Why Losing Weight Is So Hard, and Why It's Not Just About Willpower

Obesity is becoming an increasingly important health concern in India, not only in light of the rising rates of diabetes and other metabolic conditions but because the problem is no longer confined to affluent urban adults. Nearly 7 per cent of school-going children in India are estimated to be obese, according to a recent meta-analysis of 125 studies published in the Indian Journal of Community Medicine, with prevalence reaching almost 18 per cent in Arunachal Pradesh. Among adults, the latest National Family Health Survey shows that the proportion who are overweight or obese has risen to 30.7 per cent among women and 27.3 per cent among men. The burden is particularly striking in some states: nearly 45 per cent of adults in Andhra Pradesh and 42 per cent in Kerala are overweight.

The way we understand obesity is changing, too. India is preparing to introduce waist-to-hip-ratio screening in government hospitals, reflecting growing recognition that where fat is stored—particularly around the abdomen—can be as important as how much a person weighs. At the same time, obesity is increasingly being seen alongside rising rates of diabetes and other metabolic diseases, with implications not just for individual health but for the country's future productivity.

And then there are drugs such as GLP-1s, which have changed the conversation around obesity and generated enormous interest among people looking to lose weight. But how significant is India's obesity problem, what is driving it, and what does science tell us about managing it? To understand the biology, risks and possibilities, we're speaking to Dr Jasjeet Wasir, Director of the Division of Endocrinology and Diabetes, Medanta, The Medicity, Gurugram.

Reader’s Digest: Welcome, Dr. Wasir, and thank you so much for speaking with us.

Dr Wasir: Thank you so much. I'm really grateful to be here to discuss this epidemic of obesity.

Great to have you. That brings me to my first question. How would you describe India's obesity landscape today? How serious is the problem? How much progress have we made in the last 10 years? And what specifically is different about the Indian experience of battling this condition?

Obesity has increased to epidemic proportions. It's not increasing; it has already increased. From north to south and east to west, no part of the country is spared. Also, the conventional thinking that obesity is a problem of affluence and happens in urban areas is no longer true. The rural-urban divide is becoming less clear; it's getting blurred.

Like obesity, other non-communicable diseases are rising countrywide and globally. There are more than 240 health risks or diseases that obesity can cause. Diabetes, hypertension, cholesterol problems, fatty liver, PCOD, knee osteoarthritis, sleep apnoea—the one common factor joining all these metabolic, mechanical and mental-health disorders is obesity. One problem is a common factor relating to all these conditions. So shouldn't obesity management qualify as one of the strongest medical interventions for preventing these risks and diseases? Our investment as a preventive strategy must therefore be on obesity—at the level of the individual, the family, society and the country. That's our best bet for making a healthy nation.

So what is the driving force behind this rise?

Five reasons, that rest on top of a genetic podium. Genetics is a significant contributor to obesity. On top of that, we have five main factors: nutrition, fitness, certain medications, sleep and stress—to me, the last two factors are extremely important.

On top of this, environmental pollution is one of the most important contributors that we rarely talk about. Environmental pollution may be contributing not just to obesity but to a whole lot of non-communicable diseases. There is a possibility of these chemical pollutants interfering with our genetic material (what we call epigenetics) and making diseases manifest even in people who don't have a family history. And India is unique in that we face a double jeopardy of malnutrition—overnutrition and undernutrition (excess eating is also malnutrition). 

That partially explains, along with the five factors I mentioned, why obesity and other non-communicable diseases—diabetes, heart disease, hypertension and other metabolic diseases—are increasing and also occurring in younger individuals. Obesity among children is particularly concerning. There are estimates positing a 288 per cent increase in overweight and obese adolescent boys, and 125 per cent among girls. 

What kind of age group does this manifest in most?

Right now, if you look at the statistics, you will find overweight and obesity even among children under five. The numbers are smaller, but the increase is significant. Between 2005–06 and 2019–21, the prevalence among under-five children more than doubled, from 1.5 per cent to 3.4 per cent—a 127 per cent increase. So even at that very young age, we are beginning to see the problem emerge. Teens and adolescents are affected as well, and as they are growing up, the trajectory is becoming more vertical.

Just imagine if, at age 10 or 12, by whatever criteria, a child has been classified as obese. Just imagine what is going to happen when they turn 20, 40 or 50. What is happening to their longevity? That's very worrisome. But at least we have defined the problem. Only when we define the problem and know why it is happening can we come up with easy solutions.

Awareness of obesity is not new. Medical textbooks have long recognised weight as an important risk factor for non-communicable diseases, and nutrition, fitness and weight loss have always been part of their treatment. So what has changed in the way we understand and address obesity?

That's a very interesting question, and it has an easy answer: awareness. In the last 25 years of my practice, awareness about obesity has grown enormously. Very rarely, over that 25-year span, did people walk into my OPD saying, “Doctor, prescribe me X medicine for obesity.” I've been in bariatric care, metabolic medicine and weight management for a long time. We always had to find ways of opening up a discussion about weight because there was an extremely large amount of bias and stigma around it.

But that's changed. And it's not because of what I have done. I give a lot of credit to the media and social media for creating that awareness. Granted that's information and not knowledge. But that information has made people think. Some have acted on it themselves, which can be detrimental. But many others, because of the information they've received, come to us seeking answers. I can then convert that information into knowledge and, ultimately, better health.

But if the medical profession has understood for decades that weight is an important risk factor, why was there so little discussion around obesity and its treatment?

Because there was no viable solution. Only when we have a solution to a problem do we talk more about it. Before these medications appeared, people would say, “Eat less and exercise more.” So what does a person start believing? If everybody is saying, “Eat less and exercise more,” then it must be me who's a failure. I'm the one who can't control myself. I'm the one who doesn't want to exercise. That's the most illogical, absurd thing. And that's where the bias and stigma come in. I've been in this field for long enough and have been very close to understanding people who have a weight problem. You know, the heaviest burden of excess weight or obesity is on people's minds. It's on their psyche.

So there's a mental-health and psychological aspect to this which, along with the other factors pushing obesity, almost acts as a barrier to any progress that somebody might want to make. No matter how hard they're trying, it feels like two steps back.

Absolutely. We should talk more about the biology of obesity, and that's where we can qualify and banish the bias and stigma. If there is one very important message that needs to go across today, it is that if we can mitigate or at least reduce bias and stigma, we have done one of the greatest services to people and to everybody around us.

It also seems like the entire ecosystem is engineered to result in a situation where somebody is bound to gain weight. Overwork and stress can lead to a lack of or disturbed sleep, leading to unhealthy choices that reinforce the same problems and breaking away becomes increasingly difficult. So when people come to you asking for medical interventions, and specifically about GLP-1s, what is your first response?

The first part of your question has opened a Pandora's box—stress, sleep, the food industry—all these factors have a real relationship with why obesity is increasing. I'll put everything in a sequence.

Genetically and evolutionarily, the Indian genotype and phenotype are what we call a "thrifty phenotype". Famine, starvation and lack of food have contributed to a model explaining what is happening. The Asian phenotype is programmed to store energy when it receives it. When people are used to situations of famine and starvation, we find that the genetics and phenotype of abdominal obesity are perpetuated to provide and store energy immediately. That's one dimension.

Second, we can relate sleep and stress to visceral adiposity because they disturb our circadian hormonal rhythm. There are many hormones, but cortisol in particular comes into play here. There is a diurnal variation where it is supposed to be high at certain times and low at others. That follows the sun. As the sun rises, you have a different level, and as it sets, it should go down and settle.

Now, if I'm waking up at 9, 10 or 11 in the morning, I'm going against that circadian rhythm. And if I'm sleeping at 3 a.m., I've already disturbed it. That disturbance, specifically of cortisol, directly affects visceral adiposity. So we have sleep, stress, evolutionary biology and then, on top of that, the universe of hunger, which is again perpetuated by sleep and stress. The day you've not slept well, you know what happens to hunger. And my hunger is not for dal roti; it's for calorie-dense foods. Going back to your question about people looking for medical interventions …

To be able to break out of the cycle …

Well, that expression—"breaking out of the cycle"—is of feeling stuck. It's an expression of what is going on in the mind—not one’s HbA1c or cholesterol levels or triglycerides. It’s the mental-health side to the battle, exacerbated by a history of repeated attempts at losing weight—and then having the weight always come back. You're then exposed to media and social media, which gives you instant solutions.

There's a catch here. If I am thinking about something and I get a quickfire solution, I would immediately adopt it. That's where we need to be cautious about where we may go wrong. Any and every weight-loss programme should only be medically driven. Weight loss should be driven by a team effort effort—nutrition, fitness, a physician coordinating every­thing, and, where required, behavioural counselling and allied specialties should all be part of that team. In some cases, even a bariat­ric surgeon. Obesity is a chronic dis­ease and you can’t beat it alone.

It takes a combination of various interventions. So what should I ask myself when I see what appears to be a medication that is going to be a magical solution to my weight-management problem? What should I immediately be wary of? What should my first question to a doctor be?

Your first approach should be to consult a healthcare professional. It could be your general physician or an obesity-care specialist for all your baseline questions. It’s actually quite shocking—never before in my professional career have I had people come into the OPD and ask, "Doctor, can you prescribe me this particular medicine?" The first time it happened, I didn't know where to look.

Because somebody came to you asking specifically for a solution rather than asking you to diagnose the problem? So the nature of the conversation between you and an OPD visitor has changed. How do you approach that now? How do you take a patient through the first steps of this journey?

Actually, most people have informed themselves before they enter the room. I just put all the information in order. And for those who don’t, I've put up a whiteboard in my outpatient department on "obesity bias and stigma" and answers to basic questions: Why have I gained weight? Why does my weight always come back? Why do I need to lose weight? About two years ago, a weight-loss or obesity consultation used to last around 45 minutes to an hour. Now the average time ranges anywhere between 15 minutes and half an hour. That's a paradigm change.

So the approach is broadly: “Okay, you've come looking for a solution, but there are a few things you need to understand.” Whether we're managing obesity with medication or without it, the treatment has to be long-term. At times, I may say it's a disease, but if it's their first visit, I don't want to be too strong with my language. I want them to understand that this will require long-term care. Sometimes I may not use the word “lifelong”. “Long-term” is a little easier for people to absorb, and with time, they understand the need for ongoing treatment. I don't need to throw a boulder at them on day one.

Does helping patients understand that biology—and that weight regain is not simply a failure of willpower—change the way they feel about themselves?

In fact, by the time people reach me, the average number of weight-loss attempts they've made is between eight and 15. That tells you something about how difficult it is to sustain weight loss without addressing the underlying biology.

A lot of young people, especially young women and girls who come to me, actually break down during the first consultation, even if they are with their family. They say, "Doctor, nobody has ever talked about this, and I feel so relieved." It's very touching. It makes me feel happy and grateful to have been able to offer that understanding.

Another change is that first-timers rarely used to come to me, but now they do because they've seen their friends, colleagues, spouses and family members lose weight. So the first attempt should be the best attempt.

Moving on to a few rapid-fire question: BMI—still a useful tool or an outdated measure today?

Useful for screening the population. Its diagnostic accuracy in Indians may not be the best.

So if I am to judge my own health status based on BMI, that would not necessarily be an accurate representation?

Focus on waist-to-height ratio.

One misconception about obesity you wish people would stop believing?

That obesity is purely an outcome of calorie intake and calorie output. If it were that easy, there would be no obesity on the planet.

Is belly fat more concerning than overall weight?

Yes. Belly fat, or visceral fat, what we call ectopic fat, is metabolically volatile. It's like petrol—it catches fire and burns everything in its way. Wherever it's present—in the liver, it causes fatty liver; in the muscle, insulin resistance; in the heart, cardiac problems; in the pancreas, type 2 diabetes.

You've mentioned a number of factors. What would you say is the most underestimated factor driving obesity in India—the one that's given the least importance but should be taken more seriously?

Sleep. Then, stress, nutrition and fitness, in that order.

One Indian food habit you would change?

Trans fats and sugars.

Is that really practical given accessibility and availability of food options?

Maybe, but to me, it's non-negotiable. Once you really understand the health impact, you're likely to become more conscious and conscientious about what you're eating. The change has to come from within. Instead of "I'm not being allowed to eat something", it becomes, "I can, but I choose not to because I know what happens when I do."

The biggest misconception about GLP-1 drugs, or any kind of medication that feels like a quick fix?

That it's a quick fix. They are part of the journey of anybody who medically requires them. They are not meant for aesthetic improvements, and they’re not a Band- Aid. They are part of a long-term, sustained, supervised treatment protocol.

When chosen correctly and assessed properly for contraindications, they can genuinely be life-changing. And while the drug may not be for the long-term, the process certainly is. Regular follow-ups are essential. Once you stop these medications, there is a high chance of the weight coming back, along with the complications for which the medication was started.

Are GLP-1s really a game-changing breakthrough or an overhyped trend?

Healthy skepticism is definitely called for. But from a patient’s perspec­tive, game-changing is right. Because we are talking about so much more than just weight loss. These medications have excellent blood-glucose-lowering capacities. They benefit blood pressure and lipids, and the data indicates benefits for dia­betics. But perhaps the most important benefit is the protection they pro­vide to the heart, liver, kidney and brain, independent of their effect on weight. Seeing a moderate to severe fatty liver revert to normal is incredibly gratifying. So is seeing somebody with diabetes improve dramatically. And not to men­tion the mental-health benefits. Doesn’t that seem game-changing?

Can you be obese but also metabolically healthy?

No. If, according to the BMI charts, a child is classified as obese, we may not expect to see too many metabolic abnormalities at that point. But if you track that child over time—and there is enough evidence to support this—the chronicity of excess body fat may increase, and the metabolic consequences may start appearing. Obesity is fat—it's not weight; it's not BMI.

The second part is how we conventionally define metabolic health. There is a lot more we can look at, but let's restrict ourselves to the conventional markers: blood glucose, lipids, fatty liver and insulin resistance. But if you're having knee pain, back pain, snoring or acidity, you're already experiencing a complication of obesity.

To me, I don't think we should use the term “metabolically healthy” too casually. If I say someone is “metabolically normal”, what am I saying? Don't intervene. Then my prevention has gone into a dustbin. Any excess fat needs to be taken care of because medicine is not binary.

That doesn't mean every person with obesity will develop diabetes, advanced liver disease or a cardiac problem. But that's what medicine works on: relative risk. Prevention is about minimising that risk through a multi-pronged approach to weight management, which is a team effort.

What is a simple framework people should maintain for weight, health and lon­gevity?

I’ll give you five. When I put these five fingers together, I make a power punch of health. Permissive nutrition. Refrain from using the word ‘diet’—it carries its own bias. Don’t say exercise; indulge in fitness. Positive terms rein­force a positive mindset. Wherever there is a health indication, weight-loss medications should be cho­sen wisely by a healthcare provider who is qualified to take you through that long-term journey. Lastly, managing sleep and stress. These five things, when put together, lead to a successful weight-loss regimen that supports good health, translates to longevity, and a whole lot of happiness.

What should one look for in a good weight-management practitioner?

The right kind of weight-management advice must include an explanation, in lay language, of the biol­ogy behind weight gain. The patient must understand why they put on weight, why it returns, why they need to lose it, and how obesity can be treated. They need to understand the chronic­ity of the problem, its seriousness and health impact, the treatment modalities, the multi-pronged approach and the need for regular follow-ups. Because not every journey is going to be perfect. There will be potholes and speed break­ers. We need somebody, or a team, to guide you through that.

If you could leave people with one message, what would it be?

If I could, I’d universally ‘vaccinate’ every person in the country so that they develop ‘antibodies’ that fight against obesity bias and stigma. No one should blame themselves for living with obesity, or think it is their fault. After that, I’d add a ‘booster dose’ so we have a more empathetic approach to those with obe­sity. With support and sensitivity, we can contribute to a beautiful life for all.

About the expert: Dr Jasjeet Wasir Is Director of Endocrinology And Diabetes At Medanta, The Medicity, Gurugram. He specializes in obesity, metabolic health and weight management, with a clinical focus on understanding the complex biological, behavioural and lifestyle factors that influence weight and long-term health.

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