Chapter 1

Anti-Obesity Management

Introduction
Aim of chapter: This report will provide a background to the anti-obesity management market in India wrt the Indian mindset to obesity, contributing factors and also the available anti-obesity treatments such as pills, weight loss clinics, dieting options and others. An overview of each of the indications, the competitive landscape is attempted. A brief background into the psychological causes of obesity helps in greater understanding of this condition.

Obesity Management
Overview The prevalence of obesity has increased considerably in the last two decades in direct correlation with the increase in sedentary lifestyle, bad eating habits comprising largely of "junk" food and the complete lack of exercise or physical activity by the majority of the urban population. With a stellar 15-20% of the world population being obese, India too is becoming prone to what was once thought of as a Western concept. What was once a lifestyle problem has now been classified as a disease by the World Health organisation. Indians need specialised attention. As an ethnic group, we are prone to what doctors describe as central obesity. Our waist-to-hip ratio, as this index is called, is abnormally high. So instead of fat pears, Indians tend to look like fat apples.Several studies over the years at the Hyderabad-based National Institute of Nutrition indicate a steady growth in the number of obese Indians. As economic progress and globalisation spread, so do waistlines. A 2006 study by pharma company, International Day of Evaluation of Abdominal Obesity (IDEA) concludes that almost 75 per cent Indian women and 58 per cent Indian men suffer from abdominal obesity.

Diagnosis, treatment and management In general, a fatter society is also a high at risk society, in terms of the myriad of diseases such as diabetes, hypertension and other cardiovascular conditions. There are today approximately 155 million overweight Indians, a rising number of them children. It is hardly surprising then that, the slimming Industry is at its peak, with commercials promoting slimming teas and abdominal- trimmers, high and end gyms, weight loss clinics and gadgets which promise to dissolve flab. However, few realize that obesity requires long-term management with the goal of the treatment being weight loss to improve or to eliminate related health problems and not to attain an ideal weight. You are obese if youre body mass Index (BMI) is 30 or higher and/or have a waist circumference of 40 in. (101.6 cm) in men or 35 in. (88.9 cm) in women. Treatment consists of modifying eating behaviours, physical activity, monitoring your behaviour, such as understanding what may trigger you to eat, etc for a more permanent loss in weight. The following section will give an insight into the different treatment options available, costs involved, major players, market competition, efficacy of treatments, target age group, etc for each treatment to give the reader a greater understanding of the market in India. Underlying conditions of Obesity: Physiological and Pyschological In some instances obesity is an extension of a medical condition, and therefore the treatment pattern for this category of obesity differs from the regular weight loss. Some illnesses can lead to obesity or a tendency to gain weight. These include hypothyroidism, Cushing's syndrome, depression, and certain neurological problems such as brain injury or encephalitis that can lead to overeating. Also, drugs such as steroids and some antidepressants may cause weight gain. However, barring a few weight loss clinics that do entire body composition study, most gyms and clinics do not carry out tests to prevent misdiagnosis of obesity. Dr.Robin Smith, a leading psychologist, believes that while genetics and environment play a role in obesity, there is often a deeper reason for overeating and one has to get to the root

of the void that people are trying to fill with food. The psychological aspect of obesity such as comfort eating, over-eating due to stress, boredom, depressive disorders, borderline personality disorders, Klein Levin Syndrome and hypothalamus disorders are now being taken into account by some weight loss experts. However, the general obese population is still unaware of a possible psychological aspect of Obesity management. Therefore, self help books, diet books, support groups for obesity, psychological advice is the need of the hour for many Indians battling with this condition. Dieting Obesity is becoming an urban epidemic and `fighting fat` is the new age fixation. No wonder its a sellers market for fad diets, which comes in many flavors: Atkins advocates a high intake of fat; the Zone pushes protein and restricts carbohydrates; Sugar busters claims low fat doesnt work. The newer diets are the blood type diet, the warrior diet, cabbage soup diet, south beach diet, the list is endless. However, the question remains, How can you tell which highly-touted weight loss plan is sound and which isn't? Good versus bad food is one of obesities fastest changing concepts and rather confusing. However, doctors disagree with this trend with a senior nutritionist Saru Bhartia, upholding the concept of a balanced diet. She points out that on a routine basis one should have a balance of protein (milk, pulses, soya or non-veg); carbohydrates (rice, chapattis, cereal and potato) and fluids, ingredients of traditional Indian food. However, by adopting a more western style of eating especially fast food an djunk food Indians have pre-empted the onset of obesity. Fasting as way of detoxifying and cleansing our system of harmful radicals has long been adopted as a way of life. However, now Indians are paying a hefty amount to go through the detox diets, which aims to do the same but of course there are fancy terms attached to them. Also, the western diet manual has food that might not be easily available and are mostly vegetarian unfriendly, thereby decreasing the efficacy of most diets in the Indian scenario. Therefore, while for those going on these diets have easy packaged food in western countries, here in India one can only use guesswork. Also, yo-yo dieting usually, is found

to leave one with a craving that leads to binges and a return of the fat. Therefore, the diet food industry is till in its nascent stages with a few cola drinks and low cal sugar substitutes being available in the market today, however, with newer foreign products hitting the Indian supermarkets, the diet food industry is poised to grow substantially in the next few years. Weight-loss Clinics An average Indian today is inundated with direct mailers from established brands such as VLCC, Body care as well as the friendly neighborhood slimming centre, promising, no exercise, no medicine lose X number of kgs in Y days. And with the current obesity levels these ads have many takers in Urban India. With packages ranging from Rs.10, 000 and going beyond 70,000 in some cases, the survey question put across to a section of people, in the age-group of 21-40 yielded varied results. The chart below is indicative of the Indian mindset with the majority preferring to exercise by themselves (41.38%), followed by dieting (24.1%) and enrolling in a gym (20.7%). Yoga (13.8%) as the first few options if confronted with weight gain. weight loss clinics and taking pills which at 0% are the least preferred option for an urban obese Indian as the first mechanism for loosing excess weight.

A-

A-Dieting; B- Weight Mgmt Clinic; C- Pills/Drugs; D- Gym; E- Self Exercise; F- Yoga

Contrary to popular belief, Weight loss clinics are the least preferred options for obesity management, with only 6.3% of the respondents having visited a beauty clinic. Reviews of several prominent clinics on popular fitness sites attribute the non-efficacy of such programmes on several factors. The packages are priced between, 5,000-more than 40,000, however most respondents were not happy with the infrastructure provided, the attitude of the staff and also believed that most clinics over-promise and under-deliver. A common complain is that the ads for most clinics present a no-exercise weight loss regimen, however on signing up for the programme most people have realized that the diet presented is in combination with a rigorous exercise schedule. Also, the staff is found not to be suitably educated and spot-reduction techniques dont usually work out. Also, the use of appetite suppressants and a combination of pills, have in most cases wreaked havoc on the health of the patrons. Many fanatical weight watchers have destroyed their systems with unscientific diets designed by self-styled "dieticians. Drop in sugar levels, dehydration, changes in menstrual cycle in women and still others have experienced hair loss. Vacuum machines and heatpads mainly get rid of the water in the body. Also, these gadgets if not properly sterilized are known to cause infections as well. Although, immediate results can be dramatic, in the

long run water re-absorption helps regain the lost weight. Plus these centres market health food like biscuits, which come with additional costs. The table below gives an insight into the market leaders in this section, with their diet programmes salient features.

Brand

Company Profile

Product Portfolio

Cost Involved

USP

VLCC(Vandana Luthras and Curves) Qualifications: Studies cosmetology Germany, and in from a Curls

Started

in

1989,

Claims to adopt a holistic approach to slimming by modifying exercise Saunas, cellulite fat. diet is habits, advised, massages, massages,

15,000 above,

and

Regarded serves umbrella Health personal Workout

as as for

a an its

102 locations in 52 Indian cities, plans to reach 300 centres by 2008

Super-Brand,

specialization packages such as post pregnancy may anywhere between 40k 30cost

other brands like care, care, factor,

magnetic strips to melt

series of courses in beauty care, fitness, food and nutrition and skin care from London, Paris Munich,

Spa, Beauty Zone, etc. Promoted Bollywood Stars Marketing Health foods of by

Dr.Shikhas NutriHealth Systems Delhi Qualifications: MBBS

Founded in 1999 by Dr. Shikha Sharma

complete

diet but

based advises not

Rs12,000 for

for

Diet helpline and weight-loss through internet Its bio-energy base

programme, exercises mandatory. Scientifically

12 and 15,000 24weeks programme

designed

for weight loss. Recommends natural gradual way lose weight Associated with TV channels, Dr. a and to

program based on NUTRIGENETICS i.e. the study of nutrition based on the genetic individual makeup of an

Shikhas Ponds 2006.

articles, Femina

Anjali Mukherjees Total Health Mumbai Qualifications: Specialised nutrition dietetics. registered practitioner alternative medicines. Is in and a of medical

Founded in 1997 by Anjali centres Mumbai Mukherjee, only in

Diet hair

management loss, and

plus

Min Rs.2000 month

of per

Associated contest. Books by

with

Ayurvedic pills (reports of stomach hormonal problems

Femina Miss India

problems in women). Advocates 4step process, detoxification, rejuvenation, nourishment and Maintenance

Anjali

Mukherjee Media coverage in Mumbai Range snacks of health

Talwalkars Better Value Pvt Ltd

Established in 1932, 33 branches and

Diet

plus

mandatory no or pills, meal

Fees depends on approx 900 month the 600per programme,

Exercise programme, programmes designed different

based state

exercise, supplements replacements 50,000 members

of the art gyms, for sexes,

Mumbai

age groups,etc.

On the basis of the table Talwalkars is the only weight management which lays emphasis on a total body workout while most others resort to other means of weight loss. Therefore, it is imperative to get a greater understanding of the whole programme coupled with the side effect profile of any drug that one might take during the course of the treatment to ensure optimal health. Anti-Obesity Drugs The current anti-obesity drugs that are available for the treatment of obesity include phenteramines, benzphetamines, phendimetrazine tartarate, diethyl propion, orlistat and sibutramine. Though the latter two are approved obesity management drugs here, the first

is banned. That, however, does not prevent people from ingesting phenteramine-laced drugs and other largely unregulated slimming pills. The anti-obesity drugs can be classed into two major categories, anti-absorptive drugs (lipase inhibitor) and anti-satiety drugs (acts on specific centres in the brain). Unfortunately, many Indian health reporters are short of knowledge in complex health-related issues, with hardly any emphasis on the drawbacks of such blockbuster drugs. The Fen-pen, popular anti-obesity drugs was still available in India despite reports of side effects on the heart as reported in a prominent medical journal. In May 2007, in the US, Sanofi-Aventiss, Zimulti, an anti-obesity drug, has come under the scanner for reported psychiatric side effects, including suicidal tendencies. Even pills that do not contain fenfluramine can pose health risks. Some contain diuretics or laxatives that can cause skin rashes and diarrhoea. Individuals ingesting them lose water and with it, potassium and other vital body-regulating electrolytes. Reduced potassium can cause irregular heartbeat, even coma. With the obsession with weight, the market is flooded with Ayurvedic, herbal and Chinese pills, however with the law not demanding that companies warn people of the deleterious side effects, they tend to be more of risk- pills. Many Indian brands such as Baidyanath and Himalaya have ventured into this arena without having any significant impact. Although, 11.8% of the respondents in the survey did admit to trying pills as an option to weight loss, the majority were of the opinion these pills alone cannot help overcome weight issues. Therefore, the Indian market revenues for anti-obesity drugs are negligible. The penetration of the existing drugs has been poor due to their side-effects profile and the negative perception associated with anti-obesity drugs Anti-Obesity Surgery Weight reduction surgeries is not applicable to all over-weight people, but is applied generally to treat morbid obesity. It is recommended for only those who are unable to maintain weight-loss through dieting or exercise or for those who have a serious medical problem that is made worse with obesity. Majority of our respondents (93.8%), said that they would not consider weight-loss surgery, especially at the back of the high cost associated with the surgery.

Generally, Gastric or Bariatric Surgery is a weight loss surgery that literally reduces the size of the stomach to a walnut. The procedure usually involves removal of apart of stomach or small intestine. Bypassing part of the stomach reduces the capacity to eat. The small intestine in rearranged to reduce the calories the body can absorb. Therefore, although the trigger to over-eat is present but due to the stomachs reduced capacity to hold food (can only hold about six grapes), substantial weight loss usually follows surgery. In India, these surgeries are usually conducted for International patients as a part of medical tourism. Apollo Group of Hospitals and Fortis are some of the leading healthcare centres for such surgeries. At Apollo hospital the cost of bariartic surgery varies between $5500-$9300 for a period of 2-4days. Many think that surgery is the magic pill for weight loss, but some experts are now estimating that as many as 30% of those people who have the surgery will struggle with new addictions like alcoholism, gambling, compulsive shopping and sex addiction. In the absence of proper support group, this option is not considered by many in India. However, the incidence of morbid obesity increasing in India is suggestive of gastric surgery gaining prominence over the next 5-10 years. Exercising Weight depends on energy input (food) and energy expenditure (exercise). If the input is considerably higher than their output one becomes fat. Therefore, as suggested by doctors and nutritionist, long term management of obesity requires some form of exercise. This sentiment was echoed by our survey respondents who after going through several weight loss options, have chosen some form of DIY exercise,( swimming, walking, and jogging) as their first choice for weight loss (30.8%) followed by gym enrollment and Yoga, (both at 23.1%) and alteration in their diet(10.3%) as weight loss techniques. The figure below indicates the top 3 weight loss options having tried some or all of the weight loss options available such as pills, enrolling in weight loss clinics, ec.

A-Gym; B- Weight Loss clinics; C- Dieting; D- Self-Exercise; E-Yoga; F- Aerobics The exercise equipment sector has seen a meteoric increase in sales and increased competition with most equipments becoming affordable. A sizeable number of the urban working population is investing in fitness equipment which are now considered as a lifecare product rather than a lifestyle product. While people in their 20s and mid-30s, frequent gyms, those in the 40-plus category prefer the privacy of their homes to exercise, thereby increasing sales of these products. For those who can afford the market presents a whole range of home gyms to choose from, right from treadmills and exercise bikes to joggers and bench press with treadmills forming the bulk of sales. Likewise, a personal gym with 21 workouts in a single station costs anywhere between Rs 1.5 lakh and Rs 2 lakh. Brand is a vital criterion when it comes to buying fitness equipment for safety purposes, the Indian consumer today, can choose from brands such as Horizon, icon physique, Johnson, Body Solid ,Reebok and Adidas. These are primarily US-based companies, with only a few companies like Hero cycles and TI Cycles venturing into this arena with exerciser cycles, recumbent bikes, elliptical trainer, motorised treadmills and the home gyms. Also, since most of these products are now available on loans from prominent banks as well as discounts being offered the fitness

equipment industry is poised to become a highly competitive and profitable option antiobesity management for both health and commercial purposes. However, it is equally important to understand the exercise equipment and not fall for fad exercise equipments shown on the teleshop networks. These equipments promise wash board abs through sauna belts, sauna chambers, etc. However, they under-deliver like the magic pills and can cause injury to organs if not handled properly. Thus at the back of the growing obesity epidemic in urban India, consumers are presented with a whole gamut of weight loss options. However, it would be wise to adopt a more uniformed approach, with the health benefits being the sole aim rather than adopting a more cosmetic approach. While the west is now struggling to curb this condition, we in India should be able to see the red -flag and act on it promptly. There is no easy way to loose weight, and therefore anti-obesity management requires long term vision for a permanent cure.