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Obesity continues to be widely misunderstood as simply a consequence of poor lifestyle choices or lack of willpower. Yet clinical evidence shows it is a complex chronic disease shaped by genetics, biology, lifestyle, environment, mental health and underlying medical conditions. It is not a condition that can be viewed through a single lens.
According to the World Obesity Federation's World Obesity Atlas 2025, more than one billion people globally are living with obesity. In India alone, an estimated 180 million adults are affected by overweight or obesity, making it one of the country's most pressing public health concerns. Beyond its impact on quality of life, obesity substantially increases the risk of serious health conditions, including type 2 diabetes, cardiovascular disease, hypertension, obstructive sleep apnea, certain cancers, and non-alcoholic fatty liver disease.
What makes obesity particularly challenging in the Indian context is that metabolic risk often manifests differently than it does in many Western populations. Indians tend to develop obesity-related complications at lower body mass index (BMI) levels and at a younger age. A person who does not appear visibly obese may still carry significant metabolic risk. This phenomenon underscores the limitations of relying solely on body weight or BMI to assess health risk.
Why BMI Tells Only Part of the Story
Body mass index, or BMI, compares weight with height. It is useful for screening, but it does not provide a holistic view of health.
Simply put, BMI does not show whether weight comes from fat, muscle, bone or water, nor where fat is stored. Fat around the abdomen and internal organs, known as visceral fat, is associated with insulin resistance, type 2 diabetes, cardiovascular disease and fatty liver disease. BMI cannot distinguish higher-risk fat from fat stored beneath the skin.
Many Indians exhibit what is often described as the "thin-fat" phenotype, a condition in which individuals may appear relatively lean based on their weight or BMI but have a disproportionately high amount of abdominal and visceral fat. As a result, they may develop metabolic abnormalities such as elevated blood sugar, high triglyceride levels, insulin resistance, or fatty liver disease despite having a BMI that falls within the normal range.
BMI also does not reflect a person's existing complications. Two individuals with the same BMI may have very different health profiles. One may have diabetes, hypertension, sleep apnoea and joint disease, while the other may have none.
Life stage also matters. Menopause, aging, pregnancy-related weight retention, hormonal disorders and polycystic ovary syndrome can influence body composition and metabolism in ways BMI cannot capture.
This heterogeneity is precisely why a "one-size-fits-all" approach to obesity management often falls short. While lifestyle modifications remain the cornerstone of treatment, they may not be sufficient. Effective obesity care requires a personalized, evidence-based strategy that factors in the patient's clinical profile, underlying causes, metabolic health, and circumstances.
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Why Personalized Treatment Matters
The most important question in obesity management is not, "What is the best treatment?" but "What is the most appropriate treatment for this individual?"
Care should look beyond body weight to consider waist circumference, metabolic health, obesity-related complications, lifestyle, sleep, psychological wellbeing, medical history, and current medications. Treatment goals should also be individualized. For some, success may mean preventing diabetes; for others, it may involve improving blood sugar control, reducing cardiovascular risk, managing fatty liver disease, or enhancing mobility and quality of life.
People with type 2 diabetes, hypertension, sleep apnoea, polycystic ovary syndrome, osteoarthritis or fatty liver disease may need more intensive treatment. Obesity and its associated conditions should be managed together rather than as separate problems.
What Does Personalized Obesity Care Include?
Like diabetes or hypertension, obesity often requires long-term monitoring and support. A temporary diet or short burst of exercise may produce early weight loss, but sustained improvement usually needs continued follow-up.
Personalized care may include nutrition counseling that respects culture, food preferences, work schedules and household realities. Physical activity should be suited to age, fitness, mobility and medical condition. For some individuals who meet clinical criteria, anti-obesity medications may be considered when lifestyle measures alone are insufficient. These therapies are designed to complement, not replace, healthy lifestyle changes.
Most importantly, the need for medication should not be viewed as a failure. As with other chronic diseases, treatment should be evidence-based, non-judgemental, and centered on the patient's needs. Shared decision-making between patients and healthcare providers helps create realistic, sustainable treatment plans that can adapt over time.
Where Do GLP-1 Medicines Fit In?
For some individuals, lifestyle changes alone may not adequately address the biological drivers of hunger and weight gain. GLP-1 receptor agonists, such as semaglutide, may have a role in selected patients. These medicines reduce appetite and help lower calorie intake. However, they are not a universal answer or a shortcut. Their use requires clinical assessment, patient selection and medical supervision.
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Changing the Conversation Around Obesity
The future of obesity care depends as much on changing attitudes as it does on developing new treatments. We must move away from language that reduces obesity to laziness or poor discipline. Blame discourages people from seeking care and ignores the biological, social and psychological forces that influence weight.
Obesity is not a one-size-fits-all condition, and its treatment should not be either. The focus should shift from short-term weight-loss targets to lasting improvements in health, function and quality of life. Personalized care does not mean abandoning BMI. It means using it in context, seeing the person behind the number and building a treatment strategy that can evolve with their needs.
(By Dr Anil Bhansali, Former Professor and Head, Department of Endocrinology, Post graduate institute of Medical education and research (PGIMER), Chandigarh)
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