- 6/27/2025
Are GLP-1 weight-loss drugs a medical breakthrough or a ticking time bomb? The debate is louder than ever— hailed by some as miracle cures, dismissed by others as dangerous shortcuts.
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00:00We've all been sort of brought up on metformin as the first drug for diabetes.
00:05What about the ozempic face? You know, the glow, so to speak, is lost in so many celebrities.
00:11You're looking for maybe unrealistic goals.
00:14What would be the drawbacks be?
00:16Don't depend on the drug alone.
00:18People with diabetes who are put on GLP-1 lose less weight than those without diabetes.
00:25Would you prescribe a GLP-1 medicine or would you ask that patient to stick to metformin?
00:29Remember, GLP-1 field is just beginning to explode.
00:33There will be many newer drugs with less and less side effects and easier to use.
00:38We don't have to repeat everything the West has done.
00:46Well, how do I lose weight?
00:48That's actually one of the most common questions that just so many people want the answer to.
00:53It's a big talking point.
00:55Everyone is interested in losing weight.
00:57It's, in fact, one of the most searched topics on social media.
01:00Doctors are answering that question.
01:02Dr. Amrish Mittal has written a book on it.
01:05It's called The Weight Loss Revolution.
01:07And it answers many questions around weight loss and weight loss medication.
01:11It talks about this as a weight loss revolution because it is.
01:14GLP-1 medications and the interest around weight loss medicines, which are now available in India, at least one is, one is in the pipeline, is going to help diabetic patients control their weight and who are not diabetic as well can get some benefits as weight loss is the outcome of it.
01:33Dr. Amrish Mittal is now joining us.
01:36Thank you so much for your time.
01:37You are, in fact, tuned in to our new show, which is booked.
01:40And we'll discuss your book.
01:41And you also have to answer some questions around weight loss.
01:45Sure.
01:45What exactly is going on?
01:47You call it the revolution.
01:49In, you know, in the phrase that you use, the term that you use is revolution.
01:53And many do see it as a big change in the pharmaceutical industry and in the health landscape as well.
01:59You know, for the longest time in India, it is the diabetes capital of the world, as we know.
02:03And metformin is being used.
02:05But you write in your book that you see the tide, in fact, changing in favor of GLP-1 medicines.
02:14Just tell us why do you say that?
02:16So we've all been sort of brought up on metformin as the first drug for diabetes.
02:21Because metformin is safe, it has virtually no long-term side effects, possibly causes a little bit of weight loss, and possibly protects the heart a little bit in the long run.
02:35But with the newer drugs, particularly GLP-1 drugs, and there are also another class of drugs called SGLT2 drugs, with these drugs, you're moving far ahead of metformin.
02:47Because there is clear evidence that these drugs produce significant weight loss, and not only that, there is clinical trial data suggesting that they protect your heart, they protect your kidney, they very likely protect your liver too.
03:07So with this hard evidence, based on solid clinical trials, these drugs are bound to replace metformin, somewhere down the line, sooner rather than later, as first-line drugs.
03:22Alright, as first-line drugs, GLP-1 medicines are the common names that all of us are now familiar with, which is Ozempic.
03:29Also the other drugs that you could mention, sir.
03:32Yes, Ozempic or Vigovi, and Munjaro or Zep-bound.
03:37So I think in India, the relevant names are Munjaro, which is already available, Tirzapatide, or Vigovi, which I understand will soon be available in India.
03:49But even before the medicine was available, as you write in your book, lots of patients were actually procuring it from outside of India.
03:55Ozempic is not in India, but they get it from other countries because of the drastic effects that they see in terms of weight loss.
04:03So I want to ask you, if a person comes to you, if a patient comes to you and says, I'm diabetic, but that person is not clinically obese,
04:10would you subscribe, would you prescribe, I beg your pardon, would you prescribe a GLP-1 medicine, or would you ask that patient to stick to metformin?
04:17I think there are certain categories of diabetes where these drugs clearly score over the drugs.
04:24And you have to remember that type 2 diabetes, which is the common variety of diabetes, is primarily driven by excess body fat.
04:33So 80 to 90 percent of people with type 2 diabetes would be those who have excess body fat.
04:39So such people would automatically be candidates for GLP-1 drugs.
04:45So I think that's how you have to look at it.
04:47The vast majority would be candidates, but there would be some, of course, who are the lean type 2 diabetics,
04:52somewhat different in their pathophysiology or in their manifestations, who would not be candidates.
04:59But the bulk, the large chunk of type 2 diabetes patients are overweight, need to lose weight,
05:06and losing weight will help them either even reverse or at least treat their diabetes better.
05:12You know, I also want to ask you, nowadays there's a lot of chatter about the fact that BMI clearly shouldn't be an indicator.
05:18In fact, it is misleading.
05:19Just tell us, why is BMI misleading?
05:22And rather you write in your book as well that the fact is that right now you have to look at your body fat percentage,
05:28and that would be a more accurate way of determining whether a patient is obese or not.
05:34Correct. So BMI is the most convenient method, time-tested and honored method,
05:40because it just takes into account your height and your weight. That's it.
05:44Now, it doesn't take into account how much of that weight is coming from muscle.
05:49It doesn't take into account how is the weight distributed.
05:53Not all weight is the same.
05:56Right.
05:57So if you use just BMI, that is height and weight,
06:01you will end up with a lot of Indians being classified as healthy in the BMI category
06:07when they have actually a lot of central fat.
06:11And if the central fat or the belly fat or the visceral fat, that is actually the bad fat.
06:17So using just BMI would mislead us into thinking that, you know, one person is healthy,
06:23whereas actually the person has a lot of central fat and therefore is clearly unhealthy and needs treatment.
06:29All right. So BMI needs to go out of the window clearly.
06:31That is the calculator.
06:33Well, it won't go out of the window because it's been there for so long and used in so many studies.
06:38But definitely one can look at waist circumference, waist-hip ratio.
06:44And if you move ahead, body composition analysis, which is not so difficult anymore,
06:49which will tell you the actual percentage of body fat that you have?
06:53You know, I also want to ask you, and you write this, you know,
06:56the book also talks about it in detail about the fact that many Indians are actually skinny fat.
07:00They might be sinned all over, but they may have like a pot belly.
07:03You know, this could be because of anything.
07:06Cortisol fat as well, I would believe.
07:08Cortisol belly also.
07:09But, you know, why is this particularly risky?
07:12Why is this particularly problematic?
07:13You say fat around the thighs and your arms isn't particularly worrying, isn't it?
07:18Yes.
07:18Because, as I said, all fat is not the same.
07:21Hence the BMI, you know, importance is less.
07:24We call it TOFI.
07:26T-O-F-I.
07:27Thin outside, fat inside.
07:30Okay.
07:30Okay.
07:31And that's typical of South Asians or Indians.
07:33So, the fat around the viscera, that is inside, around our organs, viscera means organs,
07:39that produces a lot of dangerous inflammatory substances, different kinds of cytokines or chemicals, if you may,
07:47which incite inflammation across the body, including the pancreas, including the heart, kidney, everywhere.
07:54So, that fat, when, if that is excessive, that is very dangerous, as compared to fat on the arms or the thighs, which is direct subcutaneous fat, which may not be that dangerous per se.
08:08Okay.
08:08So, there's a big difference in the kind of fat.
08:11Okay.
08:12You know, when it comes to GLP-1, yes, there is, at initial days, there was a lot of conversation.
08:17And now also, you know, nausea, just feeling sick.
08:19I hate food.
08:20My relationship with food has turned sour.
08:23You know, these are usual statements that you get to hear from people on these medicines, like Uzampik, Monjaro.
08:29I just want to ask you, you know, what would you say is problematic here?
08:34And what should be the do's and don'ts for those people on these medicines?
08:38And how should they be, A, number one, exercising, and also, you know, watching their calorie intake and eating the right kind of food?
08:46Yeah.
08:47I mean, I think the first thing to emphasize here is that if you're using these drugs for weight reduction, don't depend on the drug alone.
08:57So, I'm asking your last part first.
08:59Basically, it's important that we understand that using so-called weight loss drugs or GLP-1 drugs is actually part of a program, which includes dietary advice, in particular, increase your protein intake because your diet is going to go down.
09:18Yes.
09:18So, if you're eating half of what you were eating earlier, then you can't afford to have half the protein, right?
09:23So, increase the proportion of protein in your diet, increase the proportion of fiber in your diet.
09:30Each single meal should be small.
09:33Don't have single large meals.
09:35The moment you have a large meal, supposing you, you know, don't eat all day, and then you have a large meal in the evening, you will certainly feel sick.
09:43So, small meals is important.
09:46Sometimes just walking after meals, five to ten minutes, makes a big difference.
09:51So, all those kind of things are important.
09:52Obviously, you know what to avoid.
09:54You know that you have to avoid fried food.
09:56You know you have to avoid baked or high-carbohydrate food.
10:01Those things are not that great for us.
10:03The moment you, you know, follow these things or don't follow these things, your body will tell you if you're not following.
10:10As I said, you'll feel sick and you may want to throw up.
10:13That's one thing.
10:14In the long run, if you're not following a healthy diet with this, you will end up with significant muscle loss.
10:22Because, and this is not because of the weight loss drugs.
10:26Whenever we lose weight, we also lose muscle.
10:30So, roughly 20-30% of the weight.
10:33So, if you lose 10 kilograms, 10 kilograms, you've lost 2 to 3 kilograms of muscle.
10:39Now, if you want to preserve that, and studies are showing that very clearly, you have to ensure adequate protein in your diet.
10:47And, along with that, you have to make sure that you're exercising regularly and that exercise should include strength training.
10:56Right.
10:56I was coming to that.
10:57By exercise, not taking a walk in the park, but lifting weights is what you're saying.
11:01Because muscle loss is inevitable.
11:02Yes.
11:03And, hence, exercising in a way is going to stop that to an extent?
11:07Yes, significantly.
11:08Okay.
11:08Significantly.
11:09So, if you think of the GLP-1 drug, if you're using it for weight reduction alone, if you think of it as a part of your weight loss program, then you'll succeed.
11:21Right.
11:22Then you'll know, you know, you'll not lose that much muscle.
11:26You'll be healthier overall.
11:28And, when the time comes to, later on, taper them or reduce their dose, you'll be in shape to do that.
11:35That's right.
11:35If, on the other hand, you're using the drugs, because they'll make you lose weight anyway.
11:39That's right.
11:39If you're using the drug just as a weight loss drug and doing nothing else, you will lose weight, but you'll also lose muscle.
11:47And, then, when you try to reduce the dose, the weight will start coming back on.
11:51So, there's a bit of a challenge there.
11:53You know, you've touched upon the Ozempic butt here, and I think that is related directly to muscle loss and sarcopenia.
12:00But, what about the Ozempic face?
12:03What happens with the face?
12:04Because, you know, the glow, so to speak, is lost in so many celebrities who have taken this medicine.
12:10They'll never admit that they have.
12:12And, I really don't know what the stigma is also, you know.
12:15Do touch upon that.
12:17So, when we lose weight rapidly, we lose subcutaneous fat.
12:21Yeah.
12:21So, the fat and the skin become a little lax.
12:25This is particularly in older people, where skin tends to sag anyway.
12:29So, if you suddenly lose weight, don't hydrate yourself well, not eating the right kind of balanced diet.
12:35And, you know, you're looking for maybe unrealistic goals for weight loss.
12:40Then, you get that little sagging on the face, which people have started calling Ozempic face.
12:45Forget this.
12:46Before these drugs came into the market, anyone we put on a very strict diet or someone who had bariatric surgery would have similar things.
12:53Yes.
12:54But, now it is called an Ozempic face.
12:56Like, a bariatric surgery would also have similar.
12:58Yes, absolutely.
12:58You can see it, actually, you know.
13:00It's basically loose skin.
13:01It's visible, yeah.
13:02Loose skin.
13:02All right, you know, I mentioned at the outset that just so many Americans are taking it.
13:08And, for a country like America, where obesity levels are going through the roof, it's perhaps the need of the hour.
13:13But, in India also, we have twin problem of diabetes and obesity.
13:18So, technically, we are the diabetes capital of the world.
13:21So, you see this medicine picking up, you know, people taking this medicine in India.
13:26What would be the drawbacks be?
13:28I mean, I think this is fairly still expensive, you know, to make it accessible to a larger population.
13:34For health reasons, how do you see this happening?
13:36So, I see these drugs as very important tools in our armamentarium to treat diabetes and obesity.
13:44I don't see them as public health measures.
13:46Oh, okay.
13:46You can't eradicate obesity by using these drugs.
13:50Yes.
13:50You have to eradicate obesity by preventing it.
13:53Understood.
13:53By lifestyle measures, not allowing children to become fat, to gain weight.
13:58You know, it is weight that drives development of diabetes.
14:02Yes.
14:02When we say India is the diabetes capital of the world, it's because our obesity is also increasing the same way.
14:08So, obesity increases, then diabetes increases, by and large.
14:11So, they go hand in hand.
14:13If you want to prevent that, you'll have to use the same lifestyle measures at an individual level, at a family level, societal level, government level.
14:23Understood.
14:23And these drugs are reserved for those who actually need treatment for their overweight, obesity, or diabetes.
14:30You know, I was actually wanting to touch upon that as well.
14:32You've spoken about the green revolution and how that actually did more harm than good.
14:40I would say in a way.
14:41No, that's not correct.
14:42I didn't say that.
14:43No, no, you didn't say that.
14:44But what I'm trying to ask you is that the very fact that millets and other grains went really out of the window.
14:49And what happened was that high-heeled wheat came in, and that actually drove, in many ways, the obesity, you know, the problem in India, the silent epidemic of obesity in India, isn't it?
15:01So, I think that's a good point.
15:02That's worldwide.
15:03Yes.
15:04Whenever we try to fight starvation, the only answer is cultivation.
15:09And when you cultivate wheat or rice, at least people will not die of starvation or hunger.
15:16Yes.
15:16That is the easiest way to do that.
15:18But when you're sort of propagating that, then people get sort of used to that diet, and that is just easier, and it's also more palatable.
15:28As a result, what happens is that the other constituents of diet sometimes get neglected.
15:33So, our diet over the years has become predominantly cereal-based or carbohydrate-based because of roti and chawal, you know, because of wheat and rice.
15:43So, therefore, and it has become more and more processed, so all the fiber goes out.
15:50So, you really have a diet there.
15:52So, in that sense, while any such sort of effort, like the Green Revolution, which saved us from malnutrition and starvation,
16:00but in terms of chronic disease, because we encouraged, obviously, the use of cereals, you ended up with all these problems.
16:11So, we have to balance it out.
16:13We don't have to repeat everything the West has done.
16:16Right.
16:16We really have to stop it in its tracks now.
16:19Okay.
16:20Right.
16:20You know, coming back to the medicine, a lot of people have this question.
16:23I'm sure you get it also from your patients that have been on the medicine, but I haven't even lost a kilo or maybe two, you know.
16:29What do you have to tell those people who are not losing weight in spite of the fact that they are on medicines?
16:35And, you know, where does the research stand on, you know, what's really going on?
16:38What could be the factors responsible for the patient to be in that situation?
16:42So, yes, I mean, that's very important to understand.
16:45That's how biology is.
16:48Every person is different.
16:50No two people are exactly the same.
16:52Same drug works well on one person, doesn't work well on the other.
16:55You see that all the time.
16:57So, GLP-1 drugs are not different.
16:59It is true that there's a wide range of variation in responses to GLP-1 drugs with regard to weight.
17:06There is less variation in their responses with regard to diabetes.
17:10Okay.
17:10Most people respond very well.
17:12Okay.
17:12So, basically, diabetic patients are not losing much weight.
17:16So, the other thing is that who are the people who don't lose much weight on GLP-1 or lose less weight?
17:21So, people with diabetes who are put on GLP-1 lose less weight than those without diabetes.
17:28Okay.
17:28So, diabetes itself is a bit of a deterrent to weight loss.
17:32Okay.
17:33So, roughly, say, 60% of weight loss in people with diabetes as compared to those without diabetes.
17:39Okay.
17:40So, let's say if a diabetic loses 15 kilograms.
17:43Right.
17:43A non-diabetic, sorry.
17:45Someone who does not have diabetes loses 15 kilograms.
17:48Someone with diabetes may lose only 10.
17:51But why?
17:51So, there are multiple factors.
17:53Okay.
17:53So, this is the hottest area of research in the GLP-1 field right now.
18:00Why do some people not lose weight?
18:03Diabetes is only one of the factors.
18:05There could be many other factors, including their level of insulin resistance, their genetic predisposition, their concomitant drug therapy.
18:13Very important.
18:14If they are on insulin and other drugs, that reduces weight loss.
18:17Okay.
18:17But also, those who make a greater effort with their lifestyle, they lose more weight.
18:24Okay.
18:24I'm going to run through some quick questions with you.
18:26Yes.
18:27Okay, sir.
18:27But, you know, I just want you to tell us a little about the fact that, A, you touched upon how those with diabetes lose less weight.
18:35But, you know, many people say that once you stop the medicine, the weight comes back, so it's lifelong.
18:39I know it's hotly being debated as well.
18:41But is there any truth to it, that you have to take it throughout your life?
18:44So, well, I think it depends on what stage of life you are being given the drug and why is it being given.
18:50So, if you're a 65-year-old diabetic who's been put on the drugs because, you know, for various reasons, you're likely to use it lifelong.
18:58And there's no reason to worry about it too much.
19:00But if you're a 30-year-old or a 25-year-old who's been put on the drug for, you know, losing weight and planning your family or reducing the risk of diabetes,
19:10you certainly should not use the drug, you know, at the moment.
19:13The evidence is not strong enough to say that I'm prescribing this for weight to a 25-year-old and the person should use it lifelong.
19:19At the moment, it's, I mean, I know people say that.
19:22Right.
19:23Especially Americans say that.
19:24But I would be wary.
19:26I would take a deep breath after two years and see what do I do now?
19:30Which direction do I go?
19:32Maybe newer drugs will appear, which is happening.
19:36Remember, GLP-1 field is just beginning to explode.
19:39There will be many newer drugs with less and less side effects and easier to use.
19:45You know, you talked about access.
19:47Right now, most drugs are injectable, although it's once a week.
19:50They have gastrointestinal side effects, nausea, vomiting, etc.
19:53And I also want to touch upon that very quickly.
19:55Yes.
19:56You know, very rare but very serious side effects, like thyroid cancer, for example, if I'm not mistaken.
20:01Also, the fact that there are some side effects which are good as well.
20:05We've heard of osmetic babies also.
20:07I believe it's helped women, and this is anecdotal also.
20:11Women conceive.
20:12Women who are told you can never conceive naturally have conceived after being on this medicine.
20:16So, what do you want to touch upon that?
20:17So, one line about thyroid cancer, exceptionally rare type of thyroid cancer called medullary thyroid cancer,
20:23suspected but not proven to increase.
20:25So, the cancer itself is very rare, and the proof that it's really associated is not established.
20:30Okay.
20:30Now, about the happy side effects.
20:33Yes.
20:34Yes, that's what I've called it.
20:35The happy side effects means that the data on these drugs, which is very exciting for us as physicians, is Alzheimer's disease.
20:44Okay.
20:45So, the evidence that they might be helping Alzheimer's by helping obesity in the brain may actually be very exciting.
20:51And what's a cardiac health?
20:53Parkinson's disease.
20:54And, of course, that I said initially that these drugs help.
20:58Cardiac outcomes are clearly better.
21:01Cardiac events are reduced.
21:03Fatty liver is reduced.
21:06Kidney disease progression is reduced.
21:08No question about that.
21:09But the brain effects are particularly fascinating.
21:11And there are so many other, sleep apnea goes down.
21:15Okay.
21:15Fertility, you were saying.
21:16Yes.
21:16When you treat a girl with polycystic ovarian disease with these drugs, you may be helping her conceive.
21:22Right.
21:22And a flip side in that is important is girls who are on birth control pills for contraception,
21:29they may actually, the birth control pill efficacy may go down.
21:32Okay.
21:33And some people have been reported to conceive while they are on birth control pills.
21:36I think it's important, Dr. Mithil, to underscore and for our viewers as well that even in the happy side effects and the serious side effects,
21:42a lot of this is in the realm of research.
21:45Yes.
21:45Isn't it?
21:45You know, these are new drugs.
21:462005 is not too many years ago.
21:49But these drugs have been around.
21:50But, of course, renewed interest, renewed research in this area will, in months and years to come,
21:56answer many of these questions that we've been asking, Dr. Mithil.
21:59I'm going to thank you for joining in.
22:00It was a pleasure having you on the show.