordability and the likely duration of treatment at the outset.If the drug reduces appetite, why are diet and exercise still so important? The medicine reduces how much you eat; it does not teach you what to eat. When food intake falls sharply, getting enough protein, fibre and other nutrients becomes harder. Simply telling someone to “eat more protein” is not good enough. Patients need a tailored nutrition and exercise programme, including strength training suited to their abilities. These habits should begin during treatment, with appropriate guidance. Medical follow-up is equally important. Nausea, vomiting, constipation or diarrhoea can occur. Do not conceal symptoms because you are pleased with the weight loss. Understand whether you qualify, disclose your medical history and let a qualified physician guide treatment. Do not start injecting yourself on a friend’s or influencer’s recommendation. These drugs can really help but only if used in the right way, in the right person, at the right time.Watch the full podcast here
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