Doctors are growing increasingly concerned that weight-loss drugs are driving new cases of anorexia, and that few safeguards are in place to protect patients with eating disorders.
Tens of millions of patients now take these medications, which can sometimes cause symptoms that mirror the effects of anorexia: hair loss, dizziness, gastrointestinal issues, extreme calorie deficits.
“At that point, it’s like, is that anorexia? Is that disordered eating? Or is that just a side effect of the medication?” said Dr. Katherine Kiley, a family and sports medicine physician in Long Beach, Calif.
Citing an “urgent need” for guidance, an international coalition of obesity medicine specialists, eating disorder clinicians and other experts released new recommendations last month on GLP-1 prescribing and eating disorders. Among their ideas for physicians: Screen all patients for signs of eating disorders before starting a GLP-1, and routinely monitor anyone on the drugs for them.
Neither of those are standard practice now. Nor are most doctors trained to recognize the signs of disordered eating, which may limit the reach of the new recommendations.
Further complicating matters is that many people get the drugs through telehealth services, with little to no oversight from a physician. In a recent study, researchers who tried purchasing weight-loss drugs from 49 websites found that only about one-third required direct interaction with a clinician before prescribing the medications, and only around half asked about eating disorders.
“We have started to prescribe a really, really serious drug, when we don’t entirely know all of the impacts it will have,” said Vanessa Longley, chief executive of Beat, a British nonprofit that runs a help line for people with eating disorders.
There is little data on how common anorexia is among people on weight-loss drugs. But a recent study that examined GLP-1 use among people with no apparent medical need found that the frequency of eating disorders in this group was six times as high as that of the general population. The research suggests that many people are seeking out these drugs to achieve dangerous levels of weight loss. If left untreated, anorexia can lead to osteoporosis, bone fractures and cardiovascular and cognitive issues. It can also be fatal.
Even if a patient discloses a history of anorexia, doctors have little guidance about what to do next. Do they prescribe the drug anyway? Or do they withhold the medication because of that risk, forgoing its benefits?
Ozempic, or anorexia?
A growing body of research suggests that for some people who are genetically predisposed to anorexia, a state of calorie deficit — like a first diet — can be the catalyst for an eating disorder. Their brains are primed to find that calorie deficit especially rewarding, creating a feedback loop that leads them to further restrict food intake. Researchers have seen bariatric surgery set off anorexia in this way.
There’s reason to think that something similar could happen to some patients on GLP-1 drugs.
“It’s a tipping point situation,” said Cynthia Bulik, the founding director of the University of North Carolina’s Center of Excellence for Eating Disorders, who was also a member of the expert panel that released the new guidelines. “It tips them into the activation of whatever genetic predisposition it is that they have.”
The medications are “pharmacologic sledgehammers” for appetite, said Dr. Amanda Banks, a physician in Philadelphia who has written a book about the link between anorexia and weight-loss drugs.
That makes the medications such an effective therapy for people with obesity. It’s also part of why the drugs have shown promise for patients with binge eating disorder.
Doctors sometimes identify anorexia by its physical symptoms: rapid, intense weight loss, dehydration, dizziness, hair loss caused by malnourishment. But those symptoms can also be effects of GLP-1s, making an eating disorder hard to detect.
It’s also difficult for doctors to discern whether a patient is intentionally trying to restrict, or whether the medication is driving them to eat less. And there is no real answer as to how much weight loss counts as too much on drugs designed to help people shed pounds.
“We’re seeing patients who are coming in experiencing what we would call pathological weight loss,” which can mean they lose an unhealthy amount of weight, said Dr. Aaron Keshen, an eating disorder specialist in Nova Scotia and a co-author on the new guidelines. “And they’re on GLP-1s.”
The line between GLP-1 use and disordered eating has become so muddled that some researchers are questioning whether the clinical definition of anorexia needs to change to reflect what the disorder can look like in someone on these drugs.
It’s a blurry line for patients, too. At the time Amanda Martinez Beck, 42, started taking Ozempic for her diabetes, she had never been diagnosed with anorexia. But Ms. Beck, an elementary-school teacher, knew her relationship with food was unhealthy. She obsessed over trying to eat as little as possible, and spiraled if she felt she had consumed too much.
Once she started taking Ozempic, in 2021, not eating felt easy. She had to force herself to get through a meal. Around this time, Ms. Beck, who had for years suspected that she might have an eating disorder, decided to see a therapist. Ms. Beck was diagnosed with atypical anorexia — a condition that shares the symptoms of typical anorexia, but mainly occurs in people with larger bodies.
Ms. Beck was reluctant to be on the drug for several reasons, including that it might make her eating disorder worse. She worried that intentional weight loss could come with harmful effects, physically and mentally.
She even stopped taking the drug for three months, but her blood sugar spiked and she went back on it.
Doctors are increasingly encountering patients like Ms. Beck, who have medical issues the drugs could treat but also show signs of disordered eating. “If they start to develop hypertension, if they start to develop Type 2 diabetes, we need to treat that,” Dr. Bulik said. “We can’t ignore it because they had a history of anorexia.”
Even for someone closely attuned to her appetite, Ms. Beck finds it difficult to differentiate between the drug’s effects and her anorexia. In the first days after she takes her weekly shot, when its effects are most potent, she hardly feels hungry. Later in the week, her appetite creeps back — but Ms. Beck still finds herself wanting to restrict how much she eats.
Every time she sits down for a meal, she reminds herself: “I can’t listen to what my brain is telling me,” she said, “which is not to eat.”
A Need for Guardrails
While the new guidelines are an attempt to protect against the risks of GLP-1s harming patients with eating disorders, putting those recommendations into practice could prove challenging, especially given the rise of online prescriptions. “If I can say, ‘I weigh 165 pounds and I have diabetes and I have hypertension,’ and none of those things are true, and nobody verifies, and I can get the drug on my doorstep in the morning — that’s a problem,” Dr. Banks said.
Even physicians who provide more hands-on care to patients on these drugs are not well positioned to deal with the risks of eating disorders. Primary care doctors, who frequently prescribe the medications, are often short on time and must address a variety of health concerns.
Obesity doctors and eating disorder specialists who could help address these issues with patients rarely have opportunities to interact with each other, said Dr. Melanie Jay, director of the N.Y.U. Langone Comprehensive Program on Obesity. And obesity doctors have little guidance on how to address anorexia, or how to spot the signs of it in the first place.
“The biggest risk isn’t the medication,” said Ms. Longley, the head of the British eating disorder nonprofit. “It’s failing to recognize the eating disorder sitting in front of you.”
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