In 2021, Dr. Wendy Oliver-Pyatt co-founded Within Health, a company with headquarters in Miami that provides telehealth for patients with eating disorders. Oliver-Pyatt has spent several years as a psychiatrist addressing eating disorders, which many providers recognize as one of the most complex and difficult to treat psychiatric problems.
In the last year, a new variable was added to this complexity. About 5% of the 100 patients Within Health serves at any given time now have a history of taking Ozempic or a similar drug that produces weight loss.
According to Oliver-Pyatt, Within Health’s therapists, psychiatrists, health and nutrition specialists are still evaluating how best to address a patient population given a drug that controls their appetite. The clinician is not sure how concerned she should be.
“I try not to jump to conclusions when there is so little research,” Oliver-Pyatt told Behavioral Health Business.
In fact, no evidence has been gathered to suggest drugs like Ozempic either cause eating disorders or make it harder to treat an existing condition like anorexia, bulimia or binge-eating.
Nonetheless, some providers fear what lies ahead.
“For people with eating disorders, these medications can intensify and exacerbate their already distorted relationship with food, leading to more severe disordered eating behaviors,” Dr. Angela Celio Doyle, vice president of behavioral health care at Equip Health, told BHB. Equip is an eating disorder treatment provider headquartered in Carlsbad, California.
Rise of GLP-1s
GLP-1s refer to glucagon-like peptide, a drug that imitates hormones that secrete insulin to the bloodstream, helping diabetic patients. In the past decade, the number of scientific studies grew arguing that GLP-1s can also inhibit food intake and address what the U.S. Food and Drug Administration has deemed “weight-related conditions,” including high-blood pressure and cholesterol.
“Basically, GLP-1s mimic the body’s response to being full,” Dr. Thomas Britton, the CEO of Accanto Health, an eating disorder treatment provider based in St. Paul, Minnesota, told BHB.
Such a drug can be quite helpful as well as lucrative, Britton added, when the CDC reports that over 2 in 5 U.S. adults are obese, an estimate based on a person’s body mass index.
In 2021, the FDA approved a drug manufactured by the Danish company Novo Nordisk called Wegovy for “chronic weight management.”
Last year, the federal agency approved another GLP-1, Zephound, for weight management. By then, the GLP-1 industry was off to the races. Physicians began regularly prescribing GLP-1s for weight loss, even drugs like Ozempic not expressly approved for treating obesity, Britton said.
In the past year, Novo Nordisk, which also makes Ozempic, has consistently posted the highest market valuation of any European Union publicly-traded company. Celebrities including Kourtney Kardashian market their own versions of GLP-1s for weight loss, and companies like Hims let patients purchase the product after filling out an online questionnaire.
According to a Kaiser Family Foundation survey published in May, 1 in 8 U.S. adults have used a GLP-1. About 40% reported taking the drug for weight loss.
Controlled eating
About 9% of the U.S. population will pick up an eating disorder at some point in their life, according to a Harvard School of Public Health study from 2020.
“The genesis of eating disorders is a confluence of different factors,” Britton said. “It can include trauma histories, psychiatric problems, social problems and loss of internal control.”
The control factor, the one most stereotypically associated with people who have eating disorders, is a source of worry.
Britton and Oliver-Pyatt hypothesized that time-crunched physicians who lack expertise in eating disorders may prescribe a GLP-1, not because of a specific medical condition, but instead a patient’s general desire to lose weight.
In the hands of such patients, GLP-1s could “normalize the use of eating disorder behaviors,” according to Equip Health’s Doyle of Equip Health.
“Eating disorder symptoms include lack of hunger cues,” Doyle pointed out, while GLP-1s “slow down movement through the digestive tract, leading to more severe disordered eating behaviors.”
In December, the National Library of Medicine published a study on GLP-1s effect on eating disorders. It was focused on strategies to better study the subject.
“More research is required before negative or positive conclusions can be drawn about the impact of GLP-1s on eating disorders,” the study concluded.
According to the study’s lead author, Sara Bartel, one complication in understanding the relationship between GLP-1s and eating disorders is knowing when to distinguish between “pathological and non-pathological dietary restrictions.”
A clinical psychologist at the Maritime Eating and Appearance Lab in New Brunswick, Canada, Bartel emailed BHB that there is “very limited evidence” that GLP-1s serve as a pathway for pathological dietary restriction.
At the same time, Bartel has seen other medications affect weight or a change in eating style. She wonders if patients medicated with a GLP-1 might be particularly susceptible to a dangerous loss of appetite, or excessive control of their eating.
“This is why additional research is so critically needed,” she stated. “We can theoretically imagine the potential negative impact of GLP-1s.”
What drugs to prescribe
As Ozempic and its equivalents are hailed as weight loss breakthroughs, the landscape of what drugs to give patients with an eating disorder is less clear cut.
For certain circumstances, Oliver-Pyatt said that Within Health prescribes Vyvanse to patients with binge-eating disorder to induce dopamine. Also, under some conditions, the provider gives antidepressants to patients with bulimia, who may benefit from enhanced levels of serotonin.
But there is not a go-to drug for a condition that can co-occur with obsessive-compulsive, anxiety, or depressive disorder, among other diagnoses.
Eating disorders tend to be a “layered problem,” Britton said.
One wrinkle is GLP-1s’ potential to not be a looming problem but a specific solution. A March study in the Journal of Clinical and Translational Endocrinology concluded that some GLP-1s have been shown to reduce binge-eating frequency.
In pilot studies, the class of drugs modulated a patient’s feelings of hunger and satiety as well as emotional responses to food. The study also said that large-scale clinical trials are needed with placebo controls.
For now, providers are skeptical that a GLP-1 is right for any eating disorder patient. Oliver-Pyatt said that she has seen patients go days without food, or consuming only carrot and celery sticks, before a binge eating spell.
“The reality is that it is a very restrictive condition,” Oliver-Pyatt said.
The psychiatrist said that GLP-1s have positive effects on some people with unhealthy eating habits, citing patients she has treated reporting improved mobility and an overall quality life. Regardless, these weight loss drugs are not going away anytime soon.
“The data is about 6-12 months away,” Britton said. “It will be an interesting next six months.”
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