GLP-1 Receptor Agonists and Eating Disorders

What are Glucagon-like Peptide-1 (GLP-1) Agonists?

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Glucagon-like peptide-1 (GLP-1) agonists are types of medications originally approved by the FDA to treat Type 2 diabetes and were later approved by the FDA for chronic weight management (i.e., Mounjaro, Ozempic, Saxenda, Victoza, Wegovy, Zepbound etc.). Common types of GLP-1’s include semaglutide, liraglutide and tirzepatide. Lower doses of the drugs are used to treat Type 2 diabetes while higher-dose versions of the same medications are used for weight loss. Since they were first developed in the early 2000’s, this class of medication has evolved to become more potent and associated with greater weight loss than earlier versions of the GLP-1’s.

How do GLP-1 Medications Impact the Body?

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GLP-1 drugs impact many different areas of the body including the GI tract, pancreas, liver, heart, thyroid and brain. For those with Type 2 diabetes and other health concerns like cardiovascular disease, they can lead to improved glucose control, lower HbA1c, decreased risk of heart attack or stroke and decreased cardiovascular mortality. 

In many people, these medications also reduce feelings of hunger and motivation to eat. Generally, people report increased feelings of fullness after eating due to the impact of the medication on the appetite and reward centers in the brain, as well as the medication’s ability to slow gastric emptying. In 60-70% of people taking these medications, significant and sometimes rapid weight loss occurs. This is of particular concern to any person with an active eating disorder, history of eating disorder or individuals with a high susceptibility of developing an eating disorder.¹ The impact of the newer GLP-1 medications on widespread systemic problems in our society which increase the burden of diseases, such as weight stigma, healthcare disparities for people living in larger bodies, and widespread race-based health inequities remains an important and unanswered question. 

What are Common Side Effects of GLP-1 Medications?

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The most common side effects for these medications include: 

• GI issues such as nausea.
• Vomiting
• Diarrhea

Other risks for medical complications can include:²

• Gastroparesis
• Hypoglycemia
• Bowel obstruction or ileus
• Pancreatitis
• Renal failure
• Hair loss
• Dehydration
• Reduction of lean body mass.
• Risk of thyroid cancer and other thyroid diseases. 
• Anecdotal reports of increased incidence of suicidal ideation have not appeared to be significant in the FDA review of large scale data. 

How do GLP-1 Medications Impact Individuals with Eating Disorders?

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There has been very little research done on the impact of taking GLP-1’s in people with eating disorders. So the short answer to the question is…we don’t know yet. We do know that dieting and drive for thinness are associated with restrictive eating disorders. Clinical experience shows us that eating in regular and consistent intervals throughout the day, fostering body acceptance, addressing weight stigma, attuning to hunger/fullness cues, and improving flexibility are important interventions for most people recovering from eating disorders.  

We also know that there is limited eating disorder training or screening in the larger medical disciplines such as primary care, family practice, pediatrics and endocrinology. Patients with atypical anorexia and non-purging bulimia are more likely to go undiagnosed (or misdiagnosed as having binge eating disorder). Research has also shown that people of color are less likely to be diagnosed or receive specialty care when an eating disorder is present. 

When we review the scientific literature on studies looking at GLP-1 medications in eating disorders, we find precious little at this point (2024). The few studies that have been conducted have shown mixed results. Some found that it may decrease binge eating episodes for those with binge eating disorder (BED) or bulimia nervosa (BN). However, these studies had very small sample sizes and only measured the effects of the drugs after 3-6 months of taking them, leaving longer term outcomes and risks entirely unknown.^1,3,4,5 Furthermore, the one randomized, controlled study on patients with binge eating disorder demonstrated that these patients didn’t experience any change in their eating disorder behaviors.^2,4 

Potential Risks for GLP-1 use in Individuals with Eating Disorders

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Since little is known about GLP-1’s impact on individuals with eating disorders or disordered eating, it is critical for patients to be informed about and consider some of the unique risks these drugs can pose before making the decision to take them. The potential risks could include:

• Misuse of the drug among those with eating disorders and disordered eating, particularly restrictive eating disorders like anorexia nervosa, atypical anorexia, or those that involve purging like bulimia nervosa.
• Rapid weight loss and malnourishment, which is a risk factor for the development of refeeding syndrome. 
• The inability to eat meals and snacks at regular intervals, which is a standard nutritional approach for people with eating disorders.
• Potential worsening of the cognitive and behavioral symptoms of eating disorders (i.e., body image concerns, weight obsessions, drive for thinness, skipping meals, or over-exercising).
• Lack of studies examining impact of GLP-1’s on people with a history of eating disorders, a current eating disorder or people at risk of developing an eating disorder in the future. 
• Impact of long-term use, including the impact of starting/stopping since little is known about this, particularly in patients with eating disorders. 
• The effect of starting and stopping the newer GLP-1 medications due to access issues, and resulting weight cycling. 
• Potential to intensify thin idealization, weight stigma and fatphobia with disproportionate negative impact on people living in larger bodies. 
• Potential for people living in larger bodies who do take GLP-1 medications to be ostracized by the eating disorder community and fat activism communities.
• Over focus on the potential benefits of GLP-1 medications while neglecting to address ongoing systemic issues like thin idealization, the role of marketing and Big Tech in perpetuating weight stigma, inequities in food access, the role that the food industry has played in changes in our food supply chain over the last two decades, and persisting health inequities in medical and eating disorder treatment for communities of color. 

Treatment Considerations

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In summary, while GLP-1 medications have been found to be helpful in the treatment of Type 2 diabetes and reduction of cardiovascular mortality, for individuals with eating disorders or disordered eating behaviors, these drugs can be harmful when not used for their intended purpose, when inadequately monitored or monitored by clinicians without eating disorder expertise, or when used for weight loss motivated by weight stigma or fat phobia in people with eating disorders. These same risks are true of people with undiagnosed eating disorders. While there is some evidence that GLP-1’s can decrease the number of binge eating episodes for those with BED, little is known about the long term physical and psychological impact on those with eating disorders. 

If you or someone you know has an eating disorder and is considering taking a GLP-1 medication, it is important to consult with an eating disorder specialist(s) and healthcare provider(s) (i.e. general practitioner, endocrinologist etc.) to inform them about your eating disorder and interest in taking GLP-1 medications so that they can consider all the potential risks and benefits before deciding what is appropriate for your situation. 

If GLP-1 medication is deemed medically and clinically appropriate by your healthcare and eating disorder treatment provider(s), it is important to discuss what your goals for treatment are and to have regular follow-ups appointments for medical monitoring and to communicate any changes in your eating disorder symptoms. It is also important that your healthcare practitioner(s) and eating disorder treatment provider(s) communicate with each other so they can coordinate and make any adjustments to your treatment plan that may be needed.