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Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) continue to skyrocket in popularity as both approved and off-label treatments for weight loss. However, their widespread use raises significant concerns about their potential impact on people with eating disorders (EDs), which are prevalent worldwide. According to the World Health Organization, 14 million people globally experienced an ED in 2019. In the United States, approximately 9% of the population (28.8 million Americans) will experience an ED at some point in their lifetime.

“I have serious concerns that these medications might have a deleterious effect on people with disordered eating and with diagnosed or undiagnosed EDs,” Elizabeth Wassenaar, MS, MD, regional medical director for the Mountain and West regions at Eating Recovery Center, told Medscape Medical News. Wassenaar noted that many patients at her clinic taking these medications haven’t been forthcoming with their physicians about their risk factors for or history of EDs.

“Some are obtaining the drug on the black market, online, or from compounding pharmacies, and their physician doesn’t even know about it,” she said.

Wassenaar added that GLP-1 RAs “present a vulnerability for people with EDs who are desperate to seek them out because it helps with weight loss.”

Aaron Keshen, MD, co-director, Nova Scotia Eating Disorder Provincial Service, and associate professor, Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada, noted similar patterns.

“GLP-1 RAs certainly have an important role in treating diabetes and obesity,” Keshen told Medscape Medical News. “But there are many potential harms, especially when it comes to EDs.”

Keshen and coauthors provide detailed talking points for clinicians seeking to discuss GLP-1 RAs with patients who meet approved requirements for GLP-1 RA prescription or who are “inappropriately using the medication to decrease binge eating.”

Prescribe Judiciously

Wassenaar urged physicians to “prescribe judiciously, after taking a history of disordered eating,” and to adhere to evidence-based guidelines and not give GLP-1 RAs merely for cosmetic purposes.

Prior to initiating GLP-1 RAs, clinicians should use screening tools such as the Screening, Brief Intervention, and Referral to Treatment for Eating Disorders for adults and the Stanford-Washington University Eating Disorder screen for college-aged students to detect ED risk, added Cynthia Bulik, PhD, distinguished professor of EDs, Department of Psychiatry, School of Medicine, and founding director, UNC Center of Excellence for Eating Disorders, University of North Carolina at Chapel Hill. Additional screening tools can be found in a systematic review.

When these medications are prescribed for indications such as diabetes or obesity, patients should be monitored carefully to ensure they’re not developing disordered eating as well as being seen by a dietitian who can help the patient to eat in the most nutritious manner possible, said Wassenaar.

Novel Pharmacotherapy for Binge Eating Disorder (BED)?

Some research suggests that GLP-1 RAs might be a “promising avenue for pharmacotherapy” for BED, which is currently treated with a combination of psychotherapy (primarily specialized cognitive-behavioral therapy) and pharmacotherapy, such as topiramate (an anticonvulsant) or lisdexamfetamine (a central nervous system stimulant). However, both these medications carry adverse effects that limit their use.

GLP-1 is a hormone and neuropeptide that inhibits the appetite, reducing eating behaviors and promoting satiety. This mechanism may be particularly relevant in BED because binge eating is associated with impaired satiety. Additionally, GLP-1 RAs may “decrease anticipatory food reward.”

Keshen co-authored a paper reviewing the research on using GLP-1 RAs in EDs, including BED.

“We found the data regarding EDs was scant in general, although some studies did show potential short-term benefit for BED,” he said.

However, Keshen noted many studies have been hampered by methodological limitations, including small sample sizes, open-label designs, and short study durations. Thus, the conclusion that GLP-1 RAs can be helpful with BED is premature.

“The purported positive effects of the GLP-1 RAs are getting ahead of the data,” Keshen said. Future studies may well demonstrate the usefulness of these agents for BED, but “we’re just not there yet.”

Joanna Steinglass, MD, professor of psychiatry, Columbia Center for Eating Disorders, Columbia University Irving Medical Center, New York City, echoed this observation.

“The data are extremely limited, although they give us reason to be curious about the potential for GLP-1 RAs for BED,” she told Medscape Medical News. “It’s certainly plausible, in the same way that other medications that help with appetite, such as topiramate, have utility.”

The problem, said Steinglass, who also serves as director of research at the Eating Disorders Research Clinic, is that large studies of GLP-1 RAs for obesity and diabetes have not included individuals with psychiatric illnesses or EDs, leaving critical gaps in knowledge about their effects in these populations.

A pharmacovigilance study using the US Food and Drug Administration Adverse Event Reporting System database analyzed over 8000 reports of psychiatric adverse events in people being treated with GLP-1 RAs. Eight categories of psychiatric AEs were identified, including EDs, binge eating, fear of eating, and self-induced vomiting. The findings highlight the importance of early intervention and risk management.

Potential Upsides vs Downsides for BED

Keshen said the potential “disadvantages and downsides” of GLP-1 RAs may “outweigh the potential advantages” in BED.

Evidence-based treatments for EDs aim “to normalize eating, which means eating in moderation, having breakfast, lunch, and dinner, and not engaging in diets or restricting food intake below the normal level,” he explained. Restriction plays a role in the eating patterns of people with BED, who “end up binging” following excessive restriction.

“GLP-1 RAs affect satiety and reduce hunger, which could negatively affect ED treatment and work counter to its goals,” Keshen said. For example, delayed gastric emptying caused by GLP-1 RAs could disrupt meal regularity and portion sizes, counteracting ED treatment objectives.

But some experts cautiously suggest potential utility in BED — with important caveats and guardrails.

“Clinically, people who have BED and are taking GLP-1 RAs say it absolutely reduces the urge to binge and to eat,” Bulik told Medscape Medical News.

“We’re seeing some people who have transitioned from four or five binges a day and constant ‘food noise’ in their heads to needing to set an alarm on their phone reminding them to have dinner,” she recounted.

“Under monitored conditions, making sure it doesn’t get out of control, there might be a future role for GLP-1 RA treatment for BED,” suggested Bulik, who also serves as professor of nutrition, Gillings School of Global Public Health. GLP-1 RAs might give a person with BED “respite from the cycle, while giving them skills, and having a planned taper off the medication at the end.”

She shared an anecdote of a patient with BED who had been taking a GLP-1 RA, who was happy with their weight loss and no longer snacked, ate excessively, or consumed high-fat and high-sugar foods.

He said, “Now, I have confidence that I’ve learned to deal with these urges.” However, Bulik noted, “this might be a false sense of confidence because he’s learned to deal with the urges while he wasn’t having them. If and when he discontinues the medication, the urges will come back in full force,” leaving the patient without the required tools to deal with this without pharmacological interventions.

Previous research has pointed to the misuse of stimulant medications for populations with EDs for the purpose of suppressing appetite, Keshen said. A recent case report described a 39-year-old patient who misused semaglutide to induce rapid weight loss, resulting in atypical anorexia nervosa (AAN). AAN involves severe food restriction with the person being technically underweight. GLP-1 RAs prescribed for elevated body mass index could inadvertently exacerbate an undiagnosed ED or lead to new-onset EDs.

Potential for Triggering a Relapse

Wassenaar described a patient who relapsed into disordered eating after 10 years of recovery. However, when prescribed a GLP-1 RA, “she had a full relapse and went all the way back down the ‘rabbit hole,’ with disordered eating thoughts, preoccupation with body size, and weight loss so rapid that she required hospitalization,” Wassenaar recalled. The patient became “so preoccupied with eating that she was unable to stay present in her life and really struggled to get back to recovery.”

The case taught Wassenaar “that there’s no time long enough in recovery for these drugs to be considered ‘safe’ for someone with a history of an ED.”

In addition, some of the physiological side effects of GLP-1 RAs (eg, nausea and vomiting) might trigger “somatic memories” in individuals with a history of bulimia nervosa. The bodily sensations can catapult a person “back into the mindset of having the disease.”

Keshen similarly described patients who had been in remission but whose ED was re-triggered following the initiation of treatment with a GLP-1 RA.

GLP-1 RAs are “promising treatments for several populations, but their use in treating EDs warrants caution,” Keshen emphasized. Clinicians should assess and remain vigilant for potential use (or misuse) of these agents, ensuring that patients are monitored closely for any signs of developing or worsening EDs.

Steinglass reported receiving royalties from UpToDate, Springer, and Wiley. Bulik reported receiving royalties from Pearson for authorship of a textbook about abnormal psychology. Wassenaar and Keshen reported no relevant financial relationships.

Batya Swift Yasgur, MA, LSW, is a freelance writer with counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape Medical News and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).