India is confronting a paradox at the heart of its growing health crisis. Even as average body mass index (BMI) levels remain lower than those seen in Western countries, rates of diabetes, fatty liver disease and cardiovascular disorders are rising at an alarming pace.
Recent findings pointed to a convergence of biological vulnerability and rapid lifestyle change, leaving millions of Indians metabolically unwell long before traditional markers like obesity or high blood sugar cross diagnostic thresholds.
Experts warn that this “hidden epidemic” is being driven by a distinct South Asian metabolic profile, characterised by higher visceral and organ fat at lower body weights, combined with diets rich in refined carbohydrates, declining physical activity, disrupted sleep and chronic stress. As a result, a growing number of Indians, many of them young, non-obese and outwardly healthy are developing insulin resistance, fatty liver and early cardiometabolic disease without obvious symptoms.
The shift has prompted renewed focus on early metabolic testing, comprehensive biomarker screening and tighter medical oversight of emerging therapies such as GLP-1 drugs as policymakers and clinicians grapple with how to slow the rise of non-communicable diseases before they become irreversible.
Firstpost spoke to Dr Ajay Phadke, Director, Strategic Business Development at Agilus Diagnostics to understand why metabolic disorders are rising so sharply in India, how early diagnostic testing can detect disease before symptoms appear and what new WHO guidance means for the safe and effective use of emerging therapies such as GLP-1 drugs.
Excerpts:
Dr Phadke: The increase in metabolic disorders in India is attributed to both genetic susceptibility and rapid lifestyle changes. Indians are predisposed to developing metabolic abnormalities at lower body weights because of a higher propensity for central and organ fat accumulation. This vulnerability is exacerbated by diets rich in refined carbohydrates and sugars, decreased physical activity, disrupted sleep patterns, and chronic stress.
In comparison to the United States and Europe, India exhibits a lower average BMI yet faces a disproportionately higher prevalence of diabetes, fatty liver, and cardiovascular disease. According to ICMR’s Indian Council of Medical Research–India Diabetes (ICMR–INDIAB) study, nearly 38% of adults with normal BMI in India have evidence of metabolic abnormalities. The WHO similarly identifies South Asians as a high-risk ethnic group for metabolic disease, which accounts for the sharp increase in metabolic diseases despite lower obesity rates than those observed in Western countries.
Dr Phadke: Insulin resistance, fatty liver and early-stage prediabetes are asymptomatic conditions. These disorders typically do not produce pain or noticeable symptoms until significant physiological damage has occurred.
Early metabolic testing can identify conditions before symptoms appear:
Insulin resistance: Occurs when the pancreas produces excess insulin to maintain normal blood glucose levels.
Fatty liver: Characterised by the accumulation of liver fat and mild enzyme changes, often long before any clinical symptoms of liver disease emerge.
Prediabetes: Represents a transitional phase in which blood sugar regulation is deteriorating but still reversible.
In clinical practice, patients may present with normal fasting glucose and HbA1c levels yet show elevated fasting insulin, increased triglycerides, or expanding waist circumference. For instance, a routine checkup may reveal normal blood sugar readings but an elevated insulin level and mild central obesity—early signs of underlying metabolic dysfunction.
Detecting these abnormalities early allows for timely interventions, improving the likelihood of reversing the condition before diabetes, cardiovascular disease, or liver complications develop.
Dr Phadke: South Asians possess a unique body composition marked by reduced muscle mass and a limited capacity for safe subcutaneous fat storage. When this storage threshold is surpassed, excess calories are redirected to visceral fat and organs, including the liver and pancreas.
Visceral fat is metabolically detrimental, as it exacerbates insulin resistance, promotes inflammation, elevates triglyceride levels, and accelerates atherosclerosis. Consequently, Indians tend to develop diabetes and cardiovascular disease at younger ages and lower BMI compared to Europeans, who typically have higher muscle mass and greater subcutaneous fat storage capacity. This biological pattern is well recognised by WHO and is the reason lower BMI and waist cut-offs are recommended for Indians.
What do the new WHO guidelines mean for the safe use and monitoring of GLP-1 drugs?
Dr Phadke: The WHO guidelines provide a conditional recommendation for the use of GLP-1 drugs in the management of obesity. This means the drugs are effective but must be used within a structured medical framework.
WHO emphasises:
– Careful patient selection
– Medical supervision and long-term follow-up
– Combination with lifestyle interventions
– Avoidance of cosmetic or unsupervised use
The guidelines also underscore the lack of long-term safety data, the potential for misuse, and the necessity of ongoing monitoring in real-world clinical settings, especially in countries such as India. Monitoring poses additional challenges in these contexts due to variations in healthcare infrastructure, inconsistent access to follow-up care, and disparities in provider training. These factors can lead to inadequate surveillance of side effects, increased risk of inappropriate prescription, and difficulty in ensuring comprehensive patient management when using GLP-1 drugs.
Why is diagnostic oversight essential for people starting or continuing GLP-1 therapies?
Dr Phadke: Weight reduction represents only one outcome of GLP-1 therapy; the primary objective is the enhancement of overall metabolic health.
Without diagnostic oversight:
– Weight may be lost disproportionately from muscle rather than fat.
– Fatty liver may persist despite weight reduction.
– Atherogenic cholesterol patterns may remain unchanged.
Ongoing monitoring ensures that GLP-1 therapy leads to improved liver function, enhanced lipid profiles, preservation of muscle mass, and reduced cardiovascular risk. Diagnostic oversight is critical for associating these medications with long-term outcomes, including decreased diabetes incidence, fewer cardiac events, and reduced morbidity, rather than focusing solely on short-term weight loss.
Dr Phadke: Metabolic diseases impact multiple physiological systems concurrently. Reliance on a single diagnostic test frequently fails to detect early or combined metabolic risks.
In India, patients often present with clusters of abnormalities, such as borderline glucose with elevated insulin, increased triglycerides with low HDL cholesterol, or mild liver enzyme elevation accompanied by central obesity. While each marker may seem insignificant in isolation, their combination indicates a high level of metabolic risk.
Comprehensive biomarker panels offer a holistic assessment, enabling clinicians to identify genuine metabolic risk at an early stage and to tailor preventive strategies more effectively than isolated tests.
Why is fatty liver becoming common even among non-obese young Indians?
Dr Phadke: The prevalence of fatty liver is rising among non-obese young Indians, primarily as a result of sedentary lifestyles, excessive intake of sugars and refined carbohydrates, late meal timing, inadequate sleep, and reduced muscle mass. This condition is now classified as MASLD (Metabolically Active Steatotic Liver Disease), highlighting its metabolic etiology. Without timely intervention, MASLD may progress to inflammation, fibrosis, cirrhosis, liver failure, and hepatocellular carcinoma, and it substantially elevates the risk of diabetes and cardiovascular disease.
Importantly, early-stage MASLD is reversible with prompt metabolic intervention, underscoring the necessity of early detection.
Dr Phadke: Advanced diagnostic tools enable clinicians to monitor the progression of metabolic risk over time, rather than waiting for disease thresholds to be surpassed. Early identification of deteriorating insulin sensitivity, adverse lipid profiles, compromised liver function, or elevated inflammatory markers allows for the implementation of interventions years before the onset of diabetes or cardiovascular disease. This approach facilitates personalised prevention strategies and aligns with WHO recommendations for early risk identification to mitigate the long-term impact of non-communicable diseases.
How can large labs integrate AI to interpret huge biomarker data more accurately? Could advanced biomarker mapping eventually predict diabetes or heart disease years in advance?
Dr Phadke: Large clinical laboratories produce substantial volumes of longitudinal health data. Artificial intelligence can assist by detecting latent patterns, monitoring temporal trends, and identifying individuals whose risk is escalating despite ostensibly normal laboratory results.
With validated datasets and appropriate clinical integration, advanced biomarker mapping has the potential to predict diabetes, cardiovascular disease, and liver disease years before clinical diagnosis, particularly in high-risk populations such as Indians. However, the implementation of such predictive technologies also raises important ethical considerations, including concerns about data privacy, informed consent, and the potential for unequal access to advanced diagnostics. Overall, this development signifies a transition from reactive diagnosis to predictive and preventive healthcare.
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