In an era of increasingly easy access to GLP-1s, some experts are raising concerns about the potential for misuse, especially among patients with eating disorders.

Access has expanded dramatically, with oral formulations now available and prescriptions often a click away via telemedicine sites that may rely heavily on self-reported weight and health information.

The concern is not without basis. Although GLP-1s are approved for patients with type 2 diabetes, obesity, or overweight with certain coexisting comorbidities, the proportion of prescriptions written for patients without these conditions increased from 4.5% in 2018 to 17% in 2023, according to an analysis of prescribing trends.

“That’s a big jump, and those are just retail pharmacies,” Amanda Banks, MD, a hospitalist at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, and a drug developer, told Medscape Medical News. Banks cited the statistic in her recent New England Journal of Medicine perspective,“GLP-1 Receptor Agonists and Eating Disorders — Cause for Concern.” 

“It’s super easy to get them,” Banks said, pointing to online vendors that do not require in-person visits. 

The potential for misuse among people with eating disorders, and the resulting harms, deserve greater attention, she said. 

Her concerns are also personal. Two years ago, her teenage daughter was diagnosed with anorexia nervosa, prompting Banks to take a deeper look at the issue. 

Clinicians need to watch for warning signs, she said, including patients who want to lose “just a little more weight” despite reaching a healthy target or those who fail to disclose a history of eating disorders. Clinicians, drug manufacturers, and patients should work together to develop consensus recommendations that help protect those with existing or emerging eating disorders. 

To better understand how these concerns are playing out in practice, Medscape Medical News spoke with four physicians about inappropriate requests for GLP-1s, eating disorder screening, and strategies for protecting patients’ health.

A Size 4 With a Double-Zero Goal

“In the last year, I’ve had more and more patients wanting GLP-1s for cosmetic reasons,” said Kevin Gendreau, MD, a family and obesity medicine physician at the Weight and Wellness Center at Signature Healthcare, Brockton, Massachusetts. 

“There is no doubt that GLP-1s are among the most effective tools we have for treating obesity and metabolic disease, but cheaper and easier access has definitely brought a surge of inappropriate requests into our clinic,” he said. 

Many patients seeking prescriptions have only minimal weight to lose. Some have a BMI in the normal range, are otherwise healthy, and want to lose 5-10 pounds, he said.

Other cases are more extreme. 

Gendreau recalled a patient who wore a size 4 and told him she wanted to become a size double zero. He declined to prescribe a GLP-1 but shifted the discussion toward overall health, offering to assess her muscle mass and body fat and refer her to a dietitian to help her eat more healthfully.

“She stuck around,” he said. 

He credits that outcome to reframing the conversation away from cosmetic concerns and toward overall health. The focus, he tells them, is not achieving their weight loss goal but bringing their metabolic markers into a healthy range. 

Gendreau screens every patent for disordered eating prior to prescribing a GLP-1, a practice he believes every clinician should adopt. Although he sometimes uses formal eating screening tools, he relies mostly on detailed clinical conversations. 

“I ask about lifetime weight patterns,” he said, including prior cycles of binge eating or significant body image concerns. 

Among the available screening instruments are the Binge Eating Disorder Screener-7 (BEDS-7) and other tools available online through the National Eating Disorders Association.

More commonly than formal eating disorder diagnoses, Gendreau encounters disordered eating patterns and unhealthy relationships with food. He often hears about obsessive food rules, intense fear of weight gain, histories of bingeing/purging/restricting, and demands for rapid weight loss in people who do not need it medically.

Many of these patients also struggle with depression, anxiety, and persistent “food noise,” Gendreau said. As a result, he routinely refers patients to psychologists or other counselors and maintains a list of local therapists who accept different insurance plans. 

“Mental health and disordered eating patterns are very much intertwined,” he said.

An Eating Disorder Is Mental Illness

“I’ve always had patients with eating disorders,” said Caroline Apovian, MD, co-director of the Center for Weight Management and Wellness at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, Boston.

About 3 years ago, Apovian prescribed a GLP-1 to a patient with binge-purge behaviors who also had periods of normal eating. She hoped the medication might help her reduce binge episodes, alongside psychiatric counseling. 

Although some research suggests that semaglutide may help patients with binge eating disorder, Apovian said her experience led her to become more cautious. 

The patient lost too much weight and remained on the GLP-1 longer than Apovian believed was appropriate, prompting her to discontinue treatment.

“They don’t have the disease of obesity; they have mental illness, and these medications are not going to help,” she said.

As for screening, Apovian believes a careful history and physical examination remain essential.

“I think any doctor can do a diagnostic history and physical exam and diagnose an eating disorder,” she said. 

Telemedicine and its easy access to GLP-1s is not going away, she acknowledged, but she believes patients should be evaluated in person at least initially and during follow-up.

Asked what could help curb abuse, Apovian was direct.

“I would restrict GLP-1s from being handled completely by telemedicine,” she said.

Vulnerability in Midlife 

Women in midlife are particularly vulnerable to inappropriate GLP-1 use, according to Nadia Sirdar, MD, MPH, a primary care physician in Bethesda, Maryland. 

“I began to see abuse and misuse in the last 3-5 years as an inpatient physician,” she said, recalling patients with loss of muscle mass, declining bone density, and pancreatitis while taking GLP-1s.

Today, many of her patients are midlife women who have already lost weight but want help losing the last 10 pounds. 

“The first thing they ask about is a GLP-1,” Sirdar said.

One patient with a documented history of an eating disorder requested a GLP-1. Instead, Sirdar asked her to keep a food journal. 

Reviewing the journal together provided an opportunity to discuss nutritional quality and explain how GLP-1-induced appetite suppression can make it difficult to consume enough protein and preserve muscle mass.

Sidar also pointed out that patient’s BMI was already below normal and that approaching menopause could affect bone density. The patient also had a family history of osteoporosis, which helped put the risks into perspective.

The conversation changed the patient’s perspective, leading her to conclude that a GLP-1 was not her best way to maintain health long-term.

“If you approach it from the perspective of whole-body health and prevention, the patient gets it most of the time,” Sirdar said.

GLP-1s in Selected Patients With Eating Disorders

“I do screen for eating disorders at every intake visit,” said Sarah Stombaugh, MD, an obesity medicine specialist in Charlottesville, Virginia, who operates a direct-pay practice. 

Stombaugh routinely asks patients whether they ever felt out of control while eating or have a history of eating disorders. If the answer to either question is yes, she follows up with the BEDS-7 screener.

She does sometimes prescribe a GLP-1 to selected patients with both obesity and binge eating disorder. When the GLP-1s reduce intrusive food-related thoughts and cravings, she said, patients are often able to establish more normalized eating patterns. 

“Anecdotally, I see that significantly in my patients,” she said.

Apovian, Gendreau, and Sirdar reported no relevant disclosures. Stombaugh serves on an advisory board for Novo Nordisk and on the speaker faculty for Lilly.