When Ozempic became popular, there was an outcry in the eating disorders world. In 2017, semaglutide medications, which are GLP-1 (glucagon-like peptide-1) receptor agonist medications, were approved for the treatment of diabetes. They decrease blood sugars by increasing insulin secretion. They also reduce hunger signals and delay gastric emptying. Pharma excitedly started marketing them as the latest weight loss solution for people desperate to feel better about themselves.
Fast forward to today, several similar drugs (Wegovy, Mounjaro, Triple G) are available for weight loss at a competitive price. Companies like Weight Watchers are marketing them, and many doctors are encouraging patients to take them for weight loss, regardless of whether they have healthy cardiometabolic profiles. Besides the high cost of the medication, should we be concerned about it?
Firstly, it’s a relatively new drug. We don’t know the long-term consequences, and it’s being prescribed to children in the US. In about one-third of people, it has some very unpleasant side effects, such as nausea, constipation, burping, and dizziness, at least initially. Also, it’s likely a lifetime medication. With an initial blood glucose spike, food cravings and increased appetite, most people gain two-thirds of their weight back when they go off. But even if we put those issues aside, the impact on eating disorders, weight stigma and potentially health is profound.
As of now, doctors seldom inquire about disordered eating symptoms before prescribing GLP-1s. If someone wants to lose weight, whether for their wedding or because they’ve struggled all their lives, most doctors are quick to offer the solution. Unconditionally and without psychological screening,the prescription pad is out. There is little concern about the impact of reinforcing the desire to be thin. There is no discussion of how they’ll lose intuitive eating: listening to hunger and fullness cues is distorted, if existent at all, on these medications. If bingeing or emotional eating is not treated, a decreased appetite is unlikely to dissuade people from eating when distressed. The failure to lose weight, even on medication, leaves people feeling even worse about themselves. It doesn’t help that so many medicated relatives and friends often flaunt their lack of appetite and inability to eat at meals with their dining partners.
With the competitive nature of eating disorders, eating with loved ones has become even more challenging as portion sizes and frequency of eating have new norms. It is even more difficult when family members recommend the medications to their children. Prolific GLP-1 use is increasing weight stigma. If there is such a so-called easy solution, why would someone possibly be at a higher weight than societal expectations of thinness?
Larger-bodied people are now blamed even more for being at a higher weight. The social devaluation and denigration of people perceived as carrying excess weight is accentuated when there is an apparent solution that they’re not choosing. As the weight bias and prejudice that exists in the medical field worsen, barriers for people to access healthcare increase, too.
When you anticipate that your doctor is going to shame you for refusing medication, why go? One of the GLP-1s mechanisms for weight loss is reducing the reward or dopamine pathways in the brain. These drugs can help with addiction and other reward-driven behaviours.
According to some reports, the decreased pleasure and loss of interest are not limited to food alone. For many taking these medications, mood is also “meh”, as is libido and all-around enjoyment of life. Yay!
So you got your dream body and can’t enjoy physical pleasure? That’s quite the cost! Very few doctors are fully explaining the potential adverse side effects of these drugs. Certainly, the online dispensaries don’t care, especially when you’re one click away from payment. Once again, thinness outweighs risks of how you get there: weight loss by any means can be justified. More than half of those considered overweight by body mass index have normal blood pressure, cholesterol and blood sugar. Nevertheless, their bodies are viewed as needing management by society and doctors. Weight loss recommendations without abnormal blood work or other health concerns are not justifiable. It is simply prejudice.
Thinness is accepted as the unquestionable norm regardless of genetics, lifestyle or body type. The GLP-1 medications do result in weight loss for most, but at what cost? There is very little consideration of what is being lost in the body itself. You’ve probably heard of the “Ozempic face, butt and boobs.” This phenomenon describes the sagging skin, hollow cheeks, looser skin texture from rapid weight loss and muscle mass in particular.
These effects are what we can see on the surface, but the less visible consequences are being ignored by most. When we lose weight, we lose more than just fat. Of every kilogram or pound of body weight lost, approximately 70% is fat mass, but about 30% is skeletal muscle loss, and 0.5-1% is bone loss. The quicker the weight loss, the more muscle and bone mass is lost. At a recent conference, the endocrinologist who was describing the benefits of the GLP-1 medications was asked whether she’d prescribe them to a 75-year-old. She scoffed and answered emphatically that she’d recommend it for an 85 or 95-year-old. I have come to appreciate the benefits of GLP-1s for more than just weight loss and diabetes. They’re protective on major organs: heart, kidneys and liver. They help with addiction and inflammation. While I initially shunned them as an eating disorders professional, they can potentially save lives in some people. However, the infatuation with these “magic pills” along with the billion-dollar industry invested in selling them is resulting in a cavalier attitude to their prescription without the appropriate guardrails.
Let’s take 80-year-old Sheila, who starts on Ozempic. Her blood work improves, and she’s losing weight. Her doctor is thrilled, as is she! She doesn’t have an appetite. That’s the goal… isn’t it? Sheila doesn’t feel any desire to eat, let alone protein-rich foods. She doesn’t have the energy to exercise, and weight training has never been her thing. She is losing weight, which includes muscle and bone. She also isn’t getting fuel to her brain, so when she loses her balance and falls, it’s not surprising that she breaks her hip. She ends up in the hospital and is vulnerable to contracting an opportunistic disease, especially in her malnourished state. Her mortality has just increased significantly, so was the weight-loss medication really necessary? These medications are here to stay, with some predicting that most of America will be on some dose in the future.
Instead of addressing the systemic issues such as poverty, equal access to healthy food and activity, and medication is offering a solution. GLP-1 medications are indeed a breakthrough for those needing diabetes care and with cardiometabolic risk factors. They are protective of our organs and, while concerned about negative consequences, I’m not so quick to throw the baby out with the bathwater. However, the unconditional prescription of these medications without stringent screening and education about the emotional and lifestyle factors that should accompany them, I fear the emergence of another health crisis.