The questions eating disorder experts have about weight loss medications

There is still much researchers don’t know about popular weight loss medications — and those lack of studies could have consequences for eating disorders, according to experts.

The medication semaglutide, sold under brand names such as Ozempic and Wegovy, is a kind of glucagon-like peptide-1 receptor agonist or GLP-1 agonist.

While originally prescribed for diabetes, semaglutide is becoming more and more popular for weight loss.

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As medications become more available, experts say they worry about the impact of these weight loss products on eating disorders.

“We noticed clinically that we were getting more and more people into our clinical services that had been started on GLP-1 agonists and had experienced new onset or worsening eating disorder symptoms,” Nova Scotia Provincial Eating Disorder Service co-director Dr Aaron Keshen, an assistant professor of psychology at Halifax’s Dalhousie University, said.

Eating disorders impact nearly one in 10 people in the US, according to the non-profit National Association of Anorexia Nervosa and Associated Disorders, which provides support services for people with these conditions.

Next to opioid addiction, it has the second-highest crude mortality rate of any mental illness, the association said.

The possibility that GLP-1 agonists could make eating disorders worse or more prevalent “makes us have to go really slowly and be very thoughtful about when we might prescribe them,” eating disorder physician Dr Jennifer Gaudiani, who founded the Gaudiani Clinic in Denver, said.

The scope of research on the connection between eating disorders and weight loss medications is quite slim, leaving experts with many unanswered questions, Lindner Center of HOPE chief research officer Dr Susan McElroy said.

McElroy, who is also the Linda and Harry Fath-endowed professor in the department of psychiatry and behavioral neuroscience at the University of Cincinnati College of Medicine, added: “I view eating disorders as the last frontier in psychiatry. The eating disorder field is hard because we’re just ignored.”

Can these drugs treat binge-eating disorder?

Are there cases in which these medications actually help eating disorder patients? Perhaps, experts said.

Generally, if a medication causes weight loss, there is a good chance it will also reduce binge eating, McElroy said.

Binge eating disorder is the most common eating disorder. But, as with anorexia and bulimia nervosa, there isn’t enough research into how to treat it with medication, she added.

“We desperately need more compounds to treat people with eating disorders,” McElroy said.

These medications could help in theory, but they have not been approved for treating binge-eating disorder, she added.

“There is a little bit of preliminary evidence that maybe GLP-1 agonists could reduce binge symptoms in some individuals,” Keshen said.

“But the evidence is fairly weak at this point, and it’s certainly not enough to recommend that people take GLP-1 agonists for binge eating.”

Keshen and McElroy worked on a 2023 paper published in the International Journal Of Eating Disorders that reviewed the existing literature on GLP-1 agonists and eating disorders.

The studies they found on binge-eating disorder were small, and many didn’t test against a placebo, Keshen said.

“More research needs to be done,” he added. “And that may happen in the future.”

Can they bring an eating disorder back?

Eating disorders happen in people of all shapes, sizes and health conditions — so doctors may prescribe these medications unknowingly to those with a history of or even an active eating disorder, Gaudiani said.

“Their ability to perhaps pay for a medication that causes weight loss, while potentially causing medical complications, is concerning,” she said.

Gaudiani said she has heard anecdotal evidence of people in remission for an eating disorder that was reignited after taking a GLP-1 agonist.

Eating disorders are complicated biopsychosocial illnesses, Gaudiani said, and the process of losing weight might trigger increased restrictive dieting, which can bring up “old gremlins”.

Additionally, these medications suppress appetite. Feeling full too quickly or feeling sick after only eating a little can disconnect a person from their innate hunger and fullness cues, she added.

“If somebody has had a history of an eating disorder, or indeed just has temperamental traits, and is surrounded by a society that is extremely focused on weight loss and fat-phobia, and they begin to lose weight, it’s not unimaginable that could devolve into something that becomes quite obsessive and quite mentally and physically unhealthy for them,” Gaudiani said.

Can they unleash a new monster?

With little research on the topic, experts cannot say if GLP-1 agonists would make it more likely for someone to develop an eating disorder, but there are reasons to be concerned, Gaudiani said.

“A lot of eating disorders do begin with restricted food intake and weight loss,” she said.

The act of reducing caloric intake and the act of losing weight physiologically have been proven to trigger eating disorder behaviours, even in those who wouldn’t otherwise be considered temperamentally or socially prone to them.”

Gaudiani pointed to the Minnesota Starvation Experiment of 1944 in which individuals volunteered to undergo starvation, so researchers could experiment with the best re-feeding methods.

There was an impact that researchers didn’t expect, she said. The volunteers became obsessed with food, reading cookbooks, chewing gum constantly, cutting the food they ate into little pieces to spend longer eating, and judging people in restaurants they deemed gluttonous.

“In short, (they were) acting like someone with anorexia,” Gaudiani said.

“There’s something about our brains that fundamentally changes when we get inadequate calories and lose weight.”

There is also a risk for behaviours such as bulimia, Keshen added. If people have a suppressed appetite, they may not eat at all during the day and then binge at night — which could then result in purging behaviours, he said.

“Perhaps a degree of moderate weight loss is a healthy outcome for some individuals, but it’s never going to be a healthy outcome to achieve rapid weight loss due to excessive pathological dietary restriction,” Keshen said.

How to protect those vulnerable to eating disorders

First, health care providers prescribing these medications need to screen for a history of eating disorders, active eating disorders and even vulnerability for an eating disorder, Keshen said.

“It may be worth trying to treat the eating disorder first, or perhaps not using a GLP-1 agonist at all in that patient,” he said.

If a doctor and patient choose to move forward with medication, it is important they also go over information about eating disorders and the importance of eating structured meals, Keshen said.

Nourishment is something people on appetite-suppressing medication should review regularly with themselves, Gaudiani said.

“Humans, like all mammals, need to nourish throughout the day to have the energy to do with our body and minds what we want to do, and so we have to check, ‘Am I eating enough?’, ‘How often am I thinking about food and body?’,” she said.

If those with histories of eating disorders find themselves reverting to old behaviours while taking GLP-1 agonists, they should contact their doctors and therapists, Gaudiani said.

And for those who haven’t been diagnosed with an eating disorder, or who might not even reach the threshold of one, if thoughts of weight and food are distracting from goals and priorities, it may be time to seek an eating disorder expert if resources are available, she said.

“If not, going on eating disorder treatment websites or listening to podcasts can just help bring some support and clarity to what’s going on,” Gaudiani said.