New Delhi:

Khalid bin Mohsen Shaari, once known as the heaviest man alive, has shed 542 kg, thanks to Saudi Arabia’s former King Abdullah. In 2013, Khalid weighed a life-threatening 610 kg and was bedridden for over three years. His condition deteriorated to the point that he depended on friends and family for even his most basic needs. Moved by Khalid’s plight, King Abdullah stepped in with a comprehensive plan to save his life.

The King arranged for Khalid to receive top-tier medical care at no cost. Khalid was transported from his home in Jazan to King Fahad Medical City in Riyadh using a forklift and a specially designed bed. A team of 30 medical professionals was assembled to develop a rigorous treatment and diet regimen.

Khalid’s treatment included gastric bypass surgery, a customised diet and exercise plan, and intensive physiotherapy sessions aimed at helping him regain his mobility. Supported by leading Middle Eastern scientists, Khalid saw incredible results. 

Once the heaviest person alive and the second heaviest person to have ever lived, Khalid bin Mohsen Shaari underwent a remarkable transformation, losing nearly half his body weight in just six months. 

By 2023, Khalid had lost an astounding 542 kg, bringing his weight down to a healthy 63.5 kg. His physical transformation was so dramatic that he required multiple excess skin removal surgeries – a common phenomenon for individuals who undergo significant weight loss, as the skin may not be able to adapt to the new body shape.

Today, he is fondly known as “The Smiling Man,” a nickname given by the medical staff who witnessed his remarkable transformation.

BMI has remained the go-to method for measuring health since it first started being used in the latter part of the 20th century.
| Photo Credit: Getty Images/iStockphoto

Body mass index (better known as BMI) has long been used to get a quick and easy snapshot of a person’s body fat levels. To calculate someone’s BMI, you divide their weight in kilograms by their height in metres times itself. The resulting number is used to determine a person’s health risk.

Although there are far better ways of getting an accurate measure of a person’s body fat levels – such as using dual-energy x-ray absorptiometry (Dexa) or magnetic resonance imaging (MRI) – these are very resource-intensive. This may explain why BMI has remained the go-to method for measuring health since it first started being used in the latter part of the 20th century.

But many health experts believe BMI has significant limitations, particularly for children and young people (whose body fat levels change as they grow), athletic people (who have high levels of muscle mass) and people from ethnic minority groups (who may develop health problems at lower body fat levels).

BMI was never created for use in health and was developed using data from European people in the 19th century. Although child and ethnicity‐specific adjusted BMI and alternative height and weight ratios have been suggested, none have made sufficient headway to improve BMI’s reputation.

Several alternatives to BMI have also been suggested – such as using waist-to-hip ratio (waist circumference divided by hip circumference) or body volume index (which uses 3D body scanners to estimate total body fat distribution).

But a recent study suggests that instead of BMI, we should be using something called body roundness index (BRI) to get a more accurate picture of a person’s body fat levels and predict health risk.

What is body roundness index?

BRI was developed by U.S. researchers in 2013 in response to criticisms of BMI. Instead of looking at height and weight, BRI mathematically quantifies body fat levels by looking at height and waist circumference instead. This provides a value typically ranging from one to 20. It is the lowest and highest values that suggest the highest health risk.

Numerous studies have shown that BRI may be better than BMI at predicting the health risks associated with different levels of body fat. This includes predicting risk of weight-related diseases such as cardiovascular disease, diabetes, kidney disease and cancer, as well as death from any cause.

This latest study, which looked at 32,995 U.S. adults between 1999 and 2018, found an association between BRI and death from any cause. Specifically, they also found that people with the lowest and highest BRI scores had the greatest health risks.

They also found that BRI was better than BMI at accurately detecting this risk. This is because BRI considers the fat held around the abdomen, which is linked to greater risk of health problems. This is different to BMI, which only considers overall weight.

BRI v. BMI

Given BRI only requires a tape measure and a maths equation, this means it’s as easy to use and accessible as BMI. But assuming BRI is manually measured, it remains as subject to human error as BMI.

One study even found that eight out of ten trained health professionals demonstrated such high levels of human error when manually measuring the abdomen that they failed to notice an increase of 3cm the second time they took the measurement. This margin of error will probably be even higher in people taking their own measurements at home.

As a new metric, BRI also does not yet have the kind of extensive data backing up its use that exists for BMI. This makes it harder to know just how effective and reliable it is compared to these more established methods.

And like BMI, BRI is a composite measure – meaning it combines multiple highly related measures into a single index. This makes it very hard to unpick the impact that different body fat levels can have on health – and can lead to misleading interpretations of the results.

While BRI may improve on some of BMI’s shortcomings, it’s not immune to misclassification. For example, people with high muscle mass might still face inaccuracies in their health risk assessments if their body fat distribution does not conform to “typical” patterns around the abdomen. Research also suggests that BRI’s accuracy at predicting the health risks may vary depending on a person’s ethnicity, age and sex.

BRI most certainly represents an advancement in the hunt for a more accurate alternative to BMI by focusing more on body shape and fat distribution rather than just body size. But it still has its limitations. Although this latest study gives us more data on BRI’s accuracy, more research is still needed before we can be certain it’s better than BMI and should replace it.

Perhaps an even better way of getting a picture of a person’s health is to use 3D body surface imaging. This creates a scale digital 3D image of the human body which allows health professionals to explore all potential existing body measures, including both BRI and BMI, as well as allowing us to explore new digital alternatives.

But regardless of which body measure you or a doctor may use to asses your health, it’s important to remember that every person is unique, and our bodies do – and should – always come in a wide range of shapes and sizes.

Alice Bullas is Senior Research Fellow, Sports Engineering Research Group, Sheffield Hallam University. This article is republished from The Conversation.

Stashing boxes of injectables in their carry-on luggage. Buying counterfeit formulas online. Importing boxes from Europe. The race to score blockbuster weight-loss drugs is pushing one of the world’s largest populations of obese people to creative lengths.

Breathless media coverage has helped create a frenzy over the treatments. Such is the interest that the anti-obesity medication market could reach $100 billion by 2030, Goldman Sachs Research said. Indians, meanwhile, have simply been watching this from the sidelines.

That’s because the latest formulations, Novo Nordisk A/S’s Ozempic and Wegovy and Eli Lilly & Co’s Mounjaro and Zepbound, won’t be available in India anytime soon, amid global supply shortages.

For some buyers, that’s not soon enough. They’re turning to the flourishing gray market, where sales of imported bulk packs and alternative medications highlight the scale of pent-up demand and raise tricky questions about potential health risks.

In her upmarket New Delhi cosmetology and metabolic treatment clinic, Instagram-famous Dr Anjali Hooda sees celebrities, wealthy locals and expatriates, as well as Indians visiting home from abroad, who are trying to get their hands on weight-loss drugs.

Women, largely between their 20s and early 50s, come seeking prescriptions, Dr Hooda said. While many are obese, some have only small amounts of weight to lose.

Hundreds of patients have sought prescriptions from her in the past six months, she said. She recently denied an Ozempic prescription to a young patient who wanted to lose quick 4 kilograms (9 lbs) and already had doses of the drug from an unknown source.

“I told her she did not meet the criteria for the use and asked her to try it only at her own risk,” Dr Hooda said.

In late 2017, Novo launched Ozempic-the GLP-1 drug that, while technically for diabetes, put weight-loss shots into the cultural consciousness. Then it rolled out Wegovy, which treats obesity. The two have raked in tens of billions of dollars in revenue for the Danish drugmaker so far. Eli Lilly started selling Zepbound in December last year – a weight-loss shot that’s predicted to become the bestselling drug in history.

The obesity drugs are now a global phenomenon and often in short supply. They’ve won over the rich and famous and blown open a new market for weight loss drugs.

Novo Nordisk has “no plans” to launch Ozempic in India but is working to make Wegovy available, a spokesperson said in an email. Eli Lilly did not respond to an email seeking comment.

In India, the only drug available is Novo Nordisk’s Rybelsus pill, which contains the same ingredients as Wegovy and Ozempic but comes in pill form. It was launched in 2022 but is considered less effective than the blockbuster injectibles.

India had the third largest number of people with obesity as of 2022, behind China and the US, according to a study in The Lancet, with numbers surging as junk food consumption becomes more commonplace. The country has about 80 million obese and 225 million overweight people, market research firm IMARC Group estimates.

A study of more than 100,000 Indians aged over 20 found more than 11% of people were diabetic, with a further 15% pre-diabetic. Meanwhile, chronic kidney disease has been ranked as the eighth-highest cause of death.

“It is not easy to procure them,” Dr Kiran Kaur Sethi, the celebrity skin doctor who runs New Delhi’s Isya Aesthetics, said of the drugs. “Many of my patients get it from their overseas channels.”

For those with prescriptions, pharmaceutical distributors can import injectables from places including Europe, in an expensive process that has been typically used for oncology drugs.

Indian distributor Ikris Pharma Network Pvt. ships the drugs from warehouses in Belgium, Bulgaria and Hong Kong, said director Bharat Sikri, in a process that can take around 10 days. Costs can fluctuate but it’s around $1,200 for a monthly supply of the drugs, after the patient pays for cold storage, shipping, customs and tax, he said.

“Most of the patients we see are unaware of the process and come without prescriptions,” Sikri said.

“They often end up going to illegitimate pharmacies who sell medicines that may be counterfeit.”

India’s gray market offers alternatives, including chemists and drug importers advertising weight-loss injectables on platforms like IndiaMart InterMesh Ltd. and ExportersIndia.com. IndiaMart did not respond to Bloomberg News queries.

A pack of Wegovy from these retailers can cost 9,500 rupees ($113) for a four-week supply, less than one-tenth of some US prices, while a four-week pack of Zepbound can cost about 7,800 rupees ($93), according to prices seen by Bloomberg News on ExportersIndia.com.

Some New Delhi and Mumbai-based chemists also bring treatments from countries like United Arab Emirates or Egypt, and sell bulk packs for cash, according to an investigation published in March by India Today.

Wegovy alternatives, like Bangladesh-based Incepta Pharmaceutical Ltd.’s Fitaro, not officially marketed in India, are also gaining popularity, as online retailers supply it to Indian buyers.

Central Drugs Standard Control Organization, India’s top drug authority, did not respond to an emailed request for comment.

Novo Nordisk’s Rybelsus pill costs about $43 for a 10-day supply. Sales of Rybelsus increased about 150% in the 12 months to April, from a year earlier, to 3.63 billion rupees, according to analytics platform Pharmarack.

The pill is one of the top products for Novo Nordisk in India, managing director for the country Vikrant Shrotriya told Bloomberg News. “India is a very critical market,” he added.

Arjun Sha, a 30-year-old writer from West Bengal, shed about 24 kilograms in seven months of taking Rybelsus, before stopping the drug in February. Sha had been obese for more than a decade, he said, and decided to take the pills after being introduced to them by his doctor girlfriend.

Now, he said he’s also stopped taking medication for high blood pressure and cholesterol, relying on exercise to continue to lose weight.

“There is generally a taboo around taking drugs in India,” Mr Sha said. “I tell people online they could try this, after consulting a doctor, because this is really helpful.”

Injectables are expected to be available in India from next year, when Eli Lilly plans to launch Mounjaro, Reuters reported. A deluge of generic weight-loss drugs are forecast to flow soon after when patents of semaglutide, used to make Novo’s weight loss medicine, start to expire in 2026.

Locally, India’s largest pharma firm Sun Pharmaceutical Industries Ltd. is developing its own weight-loss formulation, while Cipla Ltd. and Dr. Reddy’s Laboratories Ltd. are working on generic drugs.

Biocon Ltd. and Glenmark Pharmaceuticals Ltd. are already banking on generic versions of an earlier generation of obesity treatments, a liraglutide injectable sold by Novo Nordisk as Saxenda.

Dr Ramen Goel, director at Mumbai’s weight loss-focused Centre of Bariatric Surgery, said more than half of the dozen or so patients he sees daily ask about obesity drugs. The treatments are a good solution for Indians who can afford them, Dr Goel added.

“People are fully aware of what is happening internationally,” said Dr Goel, who has worked on obesity-related ailments for 24 years. “There is a lot of excitement.”