The rise of GLP-1A culture

As the use and availability of GLP-1 receptor agonists (GLP-1RAs) continue to rise, the eating disorder community must start having conversations about how to approach this shift. While medications like Ozempic and Wegovy are approved for treating conditions like diabetes, they are increasingly being used for weight loss. With over 120 similar drugs currently in development, it's crucial to better understand how GLP-1RAs—whether prescribed for diabetes or weight management—affect eating disorder treatment, especially for binge eating disorder. As the debate over weight loss intensifies, the growing focus on weight stigma can contribute to feelings of hopelessness and lowered self-confidence in individuals in larger bodies. This desire for an “easy fix” to weight concerns is also leading to medication shortages, which impacts people who are prescribed GLP-1RAs for other medical conditions. There needs to be greater concern in the medical field about the potential effects of these medications on individuals struggling with eating disorders.

What are GLP-1As?

GLP-1RAs are approved for diabetes management in the U.S., Canada, and other countries, and are available as both pills and injections. These medications regulate blood glucose by stimulating insulin release and suppressing glucagon production.¹ They also slow stomach emptying and affect brain pathways that control appetite, which can increase feelings of fullness and reduce food intake.

While GLP-1RAs are effective, they come with side effects. These can include nausea, vomiting, abdominal pain, diarrhea, and constipation, while rarer but more serious issues can also occur. There is limited research on their long-term effects.²

GLP-1RAs are celebrated for weight loss in adults, though this loss plateaus over time and the weight can be substantially regained after stopping the medication.^{3, 4, 5, 6}  Currently, GLP-1RAs are not approved for eating disorder treatment.

In terms of short-term weight loss, GLP-1RAs show effectiveness. For example, the STEP 2 study on semaglutide with lifestyle changes showed an average weight loss of 33.7 lbs over 68 weeks, compared to just 5.7 lbs without the medication.^{4, 6} However, weight loss typically slows after this period, and some participants even gained weight, diminishing the overall effect.  

Effectiveness of binge eating disorder treatment and GLP-1As

Caloric restriction can directly conflict with the goals of eating disorder treatment, and the current studies on GLP-1RAs are insufficient to draw meaningful conclusions. More targeted research is needed, specifically examining how GLP1-RAs affect eating disorder behaviors. This includes differentiating between pathological and non-pathological restriction, tracking client outcomes over extended periods, exploring the misuse of these medications in eating disorder populations, and understanding how binge eating would likely rebound significantly once the medication’s appetite-suppressing effects wear off.⁴

As the use of GLP-1RAs increases, it's crucial for eating disorder treatment programs to prepare for a growing number of clients who are already using these medications.

Approaching this issue with empathy is essential. Understanding why a client is taking GLP-1As, particularly if it's for weight loss, helps inform the risk assessment. The potential risks need to be weighed carefully to determine if they outweigh the benefits for the client’s treatment.

Evidence-based treatments for binge eating, such as therapy and non-weight-loss prescription medications, are already available and proven as effective treatment.

In a treatment setting that emphasizes regular meals and mindful eating, medications that reduce appetite can create significant challenges. Side effects may disrupt the ability to follow a structured meal plan, leading to discomfort and potential setbacks in treatment.

Moreover, GLP-1RAs can be misused as a way to manage negative body image related to weight and weight gain. This unhealthy usage can prevent clients from reconnecting with their natural hunger and fullness cues and hinder their ability to process emotions about body size and shape.  

Navigating the intersection of eating disorder treatment and weight loss medications

When navigating the use of GLP-1As in eating disorder treatment, it’s essential to recognize that if a client meets the criteria for this medication, the decision to continue or discontinue it during treatment ultimately is theirs. However, clinicians should ensure that clients are fully informed about the potential risks and benefits of using these medications in the context of their treatment. The provider then needs to assess the overall impact on eating disorder treatment and whether or not it is feasible or too risky to do.

For clients taking GLP-1RAs in relation to binge eating disorder, it’s crucial to explain that binge eating is often a physiological response to restriction. GLP-1As, which suppress appetite, can exacerbate restriction and ultimately contribute to cycles of binge eating.⁴ Since GLP-1RAs are not approved for binge eating and there is limited research on their efficacy for this condition, it’s important to highlight other evidence-based treatments which may be more appropriate. Be transparent that if the client discontinues the medication, they may experience an increase in binge episodes.  They need to know that weight loss in itself can negatively impact their relationship with food and ultimately their success in eating disorder treatment.

Even if a client is prescribed GLP-1RAs, they may remain eligible for binge eating disorder treatment. However, clinicians should be aware that these medications may interfere with the client’s ability to adhere to a structured eating plan, which is a key component in eating disorder recovery.

The conversation about GLP-1RAs should begin with respect for the client’s autonomy in making medical decisions. It’s important to understand why the client is taking the medication and whether it’s serving the intended purpose such as diabetes treatment. If the client is using GLP-1As for weight loss, acknowledge the broader societal context of weight stigma and the pervasive influence of diet culture, which may lead them to seek weight loss solutions. Validating their feelings and offering empathy can help create a productive dialogue.  

Although the conversation surrounding GLP-1RAs in the eating disorder field can be contentious, it’s important to lead with empathy and recognize all that goes into making the decision to take weight loss medications.  

Sources:

1. Food and Drug Administration (FDA). (2022) Ozempic (semaglutide) injection precribing information, revised. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/209637Orig1s009lbl.pdf

2. Bartel, S., McElroy, S. L., Levangie, D., & Keshen, A. (2024). Use of glucagon-like peptide-1 receptor agonists in eating disorder populations. International Journal of Eating Disorders, 57(2), 286–293. https://doi.org/10.1002/eat.24109

3. Rubino, D., Abrahamsson, N., Davies, M., Hesse, D., Greenway, F. L., Jensen, C., Lingvay, I., Mosenzon, O., Rosenstock, J., Rubio, M. A., Rudofsky, G., Tadayon, S., Wadden, T. A., Dicker, D., STEP 4 Investiga- tors, Friberg, M., Sjödin, A., Dicker, D., Segal, G., ... STEP 4 Investiga- tors. (2021). Effect of continued weekly subcutaneous semaglutide vs placebo on weight loss maintenance in adults with overweight or obe- sity: The STEP 4 randomized clinical trial. JAMA, 325(14), 1414–1425. https://doi.org/10.1001/jama.2021.3224

4. Wadden, T. A., Bailey, T. S., Billings, L. K., Davies, M., Frias, J. P., Koroleva, A., Lingvay, I., O'Neil, P. M., Rubino, D. M., Skovgaard, D., Wallenstein, S. O. R., Garvey, W. T., & STEP 3 Investigators. (2021). Effect of subcutaneous semaglutide vs placebo as an adjunct to intensive behavioral therapy on body weight in adults with overweight or obesity: The STEP 3 randomized clinical trial. JAMA, 325(14), 1403– 1413. https://doi.org/10.1001/jama.2021.1831

5. Wilding, J. P., Batterham, R. L., Davies, M., Van Gaal, L. F., Kandler, K., Konakli, K., Lingvay, I., McGowan, B. M., Oral, T. K., Rosenstock, J., Wadden, T. A., Wharton, S., Yokote, K., Kushner, R. F., & STEP 1 Study Group. (2022). Weight regain and cardiometabolic effects after with- drawal of semaglutide: The STEP 1 trial extension. Diabetes, Obesity and Metabolism, 24(8), 1553–1564. https://doi.org/10.1111/dom.14725

6. Davies, M., Færch, L., Jeppesen, O. K., Pakseresht, A., Pedersen, S. D., Perreault, L., ... Lingvay, I. (2021). Semaglutide 2 4 mg once a week in adults with overweight or obesity, and type 2 diabetes (STEP 2): A ran- domised, double-blind, double-dummy, placebo-controlled, phase 3 trial. The Lancet, 397(10278), 971–984. https://doi.org/10.1016/S0140-6736(21)00213-0

This content was first published via the National Alliance for Eating Disorders.

The beginning of a new year often stirs a range of emotions. While many embark on setting resolutions, it’s crucial to recognize that resolutions come in various forms. Losing weight by changing eating habits and increasing exercise is a common goal for the new year, but it doesn’t have to be yours. For individuals navigating eating disorders, seeing others focus on diet and exercise can be challenging.

Diet Culture and Resolutions

The onslaught of diet culture messages disguised as “resolutions” can induce feelings of inadequacy, especially for those struggling with their relationship to food and their body. Additionally, the winter season, with its shorter days and longer nights, poses difficulties for those grappling with seasonal depression, elevating the risk of isolation and potential setbacks in their journey.

Being more mindful about the content we are taking in each day and the harmful impact of diet culture is a more balanced way to look at change in the new year. You can do that by auditing your social media feeds to remove problematic accounts and start looking up content around new interests or hobbies for example. You can listen to podcasts or pick up a book on topics that bring light and energy to your life while silencing the diet culture’s voice.

What Other Kinds of Resolutions Can We Set?

Your New Year’s resolution doesn’t have to revolve around your weight or body. Embrace goals centered on practicing self-care, cultivating positive relationships, and pursuing personal growth. Shift the focus from external appearance to general fulfillment, promoting a more sustainable and positive approach to mental and emotional wellness.

Consider setting intentions like incorporating daily mindfulness practices, such as meditation or gratitude journaling, into your routine. Embrace physical activities that bring joy, whether it’s dancing, hiking, or trying a new sport. Prioritize mental health by committing to regular therapy sessions or dedicating time to activities that reduce stress. Schedule regular catchups with loved ones and friends. Make your new year about the addition of positivity, not the restriction of food.

This year, encourage yourself and those around you to view the new year with a different approach – one centered around intentions instead of rigid resolutions. By attaching fewer expectations, we pave the way for a year of increased self-compassion.

And if focusing on resolutions this year feels too difficult, that is also ok. January 1st is just a day like any other, and it doesn’t have to mark a life change if you don’t want it to.

If you or someone you love may be struggling with an eating disorder, help is out there. If you’re interested in learning more about our programs at Monte Nido, reach out today.

Two commonly confused terms, body dysmorphia and gender dysphoria, refer to distinct terms that involve dissatisfaction with one’s body. Although they may seem similar, they are pretty different, have different characteristics, and are addressed differently. Understanding these differences is key for recognizing and supporting individuals dealing with either.

What Is body dysmorphia?

Body Dysmorphic Disorder (BDD), or body dysmorphia, is a mental health condition where an individual becomes excessively preoccupied with perceived flaws in their physical appearance. These flaws are often minor or entirely imagined, yet they cause significant distress and impact daily life.

Key characteristics of body dysmorphia:

• Obsessive focus on appearance: Someone struggling with body dysphoria may fixate on specific features—such as skin, hair, nose, or body shape—that they perceive as not “normal”.
• Distorted perception: Often, someone struggling gets stuck in their thoughts. Family or friends may try to tell them nothing is wrong, but they continue to believe in their own perceptions.
• Compulsive behaviors: Body dysphoria can often lead to compulsive actions such as checking mirrors or begin to develop eating disorder behaviors to attempt to modify their body.
• Emotional distress: The preoccupation with appearance can lead to anxiety, depression, and isolation, severely impacting a person’s quality of life.

What is gender dysphoria?

Gender dysphoria, relates to the distress experienced when there is a conflict between an individual's assigned gender at birth and their true gender identity. While the term “dysphoria” simply refers to a state of dissatisfaction or unease, in this context, it’s tied specifically to gender identity.

Key characteristics of gender dysphoria:

• Incongruence with gender identity: Individuals with gender dysphoria feel that their body does not align with their true gender. This can result in discomfort with specific body parts (e.g., chest, genitals) or general unease with how others perceive their gender.
• Desire for transition: Many people with gender dysphoria experience a strong desire to transition to their true gender, whether through social changes (name, pronouns, clothing) or medical interventions (hormone therapy, surgeries).
• Emotional distress: The experience of body dysphoria can lead to significant emotional suffering, including anxiety, depression, and in severe cases, suicidal thoughts. This often stems from the difficulty of living in a body that feels incongruent with one’s gender identity and from societal stigma or lack of acceptance.

Although the terms sound similar, there is often confusion between gender dysphoria and body dysmorphia.

How dysphoria and dysmorphia relate to eating disorders

Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge-eating disorder, are often connected to body dysmorphia and, in some cases, gender dysphoria. Eating disorders are marked by an unhealthy relationship with food and body image, and they can arise when individuals attempt to cope with negative feelings about their bodies.

Body dysmorphia and eating disorders share a common thread: both involve an unhealthy fixation on appearance and body image. For individuals with body dysmorphia, concerns about weight or body shape may lead to disordered eating as a way to control or "fix" perceived flaws. For example, someone obsessed with their body size may engage in extreme dieting, purging, or over-exercising to achieve an unattainable body ideal.

While body dysmorphia disorder is classified as a mental health disorder by the APA and listed as such in the DSM–5 (the official listing of mental health disorders), and it can be comorbid with a variety of eating disorders, gender dysphoria is not listed as a disorder or a mental health illness.  

For transgender and gender non-conforming individuals, disordered eating may develop as a coping mechanism for dealing with body-related distress. In some cases, individuals with gender dysphoria may restrict their eating in an attempt to change the way their body looks or suppress features that feel misaligned with their gender identity. For instance, a transgender man may engage in extreme dieting to reduce the size of their chest or hips.

The incidence of eating disorders is much higher in transgender community than in the cisgender population.

In fact, 16% of college-aged transgender students surveyed in a 2015 survey had experienced or were experiencing an eating disorder. And at Monte Nido, we know from our data that 36% of all clients identify as LGBTQIA+.

Societal pressures to conform to beauty ideals, combined with the stress of living in a body that doesn’t align with one’s gender identity, can make those with gender dysphoria particularly vulnerable to developing disordered eating patterns.

Gender identity and self-image

It is still far too common for both laypeople and professionals, to conflate the body-image issues arising from a gender identity dissatisfaction with those resulting from a mental health disorder like body dysmorphia.

To put in simpler terms, a person with gender dysphoria is not mentally ill; they are dissatisfied with the gender assigned at their birth.

A person with body dysmorphia has a disorder in which they perceive their body or face as “ugly,” “fat,” or otherwise unattractive despite medical or personal reassurances.

Gender identity and self-image are inextricably linked; for a woman to look in the mirror and see a man is disorienting and distressing. Discrepancies between a person’s assigned gender and their true gender, in addition to the presence of discrimination and misunderstandings by the general public towards transgender issues, can lead to other mental health disorders, such as anxiety, depression and OCD, all of which are more prevalent in the transgender community than the non-trans community.

This all ties back to the main distinction about the difference between gender dysphoria and body dysmorphia – one involves a distorted perception of their body and the other doesn’t.

Health risks related to dysphoria and dysmorphia

Eating disorders are among the most dangerous mental health conditions, resulting in gastrointestinal, endocrine, cardiopulmonary, and neurological complications.  Without receiving anorexia treatment, there may be a mortality rate of as much as 4%.  Other eating disorders such as bulimia nervosa can result in dental problems and issues with the esophagus due to frequent vomiting. In all eating disorders, poor nutritional balance or even malnutrition are risks.

A transgender identity in and of itself carries no inherent health risks.  However, when a person decides to make the transition, they normally begin with hormone treatments, whether reassignment surgery is planned to happen or not. By introducing estrogen or testosterone, there is a slightly increased risk of cancer, and more common risks of low or high blood pressure, blood clots, dehydration, electrolyte imbalance, and liver damage. An important thing to note is that due to discrimination and societal pressure, transgender people are less likely to go through “above the board” healthcare providers, meaning the hormone treatments they receive may not be properly balanced for their body, exacerbating some of the issues raised above.

Both transgender people and people with body dysmorphia have higher than average rates of mental health and behavioral health disorders.  Prominent among these are depression and anxiety.  Both of these mental health disorders are normally caused by a combination of genetic and environmental factors, just like gender dysphoria and body dysmorphia.  In many cases, a specific trigger such as a traumatic event (i.e. abuse, a bad breakup, being in a car accident, etc.) sets off a previously hidden disorder.

In fact, our research at Monte Nido research suggests that 63% of LGBTQIA+ adults in our residential treatment programs met criteria for PTSD, compared to 45% cisgender heterosexual individuals.

The one common health risk of dysphoria and dysmorphia

Depression and anxiety are contributing factors in the one health risk that’s common to both gender dysphoria and body dysmorphia: suicide.  Rates of suicidal ideation (that is, thoughts of suicide), attempted suicide, and actual suicide are all much higher in transgender populations and in populations experiencing body dysmorphia than in the larger populace.

Body dysmorphia

• 80% of individuals have suicidal thoughts
• 24-26% have attempted suicide
• Complete suicides percentage is unknown, but thought to be very high

Transgender population

• More than 50% of transgender males have attempted suicide
• 30% of transgender females have attempted suicide
• More than 40% of non-binary adults have attempted suicide

The combination of a negative or distorted self-image and a severe mental health disorder like depression, or the combination of a mental health disorder and the societal pressures and discrimination received by transgender people, put an already at-risk group of communities even further at risk.  With the already high risk of medical complications resulting in fatalities that are associated with anorexia nervosa and other eating disorders, this creates the need for specialized, intersectional strategies for anorexia treatment in the transgender population.

A personally designed treatment plan including psychiatric treatment (if necessary) with body positivity training and behavioral therapy like Dialectical Behavior Therapy (DBT) or Cognitive Behavioral Therapy (CBT) can help people rehabilitate their body image and break out of the repeated patterns of behavior that come with both eating disorders and body dysmorphia.

While the journey to eating disorder recovery is rarely an easy one, it can be made even more difficult when added to the societal pressure and stigma associated with a transgender identity. The professional team of doctors, nurses, therapists, and psychiatrists treating a transgender individual must take into account factors beyond those which normally accompany a diagnosis of anorexia nervosa or another eating disorder. These include:

Hormone treatments

For some extreme cases of anorexia nervosa, hormone therapy is used to counteract osteoporosis and other symptoms coming from a nutritional deficiency. For transgender individuals who have begun hormone treatments to hasten their transition, medical professionals must coordinate these two types of hormone treatments to meet the client’s needs.

Body dysmorphia treatment without judgment

At the center of any effective treatment program for a trans person with an eating disorder has to be a strong understanding that gender dysphoria is not a mental health disorder.  Trans people are already at higher risk for developing body dysmorphia disorder and subsequently an eating disorder, and they face enough discrimination that they are less likely to seek medical care or psychiatric care. They need a care provider which can treat the actual disorders with sensitivity to gender dysphoria.

Gender-specific eating disorder treatment

Quite often, people seeking eating disorder treatment are more comfortable among their own gender (the distorted perceptions of “attractiveness” or past triggers of abuse are common reasons behind this), and this remains true in the trans population. The person’s true gender must be accounted for and their wishes respected during treatment.  For example, a non-binary trans person may be uncomfortable in a female-only treatment program.  For this reason, an anorexia treatment center should be flexible enough to accommodate each client’s needs in regards to gender identity.

Achieving a Full Recovery Regardless of Gender

At Monte Nido, we believe that every person deserves to find hope that their eating disorder can be treated, and full recovery can be achieved. The compassionate, empathetic staff at each of our many locations are experienced in helping people of all genders regain their lives and move on to a brighter future, free of disordered body image. If you or a loved one has received a diagnosis of an eating disorder, or simply feel you need help, contact us today to get started on the gender-affirming path to a recovered life.