She is 53, “normal” weight, and has already had a heart attack. A drug proven to prevent the next one becomes affordable in her country.
But she can’t access it because of a line drawn for someone else, on another continent. A billion people are about to fall on the wrong side of it.
On March 24, the patent on semaglutide — the active ingredient in the celebrated GLP-1 drugs Ozempic and Wegovy — expires in India. Prices for generic versions could drop by 90%, putting within reach a drug proven to reduce the risk of major cardiovascular events by 20%.
In the region, 5.2 million people lose their lives to cardiovascular disease each year. Generic semaglutide could help. But the rulebook that determines who qualifies for the drug was written for a different body.
The U.S. Food and Drug Administration approved semaglutide for cardiovascular risk reduction in patients with a body mass index of 27 or higher. The threshold was set by the authors of the SELECT trial, which enrolled participants who were 84% white and 8% Asian. The SELECT trial authors acknowledged as much themselves, noting in their supplementary appendix that South Asians face greater cardiometabolic risk at lower BMIs, yet didn’t look at people with a BMI below 27 — precisely where risk concentrates for Asian populations. That gap shouldn’t be a footnote. Those are the trials we still need.
In South and Southeast Asian populations, cardiovascular risk and visceral fat begins to accumulate at BMIs well below 27. Driven by genetics and environment, the mechanism has a name: thin-fat phenotype. Normal weight on the outside, visceral fat within —which secretes inflammatory compounds silently destroying arteries.
Semaglutide preferentially reduces visceral fat, accounting for roughly a third of the drug’s entire cardiovascular benefit.
The World Health Organization understood this two decades ago, stating for Asian populations cardiovascular and metabolic risk assessment should begin at a BMI of 23. More than half of adults studied across Southeast Asia — in the Philippines, Malaysia, Thailand, Myanmar, and Singapore — meet this definition of normal weight obesity. Applied to the region’s adults, that prevalence would imply roughly 1 billion people carrying unrecognized cardiovascular risk. Not all will need drugs, but none should be invisible. A meta-analysis, preliminary but notable, found that GLP-1s like semaglutide reduced cardiovascular events nearly twice as effectively in Asian patients as in white patients. And the need is greater, too — heart disease in Asia strikes nearly a decade earlier than in the West, claiming people during their peak productive years.
India’s Central Drugs Standard Control Organisation (CDSCO) has received committee recommendation to study semaglutide’s cardiovascular benefit in Indian patients, but has not yet defined who should receive it. If Indian regulators adopt the FDA’s BMI threshold of 27, they risk importing a standard that ignores the thin-fat phenotype. A nationally representative study found that 43% of Indian adults are metabolically obese despite having a BMI below 25.
While off-label prescribing is technically permitted in India, accessing an off-label prescription requires finding a specialist who knows to look beyond BMI and has the time to make that case. These specialists are scarce, particularly outside major cities.
The prescription is one barrier. Price is the other. Semaglutide is not on India’s National List of Essential Medicines and lacks public health scheme coverage, meaning patients pay entirely out of pocket. Generic versions arriving this month will bring prices down dramatically — but even at a fraction of today’s cost, a monthly dose would consume a significant share of an average rural income. Affordable on paper is not the same as affordable in practice.
These factors will dictate whether the drug’s expanding availability actually translates into access. Fortunately, a metric to guide prescribing is neither new nor experimental.
It requires a measuring tape. For nearly three decades, the scientific community has recognized waist circumference as a clinical vital sign to predict metabolic syndrome and cardiovascular risk. A waist-to-height ratio above 0.5 flags the “invisible sick.”
A national consensus of Indian cardiologists recommended waist circumference — rather than BMI alone — to identify which patients with cardiovascular disease may benefit from semaglutide. Korea’s obesity guidelines recommend a lower BMI threshold (23) for initiating obesity GLP-1 pharmacotherapy.
There are reasons to be cautious with semaglutide use with patients with lower BMIs. In already-lean populations, GLP-1 drugs carry a risk of muscle loss — a concern that warrants monitoring. But how to do that when bloodwork and specialists aren’t always available? Expanding access is a decision for national regulators — but safe infrastructure must be built in parallel. The tape measure gets people to the door. What happens next requires the same urgency.
The tape measure should be considered when setting the threshold — not just BMI, which misses the very obesity it’s meant to detect in Asian patients.
Without Asia-specific eligibility criteria, nearly a billion people will be priced in but ruled out — disqualified by a standard that was never written for their bodies. The cost of changing those criteria is near zero and the benefits are vast.
Two things stand between it and the people it could save: a regulatory threshold and a measuring tape. One is political, and the other fits in a coat pocket. Both are within reach.
Aditi Kantipuly, M.D., is a preventive medicine and public health resident at McGill University and visiting scholar at the University of New Mexico. She is currently working with policy stakeholders in India on access to cardiovascular medicines. Peter Singer is VK Rajah visiting professor of medical ethics at the Centre for Biomedical Ethics, National University of Singapore, and Ira W. DeCamp professor of bioethics, emeritus, Princeton University. His books include “Practical Ethics,” “The Life You Can Save,” and “The Most Good You Can Do.”
