Too Good to Be Thin: Why the GLP‑1 Gold Rush is Worrisome

By Arunima Rajan

In an interview with Arunima Rajan, Dr Anil Bhoraskar, diabetologist at SL Raheja Hospital, Mumbai, explains why GLP-1 drugs such as Semaglutide and Tirzepatide are no substitute for healthier habits, why a normal BMI can still hide dangerous abdominal fat, and why he prescribes these medications only when they are clinically essential, never for cosmetic reasons alone.

When you started prescribing GLP-1 drugs, can you let us know about the type of patients who were sitting across from you in that consultation room? And what sort of patients are you seeing now?

Initially, the individuals who chose to go with GLP-1 drugs included obese patients suffering from diabetes or related diseases who have already tried other approaches to lose weight. Nevertheless, today, there are more and more young people, living in cities, who have heard of the existence of drugs such as Semaglutide and Tirzepatide and regularly ask to use them solely for aesthetic reasons. The Internet contains plenty of information on these drugs, even though not all sources are trustworthy. There are also certain social pressures to look a particular way, especially among young women, which makes people want to get a quick solution to their problems. While GLP-1 treatment offers significant benefits for certain individuals, it risks becoming a substitute for healthier lifestyle habits rather than a complement to them.

Before you write a prescription for weight management, what does a patient need to bring to that conversation besides money and a desire to lose weight?

Prescription of GLP-1 treatment should not be considered solely based on losing weight. There are many things that need to be considered, especially metabolic risk factors, especially abdominal obesity. This is important because the presence of abdominal fat increases the risk of getting many diseases like heart disease, diabetes, high blood pressure, and stroke. Many Indians are referred to as “thin fat Indians.” What this implies is that even though their Body Mass Index (BMI) may be within the range, they possess excess fat in the abdominal region. Even with a BMI of 21, they may have a waist size above 90 cm.

After due consideration, if a patient does not qualify for medication, my next action will be to concentrate on:

• Exercises

• Nutrition

• Diet restrictions

Do you feel pressure to prescribe GLP-1 drugs more widely than your clinical judgment would allow?

I will only prescribe a medication when it is absolutely essential, and extremely beneficial to the patient. It is also important for people to understand that rapid weight loss can have side effects, including:

• Hair thinning

• Fragile nails

• Concentration problems

• Facial sagging

• Weak immunity

• Digestive complications

There should never be a compromise between quick results and long-term health.

When things go wrong and patients land in the emergency room after taking GLP-1 drugs without proper supervision, what happens then?

I will prescribe the medication only if it is necessary for the patient. People should know that rapid weight reduction may lead to side effects like:

• Hair fall

• Brittle nails

• Difficulty in concentration

• Sagginess of face

• Weak immunity system

• Digestive problems

The pursuit of rapid results should never come at the expense of one's health and safety.

More than half of patients stop GLP-1s within the first year, and the weight tends to come back. How do you communicate that risk honestly?

Those who use drugs without medical advice from a qualified doctor can get into serious trouble — not only with new medicines, but with any medicine. Thus, it becomes highly imperative to brief patients regarding the side effects of these medications. The complications include:

• Pancreatitis

• Severe Gastrointestinal disorders like vomiting, diarrhoea, dehydration, and low blood pressure

A comprehensive history of medication and adequate medical assistance becomes highly important.

India's GLP-1 boom needs a gatekeeper

Dr. Vijay D’silva, Medical Director of White Lotus International Hospital and Clinical Advisor and Mentor of Heartnet India on keeping GLP-1 drugs anchored to metabolic risk, not aesthetics, and the guardrails Indian hospitals can no longer postpone.

Over the last 1–2 years, what shifts have you seen in who is asking for GLP‑1 prescriptions—especially relatively healthy, affluent patients who want to be thinner rather than address serious metabolic risk?

In the past few years, the types of patients asking for GLP-1s have changed from primarily those with diabetes or obesity-related conditions to more than just wanting to lose weight or improve their appearance, even healthy patients, especially younger patients. This change can be attributed, in part, to social media and celebrity influence. Clinicians' major concern is that GLP-1 drugs are active biologic agents that affect appetite regulation, insulin response, and gut function. Therefore, those seeking the expected “rapid weight loss” often need careful medical counselling.

When a patient with only mild overweight and no major comorbidities insists on GLP‑1 drugs and is willing to pay out of pocket, what ethical framework or internal criteria do you personally use to decide whether to prescribe or decline?

A decision to commence GLP-1 for a person who is mildly overweight is based on overall metabolic risk rather than just the amount of weight they have on their body. It is important to take into account a multitude of factors besides just body weight, such as waist size, family history, insulin resistance, blood pressure, quality of sleep, and whether they have made a serious effort to change their lifestyle.

Gaining weight is typically due to stress, living a sedentary lifestyle or poor eating habits; therefore, a pill may not address these issues. Another thing to consider is sustainability. Rapid appetite suppression can lead to unintended muscle loss or nutritional deficiencies when not adequately monitored. Therefore, the discussion has to remain medically balanced and not driven solely by aesthetic concerns.

Has your hospital or department created any formal or informal guidelines on which categories of patients should be prioritised for GLP‑1 therapy, especially during shortages, and how do you ensure these drugs are not captured by purely cosmetic demand?

Clinicians tend to make the decision to prescribe GLP-1 medications based solely on the appropriate medical conditions, particularly metabolic disorders such as obesity or diabetes. At Heartnet, we are cautious about prescribing these agents without appropriate evaluations and follow-up plans, especially during the shortage periods. Clinicians spend time trying to clarify patient expectations because some patients approach the use of GLP-1 medications as though they are a separate means of achieving weight loss rather than understanding that these medications are most effective when combined with nutrition, exercise, and long-term treatment of metabolic disorders.

From what you are seeing on the ground, what worries you most about the “GLP‑1 gold rush” in terms of misuse—whether that is unsupervised use, doctor‑shopping, online procurement, or pressure on clinicians to prescribe?

An emerging concern is the rise in non-medical use of GLP-1 medications due mainly to social media recommendations, online communities or non-medical advice being imbalanced. Patients are obtaining medications online or changing their dosing schedules to obtain faster weight loss than what physicians

would recommend. Misuse of medications could affect many aspects of metabolism, e.g., gastric emptying, hydration, blood sugar responses and more, resulting in severe complications.

Patients are now doing more doctor shopping to receive prescriptions for medications to meet their personal expectations rather than by medical necessity. The biggest challenge faced by clinicians is providing evidence-based prescribing while satisfying an ever-growing demand from the public to assume these agents are simply lifestyle enhancers.

Can you share examples (without naming patients) of complications or near‑misses you have encountered in the emergency room or OPD that you suspect were related to poorly monitored or inappropriate GLP‑1 use? How did those cases change your own thresholds for prescribing?

Sometimes, patients greatly diminished their food intake because appetite suppression was stronger than expected. It could lead patients to become fatigued and dizzy after losing weight too quickly in conjunction with not drinking enough water or eating enough protein. It is observed that clinicians have now taken caution in prescribing GLP-1 without creating a plan for properly monitoring the patient and educating them about its safe usage.

How are you handling follow‑up and monitoring—who in the system is responsible once the initial excitement wears off, but the patient is still on the drug and at risk for nutritional, psychological or cardiac side‑effects?

The follow-up process is an essential component of GLP-1 therapy. Following the initial enthusiasm for weight loss through GLP-1 therapies, patients will continue to need to be assessed for their nutritional status, hydration, muscle health and metabolic response. The goal of the follow-up process should be to implement a multidisciplinary approach involving the prescribing physician, the nutritionist and possibly some type of behavioural counselling support. For patients with pre-existing cardiac conditions, the frequency of evaluation becomes increasingly critical in order to ensure that the GLP-1 therapy continues to remain safe, effective, and clinically appropriate.

GLP‑1 drugs can be highly profitable for hospitals and clinics. How do you navigate the tension between revenue opportunities and your duty to avoid overtreatment, and have you ever felt pressured (subtly or explicitly) to be more “liberal” in prescribing?

The creation of GLP-1 therapies has created commercial opportunities due to the high demand for these therapies. However, the clinical responsibility remains the same; treatment must be provided when there is a reasonable medical indication and long-term benefit. Patients have high expectations when they view these drugs as quick solutions influenced by social media or celebrity culture. But overtreatment becomes a concern when weight loss is approached purely cosmetically without evaluating metabolic health, nutrition, or sustainability.

Looking ahead, what kind of internal rules or industry‑wide guardrails do you think Indian hospitals and professional bodies urgently need so that GLP‑1 drugs remain a tool for high‑risk metabolic disease, rather than just the latest status symbol for being thin

The discussions regarding GLP-1 drugs in India are progressing rapidly, but there are still many ways to develop a system with long-term safety.

Possible safeguards that could assist include:

• Clear eligibility criteria based on metabolic and cardiovascular risk, not cosmetic demand alone
• Standard follow-up protocols for nutrition, muscle health, hydration, and metabolic monitoring
• Restrictions on unsupervised online sales and self-medication practices
• Greater emphasis on patient counselling regarding realistic outcomes and long-term lifestyle management

GLP-1 therapy can serve as one component of preventative health, but its long-term reliability will depend on whether the issues related to patient safety and evidence-based prescribing are kept at the forefront of the conversation.

For hospitals, GLP-1 prescribing is sitting at an uncomfortable place right now. Does your institution have a formal position on this?

Every prescription issued at this hospital is ethically grounded and driven exclusively by patient welfare.

If you could speak directly to endocrinologists in India who are seeing a wave of patients asking for these drugs for cosmetic purposes, what would you want them to know?

If patients seek to lose weight purely for cosmetic reasons and are prepared to pay enormous sums of money to avail these drugs, they should be counselled in an ethical manner. The drugs might work for some time, but once discontinued, their effects will reverse, resulting in weight gain that poses risks since the weight gained will be predominantly fat and not muscle. All Indian endocrinologists are ethical, and the drugs must always be prescribed with caution in mind, keeping the wellbeing of the patient's paramount.

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