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India is facing an inflection point in its cardiometabolic health trajectory. Once viewed as a country predominantly burdened by undernutrition, India today carries one of the world’s largest populations living with diabetes and a rapidly expanding prevalence of overweight and obesity. Data from the ICMR–India national study shows that approximately 11–12 per cent of Indian adults currently have diabetes, with a further 15–16 per cent having prediabetes, while generalised obesity affects nearly 30 per cent and abdominal obesity close to 40 per cent of the adult population, figures that are consistently higher in urban India but now rising sharply in rural regions as well.
The International Diabetes Federation estimates that nearly 90 million adults in India were living with diabetes in 2024, a number projected to cross 150 million by 2050 if current trends continue. This escalating burden reflects not merely a glucose problem, but a broader metabolic crisis driven by excess adiposity, sedentary lifestyles, dietary transitions and genetic susceptibility.
It is this confluence of diabetes and obesity that has led to the increasing use of the term “diabesity”. The concept captures a clinical reality that physicians encounter daily: obesity and type 2 diabetes share common pathophysiological roots, progress together, and jointly amplify cardiovascular, renal and hepatic complications. In India, where diabetes often presents at a younger age and lower body mass index thresholds, the metabolic consequences of excess visceral fat are particularly pronounced. Diabesity has therefore emerged not as a theoretical construct, but as a defining framework for understanding India’s cardiometabolic epidemic.
For decades, lifestyle modification formed the cornerstone of therapy for both conditions, and it continues to remain fundamental. Dietary adaptation, physical activity and behavioural interventions are essential at every stage of disease. Yet, real-world evidence and clinical experience have consistently shown that lifestyle measures alone often fail to deliver durable weight reduction and sustained metabolic control in a large proportion of patients. Biological counter-regulation, appetite dysregulation and metabolic adaptation frequently limit long-term success, particularly in individuals with established obesity and long-standing diabetes. As a result, clinicians have increasingly sought therapies that address not just glycaemia, but the underlying drivers of weight gain and metabolic dysfunction.
GLP-1 receptor agonists represent a therapeutic class born out of this need. Glucagon-like peptide-1 is an endogenous incretin hormone released from the gut in response to nutrient intake. It enhances glucose-dependent insulin secretion, suppresses inappropriate glucagon release, slows gastric emptying and acts centrally to promote satiety and reduce appetite. GLP-1 receptor agonists are pharmacological analogues that amplify these physiological effects in a sustained and clinically meaningful manner. Semaglutide is a long-acting GLP-1 analogue designed for prolonged receptor engagement, enabling once-weekly subcutaneous dosing, as well as oral administration through advanced formulation technology.
Semaglutide exerts its benefit across multiple domains. In people with type 2 diabetes, it produces robust reductions in HbA1c with a low intrinsic risk of hypoglycaemia when used appropriately. Simultaneously, it induces significant and sustained weight loss by reducing hunger, lowering caloric intake and improving eating behaviour. These effects translate into improvements in blood pressure, lipid parameters and inflammatory markers. Clinically, semaglutide is now used across the spectrum of cardiometabolic disease: in type 2 diabetes, in chronic weight management for individuals with obesity or overweight with comorbidities, and increasingly in patients at high cardiovascular or renal risk. Large outcome trials have demonstrated reductions in major adverse cardiovascular events in high-risk populations, as well as meaningful slowing of kidney disease progression in people with diabetes-associated chronic kidney disease. Emerging evidence has also highlighted its role in metabolic liver disease, where significant resolution of steatohepatitis has been observed, closely linked to weight reduction and improved insulin sensitivity.
As with any therapy, GLP-1 receptor agonists are associated with adverse effects, the vast majority of which are mild, predictable and manageable. Gastrointestinal symptoms such as nausea, early satiety, vomiting or loose stools are the most commonly reported and typically occur during dose escalation. These effects are largely transient and can be minimised through gradual up-titration, patient education, portion control and reassurance. Importantly, when introduced appropriately and monitored carefully, discontinuation rates due to intolerance remain relatively low, reinforcing the feasibility of long-term use in routine practice.
The expanding evidence base around semaglutide has fundamentally altered how clinicians view cardiometabolic disease. The focus is shifting from isolated surrogate markers toward long-term outcomes that matter most to patients: fewer cardiovascular events, delayed kidney failure, improved liver health and sustained weight reduction. In the Indian context, where diabetes-related complications drive enormous healthcare costs and productivity loss, this shift has profound implications.
For Indian pharma, this moment represents a potential growth wave unlike any seen in the diabetes segment before. The opportunity is not confined to endocrinology alone but spans cardiology, nephrology, hepatology and primary care. However, alongside opportunity comes responsibility. Peptide-based therapies such as semaglutide are inherently complex molecules. Importantly, the originator semaglutide molecule is manufactured using patented recombinant DNA (rDNA)-based technology, which allows precise biological expression of the peptide chain followed by controlled modification and purification. In contrast, several Indian versions currently available are synthetic copies manufactured entirely through chemical synthesis in laboratory settings, commonly using solid-phase peptide synthesis techniques. While chemical synthesis has legitimate applications in peptide production, it carries a higher inherent risk of sequence-related impurities, additions or deletions in the peptide chain, aggregation or fibrillation, if not controlled with extremely stringent analytical and manufacturing standards.
Recent global regulatory warnings around unapproved or inadequately evaluated GLP-1 products underscore the risks associated with shortcut approaches, particularly when therapies are intended for long-term, large-scale use. For a medicine designed to be used chronically, often in otherwise stable patients, even subtle differences in molecular consistency can potentially influence safety, immunogenicity and long-term outcomes. While affordability remains a critical consideration in India, patient safety and therapeutic reliability cannot be compromised.
In many ways, the rise of GLP-1 receptor agonists signals the maturation of cardiometabolic care in India. Diabesity is forcing a re-thinking of disease definitions, therapeutic goals and industry priorities. If deployed responsibly, backed by robust science and uncompromising quality standards, therapies like semaglutide have the potential not only to transform patient outcomes, but also to reshape the future of Indian pharma. The real success of this growth wave will not be measured by market size alone, but by safer lives, fewer complications and a tangible slowing of India’s cardiometabolic tide.
(Author is a clinical trial consultant and internal medicine specialist)
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