Initially developed to treat type 2 diabetes, drugs such as Ozempic and Wegovy (brand names for semaglutide) have become household names in recent years.
They belong to a class of medications known as GLP-1 receptor agonists, which lower blood sugar levels and suppress appetite, and can help people lose weight.
For many people with type 2 diabetes and obesity, the new generation of drugs are a “game changer”. But for others, their rapid rise and surging popularity has been fraught.
“They can be very appealing to people who have an eating disorder, are at risk of one, or have a history of disordered eating,” Sarah Cox, clinical psychologist at the Butterfly Foundation, said.
“They’re marketed as a quick, easy fix [for weight loss], which is actually not true.“
Dr Cox, who leads the Butterfly Foundation’s national helpline for Australians seeking support for eating disorders and body image issues, said a growing number of people had called the helpline wanting to discuss the weight-loss drugs.
“Some of the main themes we find are people talking about having urges to try the drugs for the purposes of their own weight loss.
“It’s still a relatively small amount of our overall volume, but it is definitely a trend that’s increased over the past year or so.”
Loading…
In Australia, drugs like Wegovy, Mounjaro (tirzepatide) and Saxenda (liraglutide) are approved for weight loss management. While Ozempic is not approved for weight loss it can be prescribed “off-label” for this purpose.
Acknowledging the benefits that GLP-1 agonists can bring for people with type 2 diabetes and obesity, Dr Cox said the drugs also had the potential to reinforce harmful messages about disordered eating and perpetuate weight stigma.
“If somebody is at risk of or they have an eating disorder and start taking one of these drugs … it can contribute to their thinking becoming more distorted or rigid,” she said.
“It can also start reinforcing that [their] sense of worth is linked to their body size and their weight.”
Disordered eating and the potential for misuse
In Australia, it’s estimated more than 1.1 million people are living with an eating disorder, and less than a third of those receive treatment or support.
Eating disorders are complex and potentially life-threatening mental illnesses in which people have an unhealthy relationship with food, eating, and/or body weight and shape.
Despite incorrectly and stereotypically being associated with people who are underweight, clinical psychologist Sarah Trobe said more than half of people with an eating disorder have a higher weight, which includes those living with overweight or obesity.
“There is a fairly high risk that people with an eating disorder are going to seek support for weight loss,” Dr Trobe, national director of the National Eating Disorders Collaboration (NEDC), said.
“We know people [with eating disorders] are more likely to seek weight loss support than eating disorder treatment.“
Research shows rates of disordered eating are higher among people seeking weight loss treatments such as bariatric surgery.
According to the NEDC, people experiencing disordered eating may misuse GLP-1 agonists “in an attempt to control their weight or compensate for food intake”, which can lead to “dangerous health consequences”.
When people stop using these medications, they often regain some, if not all, of the weight they lost. This could cause psychological distress, Dr Cox said, and exacerbate an existing eating disorder or even trigger the start of one.
“That rebound weight gain can really fuel guilt, shame and body dissatisfaction, which can then push people into those disordered behaviours to try to lose weight again.”
GLP-1 agonists work by imitating hormones that make people feel full for longer. (Getty Images: Mario Tama)
Even for people not using the medications, media coverage “celebrating weight loss” and showing “before and after” pictures can also contribute to disordered eating, she said.
“We have people [calling the helpline] talking about celebrity culture, seeing media portraying rapid weight loss … and just the negative impact that has as far as their own shame, guilt and body dissatisfaction.”
Universal screening to combat weight stigma
There is little research on the effects of GLP-1 agonists in people with eating disorders, and Dr Trobe and Dr Cox agreed more research was needed.
In the meantime, both experts would like to see increased screening by health professionals of eating disorders and body image concerns among people seeking out or being recommended weight-loss medications.
One group at particular risk of inappropriate prescribing of GLP-1 agonists are individuals with higher weight and restrictive eating disorders.
This group includes people with atypical anorexia, who have anorexia nervosa symptoms — including distorted body image, intense fear of weight gain, and restrictive eating patterns — but are of average or above average weight.
“What we’re doing [if we prescribe weight-loss medications to people with an eating disorder] is causing further harm because … we’re focusing on a number on the scale rather than looking at holistic health,” Dr Trobe said.
“One thing medical practitioners can do is think about their own internalised weight stigma.“
Some experts are concerned GLP-1 medications may negatively impact eating disorder symptoms and treatment. (Getty Images: Carolina Rudah)
So far, there is no evidence to suggest GLP-1 agonists “target any of the underlying mechanisms” of eating disorders, Dr Trobe said, and in no circumstances should someone with atypical anorexia be prescribed weight-loss medications.
“If they continue to lose weight, they are going to experience the same risks as someone with a low-weight anorexia.”
Could GLP-1s curb binge eating?
To complicate matters, there is some research to suggest GLP-1 agonists may have a role to play in the treatment of binge eating disorders, by curbing appetite and giving people control over their impulse to binge.
People with binge eating disorder, the most common eating disorder in Australia, regularly eat large quantities of food in short amounts of time and feel a loss of control while doing so.
A recent systematic review found the use of GLP-1 agonists in people with binge eating disorder reduced behavioural and cognitive symptoms associated with binge eating.
The studies’ sample sizes were small, however, and had short follow-up periods, leaving longer term outcomes and risks unknown.
Rather than solely encouraging food restriction, Dr Cox said more studies were needed to understand whether the drugs could address binge eating’s fundamental drivers.
“For any mental health condition, there are usually belief systems that underlie it.
“If you’re only addressing one component, and you’re not, for example, addressing negative thinking or beliefs … the great likelihood is that the recovery is not going to be long term.”
Gold standard treatment for binge eating disorder involves “individualised, person-centred care” with a multidisciplinary team that typically includes a GP, mental health professional and dietitian, she said.
Where someone has a co-occurring condition such as obesity, for which weight loss is medically recommended, treatment decisions needed to happen “in a team” and consider potential impacts on eating disorder treatment, Dr Trobe said.
“Regular eating is a core part of eating disorder treatment, and weight-loss medications might actually stop that from being able to happen.
“We need to focus on: ‘Does this person need to lose weight via weight-loss medication, or can we look at holistic health behaviours and eating disorder treatment together?'”
Dr Cox added it was essential for anyone experiencing an eating disorder and using weight-loss medications to consult a trained health professional.
For support with eating disorders and body dissatisfaction call the Butterfly National Helpline on 1800 ED HOPE (1800 33 4673) or visit www.butterfly.org.au to chat online or email, 7 days a week, 8am-midnight (AEST/AEDT).
