Oh-zempic! Smaller waists and bigger questions

There was much more ambivalence about body shape when I was growing up. The obese were named and shamed (a friend was called, quite openly, mota (fat) Bapi), but you could not be too thin either. I would get quite openly criticised for my lack of heft — kangla was the description of choice — and this came with diet suggestions. Often it was Horlicks, that curiously Indian drink made from milk solids and malted wheat. I discovered it was easiest to say yes and then not do it, since I have always had (a very non-Indian) aversion to all warm milky drinks.

This was in the 1970s, long before we heard of fat-shaming or size zero, long before social media with its obsession with how the world sees us, and all the unsolicited advice about how to improve our public persona. Very long before the looksmaxxers, misogynistic young men, convinced that women care only about how they look, and fixated on getting the right kind of body (svelte). And even in India, at least among the social class that can afford make-up, gym subscriptions, and health foods, the norm has clearly shifted. Korean beauty tips on social media featured prominently in a recent conversation we had with college students in Kolkata, and the Korean ideal clearly starts with slim.

There is much to be said in favour of this shift: India has a very large and growing obesity problem. Under the US definition of obesity, which sets the threshold of obesity at BMI of 30 (which places someone who is 5’6 and 85 kilos exactly on the cusp), roughly 10% of adult Indian women and 5% of adult Indian men qualify as obese in 2022, compared to 1.5% of women and 0.5% of men as recently as 1990. But a wide range of medical experts now think that the US definition is not appropriate because South Asian bodies are different — a higher proportion of our body mass is fat and, for that reason, they want a lower threshold of 25 (which means that our 5’6 friend would be obese if he weighed just 70 kg). There is speculation that this owes to our long history of food insecurity and recurrent famines, which puts an evolutionary premium on storing fat in the body.

With this definition, nearly a quarter of both men and women would qualify as obese in 2019-21, up from about a fifth just five or so years before. To make matters worse, it turns out that the South Asian body shape, with our tendency towards a well-rounded midriff (perhaps because it is the easiest place to put that fat stored away for emergencies) — what the health experts call abdominal obesity — creates health problems even among relatively thin people. The same trend is there even among children and adolescents — 20% of whom are already overweight or obese, up from less than 15% in 2010.

This is frightening because it presages a health crisis in the very near future, similar to the one that the US is now struggling with. It is widely agreed that obesity is a major cause of diabetes, heart ailments, blood pressure, fatty liver disease, and other chronic ailments. And we already have a big problem in these areas: with less than 18% of the world population, India suffered 31% of the loss of lives from cardiovascular diseases.

The potentially good news is that in March this year, semaglutide, one common form of GLP-1, came off patent in India, bringing down prices from north of Rs 14,000 a month to a little over  Rs 1,000 a month for generic versions, still expensive but accessible to many more. GLP-1 (sold under the brand names Ozempic, Mounjaro and Wegovy) is an appetite suppressant. It manipulates our brains to think that we have had enough even when we have not, and slows down absorption. People on it talk about instinctively reaching for that second helping of pasta or third slice of pizza, and realising that they actually don’t want it. They lose, on average, 20% of their body weight.

Used with caution — nausea and other digestive disorders are the usual side effects, at least at the beginning (but there can be other, more dire, reactions, albeit very rarely) — this can be a lifesaver for many.

But will we actually use it right? After all, we have a widely documented culture of casual pill-popping. By abusing antibiotics when they are not called for, we have ended up as the world centre of anti-microbial resistance, meaning we have helped the bacteria to mutate to the point where they are immune to most standard antibiotics. Why would it be any different with GLP-1?

Many years ago, while studying prescribing behaviour in West Bengal, we discovered something both funny and frightening. Apparently, in many village kirana stores, one could buy a puria — a paper package with powdered steroids to help would-be brides gain weight quickly. I assume they were kangla like me, not attractive by the norms of the day. The result was that there were many young women with strangely thickened necks — a sign of steroid use, apparently — who had given up a part of their future health (that is what steroid abuse does to you) to be more marriageable. Why would that not happen now with GLP-1, just in the other direction? In fact, there are already news reports of ‘wedding packages’ for a hefty price that include weight-loss drugs, but I assume those prices will come down, and usage will explode.

To the extent that we know, the side effects of GLP-1 are less severe than those of steroids, and therefore that trade-off may be worthwhile in terms of pure health gains even for many mildly overweight people. Perhaps it is even true that, given the amount of misery families go through to marry their daughters, this is a small cost to pay. I am not an expert.

Two things, however, worry me. First, children. GLP-1 is now approved for the small minority of teenagers who are extremely obese or suffering from very early-onset type 2 diabetes. For these unfortunates, the drug is likely to be a lifesaver. My concerns are with the rest, the young man or woman who is somewhat overweight and is tired of being tagged as such, and the resulting impact on their social life (along with concerns about their long-term health).  I can see why many parents will be tempted to get them the drug even if it is not authorised, and given the laxity of our regulations, this won’t be particularly hard. Indeed, I am sure they could even get the drug for their rotund pre-teen, for whom the drug is currently absolutely forbidden.

There are very good reasons why these drugs are not yet recommended for most young people. Adolescence is when our bodies grow. GLP-1 dampens our appetites. I remember age 14 as a time of eating, playing sports (with a great deal of enthusiasm and less success) and growing. And eating more. My mother told me that at some point, feeding me became such a challenge (my parents did not have a lot of money at the time) that we had to make a plan to keep the costs down: it was doi-chiré (flattened rice with yogurt and bananas with a dash of gur and maybe some aam papad) on odd days and dal-roti-achaar on even. Sundays were reserved for something special.

GLP-1 interrupts that connection: not feeling hungry all the time; not needing to work that meal off by exercising; not feeling hungry again after the exercise. I worry that it will change the way kids grow and the kinds of adults they will be — when they are 65 like me, for example, will they manage to exercise regularly if they didn’t acquire that habit in teenage?

More generally, and this is my second concern, adolescence is a time when we go through hormonal changes; what does adding another very powerful hormone (GLP-1) to the mix do to that process? In particular, there is a suggestion that, along with the desire for food, GLP-1 generally suppresses all desire. The New York Times columnist Ezra Klein experimented with a low dose of GLP-1 for some time and describes the experience as something akin to being depressed. Adolescence is critically the period when we first feel the full force of sexual desire — it impels us to make ourselves attractive to others and teaches us to manage our most volatile emotions. Do we want our children to grow up without going through those? And for that matter, is the state of being half depressed what we want for a large fraction of our adults?

Right now, no one knows very much about any of these things, about which of these worries deserve more attention, and where can we relax? Multiple trials are on but, at least in the case of children, it will take years before we find out, since what is at stake is the adult we grow up to be.

In the meantime, it is critical that we don’t get so sold on the idea that GLP-1 will solve all our problems that we give up on healthy eating and exercise, two things we know are good for almost everyone. The rise in obesity, especially among the youth, but also in the rest of the population, is clearly due in part to the switch to packaged junk foods and the increased time in front of screens. I recognise that there is less time now to prepare food at home and that the pressure of work and homework, the vile air of our cities, the rising temperatures, and the lack of green spaces discourage exercise. On the other hand, there is data (not sure how reliable) showing that the average Indian spends 2.5-3 hours a day on social media. Surely, we can do something better with that time.

RECIPE FOR DOI CHIRE (DAHI CHIVDA)

Phalahar or pholar gets mentioned in late medieval Bangla texts (such as mongolkabya) as a breakfast food. It was also food that a travelling brahmin could prepare for himself with things he could easily buy, something nutritious but uncooked, and thereby avoid eating something “impure”. What we called doi-chiré is a particular version of pholar, ideal for a summer breakfast or snack.

Soak 50 gms sweet and sour aam-papad in 1/3 cup warm milk for 10 minutes, and while that is soaking, put 2 cups flattened rice (poha) in a bowl of water for 5 minutes. Drain the flattened rice and mix with 1 cup chilled yogurt, and crush 2 sweet bananas and ¼ cup gur into it (ideally gur from the date palm). Break the soaked aam papad into small fragments and add to the mixture along with a pinch of salt. Mix together well and serve, ideally with a drizzle of liquid gur. Makes a good breakfast or snack for two hungry teenagers (or anyone else).

(This is part of a monthly column by Nobel-winning economist Abhijit Banerjee, illustrated by Cheyenne Olivier)