The rise of GLP-1A culture

As the use and availability of GLP-1 receptor agonists (GLP-1RAs) continue to rise, the eating disorder community must start having conversations about how to approach this shift. While medications like Ozempic and Wegovy are approved for treating conditions like diabetes, they are increasingly being used for weight loss. With over 120 similar drugs currently in development, it's crucial to better understand how GLP-1RAs—whether prescribed for diabetes or weight management—affect eating disorder treatment, especially for binge eating disorder. As the debate over weight loss intensifies, the growing focus on weight stigma can contribute to feelings of hopelessness and lowered self-confidence in individuals in larger bodies. This desire for an “easy fix” to weight concerns is also leading to medication shortages, which impacts people who are prescribed GLP-1RAs for other medical conditions. There needs to be greater concern in the medical field about the potential effects of these medications on individuals struggling with eating disorders.

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What are GLP-1As?

GLP-1RAs are approved for diabetes management in the U.S., Canada, and other countries, and are available as both pills and injections. These medications regulate blood glucose by stimulating insulin release and suppressing glucagon production.¹ They also slow stomach emptying and affect brain pathways that control appetite, which can increase feelings of fullness and reduce food intake.

While GLP-1RAs are effective, they come with side effects. These can include nausea, vomiting, abdominal pain, diarrhea, and constipation, while rarer but more serious issues can also occur. There is limited research on their long-term effects.²

GLP-1RAs are celebrated for weight loss in adults, though this loss plateaus over time and the weight can be substantially regained after stopping the medication.^{3, 4, 5, 6}  Currently, GLP-1RAs are not approved for eating disorder treatment.

In terms of short-term weight loss, GLP-1RAs show effectiveness. For example, the STEP 2 study on semaglutide with lifestyle changes showed an average weight loss of 33.7 lbs over 68 weeks, compared to just 5.7 lbs without the medication.^{4, 6} However, weight loss typically slows after this period, and some participants even gained weight, diminishing the overall effect.  

Effectiveness of binge eating disorder treatment and GLP-1As

Caloric restriction can directly conflict with the goals of eating disorder treatment, and the current studies on GLP-1RAs are insufficient to draw meaningful conclusions. More targeted research is needed, specifically examining how GLP1-RAs affect eating disorder behaviors. This includes differentiating between pathological and non-pathological restriction, tracking client outcomes over extended periods, exploring the misuse of these medications in eating disorder populations, and understanding how binge eating would likely rebound significantly once the medication’s appetite-suppressing effects wear off.⁴

As the use of GLP-1RAs increases, it's crucial for eating disorder treatment programs to prepare for a growing number of clients who are already using these medications.

Approaching this issue with empathy is essential. Understanding why a client is taking GLP-1As, particularly if it's for weight loss, helps inform the risk assessment. The potential risks need to be weighed carefully to determine if they outweigh the benefits for the client’s treatment.

Evidence-based treatments for binge eating, such as therapy and non-weight-loss prescription medications, are already available and proven as effective treatment.

In a treatment setting that emphasizes regular meals and mindful eating, medications that reduce appetite can create significant challenges. Side effects may disrupt the ability to follow a structured meal plan, leading to discomfort and potential setbacks in treatment.

Moreover, GLP-1RAs can be misused as a way to manage negative body image related to weight and weight gain. This unhealthy usage can prevent clients from reconnecting with their natural hunger and fullness cues and hinder their ability to process emotions about body size and shape.  

Navigating the intersection of eating disorder treatment and weight loss medications

When navigating the use of GLP-1As in eating disorder treatment, it’s essential to recognize that if a client meets the criteria for this medication, the decision to continue or discontinue it during treatment ultimately is theirs. However, clinicians should ensure that clients are fully informed about the potential risks and benefits of using these medications in the context of their treatment. The provider then needs to assess the overall impact on eating disorder treatment and whether or not it is feasible or too risky to do.

For clients taking GLP-1RAs in relation to binge eating disorder, it’s crucial to explain that binge eating is often a physiological response to restriction. GLP-1As, which suppress appetite, can exacerbate restriction and ultimately contribute to cycles of binge eating.⁴ Since GLP-1RAs are not approved for binge eating and there is limited research on their efficacy for this condition, it’s important to highlight other evidence-based treatments which may be more appropriate. Be transparent that if the client discontinues the medication, they may experience an increase in binge episodes.  They need to know that weight loss in itself can negatively impact their relationship with food and ultimately their success in eating disorder treatment.

Even if a client is prescribed GLP-1RAs, they may remain eligible for binge eating disorder treatment. However, clinicians should be aware that these medications may interfere with the client’s ability to adhere to a structured eating plan, which is a key component in eating disorder recovery.

The conversation about GLP-1RAs should begin with respect for the client’s autonomy in making medical decisions. It’s important to understand why the client is taking the medication and whether it’s serving the intended purpose such as diabetes treatment. If the client is using GLP-1As for weight loss, acknowledge the broader societal context of weight stigma and the pervasive influence of diet culture, which may lead them to seek weight loss solutions. Validating their feelings and offering empathy can help create a productive dialogue.  

Although the conversation surrounding GLP-1RAs in the eating disorder field can be contentious, it’s important to lead with empathy and recognize all that goes into making the decision to take weight loss medications.  

Sources:

1. Food and Drug Administration (FDA). (2022) Ozempic (semaglutide) injection precribing information, revised. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/209637Orig1s009lbl.pdf

2. Bartel, S., McElroy, S. L., Levangie, D., & Keshen, A. (2024). Use of glucagon-like peptide-1 receptor agonists in eating disorder populations. International Journal of Eating Disorders, 57(2), 286–293. https://doi.org/10.1002/eat.24109

3. Rubino, D., Abrahamsson, N., Davies, M., Hesse, D., Greenway, F. L., Jensen, C., Lingvay, I., Mosenzon, O., Rosenstock, J., Rubio, M. A., Rudofsky, G., Tadayon, S., Wadden, T. A., Dicker, D., STEP 4 Investiga- tors, Friberg, M., Sjödin, A., Dicker, D., Segal, G., ... STEP 4 Investiga- tors. (2021). Effect of continued weekly subcutaneous semaglutide vs placebo on weight loss maintenance in adults with overweight or obe- sity: The STEP 4 randomized clinical trial. JAMA, 325(14), 1414–1425. https://doi.org/10.1001/jama.2021.3224

4. Wadden, T. A., Bailey, T. S., Billings, L. K., Davies, M., Frias, J. P., Koroleva, A., Lingvay, I., O'Neil, P. M., Rubino, D. M., Skovgaard, D., Wallenstein, S. O. R., Garvey, W. T., & STEP 3 Investigators. (2021). Effect of subcutaneous semaglutide vs placebo as an adjunct to intensive behavioral therapy on body weight in adults with overweight or obesity: The STEP 3 randomized clinical trial. JAMA, 325(14), 1403– 1413. https://doi.org/10.1001/jama.2021.1831

5. Wilding, J. P., Batterham, R. L., Davies, M., Van Gaal, L. F., Kandler, K., Konakli, K., Lingvay, I., McGowan, B. M., Oral, T. K., Rosenstock, J., Wadden, T. A., Wharton, S., Yokote, K., Kushner, R. F., & STEP 1 Study Group. (2022). Weight regain and cardiometabolic effects after with- drawal of semaglutide: The STEP 1 trial extension. Diabetes, Obesity and Metabolism, 24(8), 1553–1564. https://doi.org/10.1111/dom.14725

6. Davies, M., Færch, L., Jeppesen, O. K., Pakseresht, A., Pedersen, S. D., Perreault, L., ... Lingvay, I. (2021). Semaglutide 2 4 mg once a week in adults with overweight or obesity, and type 2 diabetes (STEP 2): A ran- domised, double-blind, double-dummy, placebo-controlled, phase 3 trial. The Lancet, 397(10278), 971–984. https://doi.org/10.1016/S0140-6736(21)00213-0