Are GLP-1 Drugs Causing Eating Disorders? Part 1

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Many of you asked me to write about the NBC News Article “Weight loss drugs like Wegovy may trigger eating disorders in some patients, doctors warn” by Liz Szabo, Marina Kopf and Akshay Syal, M.D. (As per my policy, I don’t link to articles that contain weight stigma and diet culture, but I make sure to offer enough information to allow you to Google them.)

Content note: There is going to be lots of talk about eating disorders, including specific symptoms, in this piece so please take care of yourself. The quotes from the article are indented so you can skip those for harm reduction.

Before I begin I want to note that I hear from people who are taking these drugs for Type 2 Diabetes (T2D) who worry about the impacts that are being discussed around the weight loss versions of the drugs. I want to point out that there is a significant difference between the dosing and titration of these drugs for type 2 diabetes and weight loss. That’s because these are drugs meant to treat T2D that have a side effect of weight loss.  So for T2D, the goal is to give the patient the minimum dose they need to achieve the desired glycemic management and minimize side effects. For weight loss the goal is to prescribe as much of the medication as possible in order to maximize the weight loss side effect which will, of course, maximize all dose-dependent side effects.  Thus, patients who are on the drugs for type 2 diabetes may be on much lower doses (for example, the minimum therapeutic dose of Ozempic (Semaglutide for T2D) is .5mg, but the recommended dose of Wegovy (Semaglutide for weight loss) is 2.4mg. That’s not to say that those taking these drugs for T2D may not experience these side effects, but I do want to make clear the differences. Also, the risk/benefit analysis for a give patient can be very different for achieving desired glycemic management vs attempted body size manipulation.

The piece opens with a quote from Tom Hildebrandt, PsyD.  who runs the Hildebrandt Lab at  Mount Sinai in New York, which houses Mount Sinai’s Center of Excellence in Eating and Weight Disorders.

The name was an immediate red flag for me so I looked it up and sure enough they list “ob*sity” as an eating disorder. This is pure (and harmful) nonsense and cannot be defended scientifically. Ob*sity is, in fact, simply a height-weight ratio that, itself, lacks a consistent definition.  Regardless, people who meet any/all of the various criteria for “ob*sity” have all the same eating patterns and relationships with food that thin people do. I don’t want to get off topic so I’ll write a separate piece about it, but while there is no shame in being higher-weight and/or having an eating disorder, simply existing in a higher-weight body does not constitute an eating disorder, and claiming that it does harms many people.

At any rate, the opening quote from Dr. Hildebrandt is:

“They start using this drug and next thing you know, they’ve developed what looks very much like anorexia nervosa,”

Let’s examine the situation - giving people who are seeking thinness a drug that promises thinness by disrupting the body’s ability to sense hunger leads to people under-nourishing themselves? I exhibit no surprise. This was completely predictable, but we’ll get to that.

The article continues:

The blockbuster medications have been hailed as wonder drugs for their profound effects on diabetes and weight loss, but a growing number of doctors are concerned that the medications are triggering or worsening eating disorders in some people.

Here I’ll quickly point out that being hailed as a weight loss wonder drug (predominantly by people making money from them) is not the same thing as actually being a weight loss wonder drug, as Wegovy’s four-year outcome study shows. That said, I’m grateful that doctors are speaking up about the eating disorders issue.

This class of drugs, called GLP-1 drugs, which also include the diabetes drugs Ozempic and Mounjaro, work by mimicking a naturally occurring hormone released by the gut called glucagon-like peptide 1, which regulates blood sugar levels and curbs hunger. In one clinical trial, people taking the highest dose of Eli Lilly’s Zepbound lost 21% of their body weight. (The weight tends to return when people stop taking the drugs.)

Actually, this is how they thought it would work but they are now learning that it also, and perhaps for weight loss predominantly, works in the brain by an unknown mechanism and for an unknown amount of time (Content warning - link includes weight stigma and diet culture.) which seems pertinent here. Also, while some people on the highest dose lost 21% of their body weight, 9% of the people taking the highest possible dose failed to lose even 5% at 72 weeks. I do appreciate them discussing the weight regain but “tends” seems like a softball way to say “almost certainly.”

In some cases, a person’s brain may interpret such dramatic, sudden weight loss as starvation, Hildebrandt said, making people more obsessive about food. People who are taking these new weight loss drugs, he posited, may then find themselves compelled to further limit how much food they eat, even when it endangers their health.

My question is, how else is the brain supposed to interpret a major reduction in food intake resulting in dramatic, sudden weight loss?

“The restrictive eating unintentionally spirals out of control” until people can’t help themselves, said Dr. Aaron Keshen, co-director of the Nova Scotia Eating Disorder Provincial Service in Canada and an associate professor of psychiatry at Dalhousie University.

Here is where I point out that if we were focused on health from a weight-neutral paradigm instead of hoping that thinness will create health, we could stop intentionally promoting restrictive eating in the first place. The weight loss industry’s desperate attempts to suggest that prescribing symptoms of eating disorders to people is fine as long as those people are higher-weight gets us to this. It’s especially dangerous since higher-weight people are less likely to be diagnosed with eating disorders and more likely to being given no or lower-level treatment than thinner people with the same presentation.

Experts don’t know what percentage of people taking the new class of weight loss drugs are at risk of eating disorders, because there are no published clinical trials addressing the question, said Keshen, who would like to see a rigorous study.

I would also like to see a rigorous study, but I imagine the drug’s manufacturers (who fund the vast majority of research around them) won’t be in a hurry to fund/conduct it, given that the weight loss industry, and those on their payroll, are working overtime to convince us that weight loss attempts do not create/exacerbate eating disorders.

Misuse of over-the-counter and prescription medication, however, was common among people with eating disorders long before GLP-1 drugs came on the market. Some people with eating disorders take diet pills, which can contain appetite suppressants, caffeine or even amphetamines. Others misuse laxatives and prescription medications such as insulin and pills used to treat thyroid disorders.

Given that it was already well known that this was an issue with weight loss drugs, the real question is why there wasn’t investigation into this from the beginning with these new weight loss drugs – that are meant to be prescribed for far longer than previous drugs (indeed, they are being aggressively marketed by their manufacturers as “lifetime medications”) that promise even greater disruption of normal hunger? Again, the fact that these drugs have the capability to create/exacerbate eating disorders is not a surprise.

Yet in terms of the abuse of weight-loss drugs, “nothing compares to the phenomenon that we’re seeing right now with these GLP-1s,” said Melissa Spann, a psychotherapist and the chief clinical officer at Monte Nido, an eating disorder treatment group that runs 50 programs and in 28 states virtually.

Again I say - not shocking. Remember that prior to Wegovy’s FDA approval as a weight loss drug, Novo Nordisk promised their shareholders “one of the fastest Novo Nordisk launches after approval ever.”(Content note – link contains significant weight stigma and diet culture content.)  Again – knowing that weight loss drugs create/exacerbate eating disorders and knowing that the weight loss industry is trying to create “blockbuster” drugs to fill their shareholders coffers, this was all entirely predictable and it should have been studied from the beginning, not the topic of a discussion about the lack of research now.

In Part 2 we’ll look at the rest of the article and discuss what can be done about this.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.