GLP-1 medications, such as semaglutide and tirzepatide, have revolutionized the treatment of Type 2 diabetes and obesity. By reducing appetite, slowing gastric emptying, and promoting significant weight loss, they have generated considerable interest in both the medical field and public opinion.
However, their wider use in the population has raised an important question: What happens when these drugs are prescribed to people with eating disorders or who are at risk of developing them?
A recent consensus article published in World Psychiatry has addressed this question. Using the Delphi method, 45 experts and people with personal experience of eating disorders have elaborated several recommendations for clinical practice and future research.
The principal message of the consensus is that GLP-1 medications can offer several benefits, but they carry potential risks for people with eating disorders. Their use, therefore, requires careful attention, personalized decisions, and continuous monitoring.
Potential Benefits of GLP-1s for Binge Eating Disorder
There is growing interest in the possible use of GLP-1 medications in the treatment of binge-eating disorder (BED). Some studies have found a reduction in binge-eating episodes; however, the evidence remains limited because most studies are small, uncontrolled, retrospective, or based on single clinical cases.
Moreover, the study with the strongest methodological design found no significant reduction in binge-eating episodes with liraglutide compared with placebo, although the medication produced greater weight loss.
Potential Risks: Extreme Dietary Restriction and ED Relapse
Published clinical cases have reported relapse into extreme dietary restriction in people with a history of anorexia nervosa while taking GLP-1 medications. In my clinical practice, I have also met some patients who have developed atypical anorexia nervosa during GLP-1 treatment. The gastrointestinal side effects (e.g., nausea and vomiting) can further complicate the clinical picture, particularly in people who are vulnerable to purging behaviors.
For this reason, the expert group has recommended screening to detect any current or previous eating disorders in all people before starting treatment with GLP-1 medications. This recommendation has reached a 94.7 percent consensus.
When GLP-1 Medications Should Be Avoided, or Used Cautiously
One of the recommendations that reached the highest consensus—100 percent—was to avoid the prescription of GLP-1 medications in people with current diagnoses of atypical anorexia nervosa or bulimia nervosa associated with a strict dietary restraint and restriction and/or significant weight suppression. The experts also recommended caution in people with a history of these eating disorders. These indications are not absolute contraindications, but they underline that prescribing decisions should not be based exclusively on body weight.
The situation is more complex in people with BED. Although GLP-1 medication, as described above, might be useful for some people with BED, in others they might worsen the eating disorder psychopathology, particularly in the presence of the over-evaluation of shape and weight, significant weight suppression, and marked dietary restriction. These features can negatively affect treatment outcomes and should be assessed before and during medication intake.
Therefore, the expert group has recommended that future studies should assess not only the weight loss and the frequency of binge-eating episodes, but also the dietary restriction, the over-evaluation of shape and weight, and other psychological features of eating disorders.
Reducing “Food Noise” Is Not the Same as Curing an Eating Disorder
The term food noise describes the persistent presence of food and eating thoughts that people often experience as unwanted. GLP-1 medications seem to reduce these thoughts, offering relief to some people.
However, less worrying about food and eating does not necessarily indicate an improvement in eating disorder psychopathology. A person can experience reduced food noise and still adopt extreme, rigid dietary rules, maintaining an intense fear of weight gain or an over-evaluation of shape and weight.
Monitoring During GLP-1 Treatment
The expert group recommended continuous monitoring to detect any appearance or worsening of eating disorder symptoms in people treated with GLP-1 medications. The assessment should include the psychopathology of eating disorders, the weight trend, the food intake, the hunger and satiety levels, the physical condition stability, and the quality of life,
Eating Disorders Essential Reads
Monitoring intensity should be proportional to individual risk. Frequent monitoring should be planned for people with an eating disorder history, positive screening of eating disorders, rapid weight loss, or a marked suppression of appetite.
One of the most difficult clinical challenges is to distinguish the expected effects of the GLP-1 medication from the developing symptoms of eating disorders. Reduced appetite, smaller meals, and weight loss are expected treatment effects. On the contrary, the onset of rigid and extreme dietary rules, the intense fear of weight gain, or a progressive increase in the over-evaluation of shape and weight can indicate the development or the worsening of the eating disorder psychopathology.
Finally, the expert group recommended associating an evidence-based psychological treatment in people with eating disorders who use GLP-1 medications. This recommendation received an 81.6 percent consensus.
An important issue to be investigated is to evaluate the possibility that GLP-1 medications improve outcomes when they are associated with psychological treatments for BED. However, the available evidence does not support the routine use of these medications in BED treatment.
What Research Should Be Prioritized Next?
The consensus paper has identified several important gaps in the available knowledge.
First, it is necessary to conduct long-term studies to establish whether GLP-1 medications increase, reduce, or do not change the risk of developing an eating disorder.
Second, researchers need reliable methods to distinguish medication-induced appetite changes from pathological dietary restriction.
Third, clinical studies on BED should be designed to evaluate not only binge-eating frequency and weight loss, but also eating disorder psychopathology, dietary restriction severity, food noise, quality of life, nutritional security, and outcomes of suspending pharmacological treatment.
Finally, with the increasing popularity of GLP-1 medications, collaboration between specialists in the treatment of obesity and eating disorders will become increasingly important.
