GLP-1s and Eating Disorders - Part 2

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In Part 1, by reader request, I began a discussion of 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, but I make sure to offer enough information to allow you to Google them.) Today I’ll finish my look into the article.

The NBC article includes a sub header that reads:

 “Crossing the line from weight watching to eating disorder”

Again, I think the real question to be asking here is whether this is really a much of line at all. As Dr. Deb Burgard, a psychologist and Academy for Eating Disorders Fellow has pointed out, we prescribe to higher-weight people that which we diagnose and treat in thinner people. To call this a “misuse” of the drugs may well be victim-blaming since higher-weight people are, early and often, given the message that being thin is worth risking their quality of life and even lives with various pharmacotherapies and surgeries.

Also, as Dr. Keshen points out in the article:

“People don’t need to abuse the new drugs, however, to develop eating disorders.” The article continues “He’s seen eating disorders develop in people who take the drugs as prescribed.”

The article shares the story of Cynthia Landrau who started taking Tirzepatide (Eli Lilly’s drug called Mounjaro for its Type 2 Diabetes application and Zepound for its weight loss application.)

The drug, she said, led her to stop binge eating After a few months, however, she said that she “went from one extreme to another,” restricting her diet even further, beyond what was medically recommended and  consuming only about one-third of the calories recommended for a woman her age. “You begin to realize that you do not want to eat,” said Landrau, of Queens, New York. “You are not eating. And you are OK with that because you want to lose weight. That’s when it crosses the line” from healthy weight loss into an eating disorder, she said.

Let’s remember that patients don’t get the idea that they should want to not eat from nowhere, they get it from a healthcare system that, for decades, has been obsessed with giving higher weight patients less nourishment than they need in the hopes that their bodies will consume themselves and become smaller, with little to no regard for the abject failure of this as a healthcare intervention or the harm it can do.

Landrau’s experience speaks to another issue with these drugs, which is the idea that they are a “cure” for binge eating disorder, sometimes based on the (faulty) assumption that BED is simply caused by patients having faulty hunger/satiety cues, or based on hopes about the currently-not-understood impact of the drugs on the brain itself. Like all eating disorders BED is a complex bio/psycho/social condition and it’s possible that these drugs may help but we are a lot of research away from knowing that and we must be careful to both be honest about that, and not oversimplify BED.

I want to point out that she says “You are not eating. And you are OK with that because you want to lose weight.” It may also be that you are ok with that because you are taking a drug that disrupts your normal hunger signals, convincing you that you are not hungry even if you are under nourishing yourself.

The article discusses the Collaborative of Eating Disorders Organizations (CEDO) which does excellent work, including calling for, at the very least, eating disorder screening for all patients before prescribing these drugs.

The article also quotes Dr. Hildebrandt as saying that those who are the greatest risk of eating disorders related to weight loss drug are those who

 “have an unhealthy relationship with food in your history, whether that’s eating too much, feeling out of control of your eating, having had periods where you lost weight and felt like you couldn’t get yourself to eat.”

Given these criteria, it seems to me that most if not all of those with a history of intentional weight loss attempts and weight cycling likely qualify as having the “greatest risk.”

Because the drugs reduce hunger, researchers are studying their use for the treatment of binge eating, McElroy said, though she added that there haven’t been any large, rigorous studies to prove that they work in this population.

Here, again, is the problematic notion that a drug-induced disinterest in food is the same things at “treating” binge eating. Again, like all eating disorders, Binge Eating Disorder is a complex bio/psycho/social health issue that often includes, or in fact derives from restriction.

Melissa Spann explains this in the article:

“Any type of restriction and restrictive behavior is going to put somebody at risk for an eating disorder”

There is plenty of cause for concern because, as Dr. Hildebrand points out:

“Most of the people prescribing these drugs aren’t necessarily trained to assess or treat those kinds of risks,”

The article points out that this may be especially concerning given that Wegovy (Semaglutide for weight loss) is approved for children as young as 12. Hildebrand explains:

“We’ve seen adolescents, we’ve seen young adults, we’ve seen middle-aged folks” develop eating disorders after using a GLP-1 drug…It’s having a profound impact on their life in terms of disrupting the relationships that they do have.”

In the article, Melissa Spann argues that drug labels should warn potential users about eating disorder risks, and I strongly agree with her.

The article then says: 

Dr. Raveendhara Bannuru, vice president of medical affairs and quality improvement outcomes at the American Diabetes Association, said there’s not enough research on GLP-1 drugs to know if they increase or decrease the risk of eating disorders.

The article didn’t mention that Novo Nordisk is, per the American Diabetes Association (ADA,) a “long time supporter,” at the highest level of sponsorship for the ADA and, along with Eli Lilly and Sanofi they have given a collective $53.6 million dollars, as well as being Banting Circle Elite supporters, sponsors of the Consumer Guide and, per this website that requires that you be a non-US healthcare provider to view it fully, heavily involved in the ADA’s annual “Scientific Sessions.” This is not an exhaustive list of conflicts, just what I found with about 15 minutes of digging.

The article ends with a quote from Dr. Rita Redberg “a cardiologist and professor at the University of California, San Francisco, who advocates for transparency in medical research and scrutinizes the evidence behind popular interventions” who said:

“The reports of eating disorders associated with these drugs raise concern and emphasize the need for independent analysis of the data…We should have robust and publicly available data on the risks and benefits.”

I could not agree with her more.

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*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.