Ozempic, Eating Disorders, and Diabetes: GLP-1 Weight Loss Drugs Explained

Transcript

Ellie Pike: 
Welcome to Mental Note Podcast. Today we're exploring the complex world of GLP-1 weight loss drugs such as Ozempic and Wegovy. These drugs have gained popularity for their weight loss potential, but what do they actually do? How do they function and why are they the subject of so much controversy? We'll also delve into societal pressures to be thin and the significant risks these drugs may pose for individuals who are at risk of developing eating disorders.

Most importantly, for those who have both an eating disorder and diabetes, we'll provide you with the information you need to ask your doctor the right questions about GLP-1s. We're honored to have Dr. Elizabeth Wassenaar, Regional Medical Director for the Eating Recovery Center and Pathlight Mood and Anxiety Center here with us to provide her expert perspective. You are listening to Mental Note Podcast. I'm Ellie Pike.

Dr. Elizabeth Wassenaar: 
I am Dr. Elizabeth Wassenaar. I am a child and adolescent psychiatrist, and also trained in pediatrics, the Regional Medical Director of Eating Recovery Center and Pathlight Behavioral Health. And I oversee our facilities in Colorado, Washington State, and California.

Ellie Pike: 
I'm really looking forward to our conversation today, and I'm going to just go ahead and jump in and ask what are GLP-1 RAs and what do they do and how do they work?

Dr. Elizabeth Wassenaar: 
GLP-1 RAs or GLP-1 glucagon-like peptide-1 receptor agonists like semaglutide, commonly known by its brand name Ozempic, are a class of medications that mimic the action of the hormone GLP-1 in the body, which is released after we eat. So this is a hormone that we all have and everybody's body releases it. But what we have found is that the GLP-1 receptor agonists work in ways to help people support their blood sugar levels. And when that happens, it impacts the way people experience appetite drive. So the sense of feeling hungry or full. It also regulates their blood sugar, which is why these medications have a primary indication for type 2 diabetes.

However, a side effect of these medications is weight loss. And so because we live in the society that we do, once it was recognized that this side effect was a desirable side effect, manufacturers of these medications pursued an FDA indication to be able to prescribe these for weight loss, which is now I think the most common reason these medications are prescribed, which is for weight loss for people who are living in a larger body and may or may not be diagnosed with metabolic diseases related to living in a larger body.

Ellie Pike: 
What makes these GLP-1-RAs controversial in the first place?

Dr. Elizabeth Wassenaar: 
I think that the controversy from these medications really stems from the fact that they initially were created and prescribed for the treatment of type 2 diabetes, and that is a noble and worthwhile thing to have a medication that works well for type 2 diabetes. However, they have this desirable side effect of weight loss. And so they initially were prescribed off-label, which means that they didn't have an FDA indication for weight loss for people who were seeking weight loss cosmetic or otherwise without the diagnosis of type 2 diabetes. And it really drove the frenzy for these medications, and I think that is an accurate word to describe.

You cannot turn around without seeing something about one of these medications or hearing it mentioned in the media or the press. The medications were prescribed off-label for weight loss, and then the manufacturers decided to go ahead and seek FDA indication for the primary diagnosis of weight loss, which means that they're prescribed on-label for weight loss. And the reason why that's important is that when it comes down to having insurance coverage or billing coverage for the medications, it also indicates that these manufacturers have done studies to show that these medications can impact weight as a primary target or a primary goal.

It's not just a side effect. So we live in a very weight-centric, diet culture society, and many people believe that by impacting the size of their body, they'll be able to impact their health and their happiness. The real frenzy for these medications, the intensity to get these medications prescribed, escalated to the point where they are in short supply almost everywhere. People who need them for the treatment of type 2 diabetes can't get them. They're very, very expensive. And what we're also seeing is a tremendous increase in access to these medications in other alternative ways, so through health spas and infusion centers.

And then I have also begun to hear about patients who are accessing these medications in their sort of raw form and in compounding themselves at home and injecting them themselves. So dosing themselves, putting medications together into something and then putting it into their body with the goal of weight loss.

Ellie Pike: 
So since these drugs weren't initially made for weight loss, are there any dangers in taking them if you don't have diabetes?

Dr. Elizabeth Wassenaar: 
So that is the reason that these manufacturers pursued the primary indication of the diagnosis of weight loss is to show that it wasn't dangerous as defined by the Federal Drug Administration to be able to prescribe these medications for weight loss. We have to recognize that all medications, prescription or over-the-counter have inherent risks. Anything we put in our body that alters the way our body works has an inherent risk. So nothing is 100% safe. There's always a risk with everything. And for these medications, I do think that it's very important to have a really comprehensive informed consent discussion with your physician or prescriber.

And the thing that I think no one is really talking about is how these medications can impact and influence the ongoing idea that thinner is better. So reinforcing the ideas that diet culture teaches us about what our body should look like and what health is as opposed to what it might be like to be in your body and actually pursue health goals that matter to you.

Ellie Pike: 
So they perpetuate the common thoughts of thinner is better and perpetuating weight stigma in the midst of that, which is really a huge side effect of all of this, especially when it's being marketed as the "magic pill" for "health", also quote-unquote, and even marketed by celebrities like Oprah. And so I'm wondering what are some of the ways that this message is harmful to consumers? That thinner is better.

Dr. Elizabeth Wassenaar: 
Anytime we have a thing that reinforces and perpetuates diet culture and the idea that the only way to be healthy is to be thinner, that all larger bodies are unhealthy and that we have to go to any means to be able to have thinner bodies, that we are perpetuating harm. And I believe that very few people that take these medications are actually having a discussion with their prescriber or physician about the harms of diet culture and how it has impacted them, which is very sad. These medications are being marketed as this sort of magic intervention that cause weight loss without any side effects.

It makes it easy. Actually, you do an injection or an infusion twice a week to deliver these medications and then you can live your life and your weight just falls off of you and you can be happy and healthy and all of the lies that diet culture tells us about how our weight interfaces with our health.

Ellie Pike: 
Can you speak to what the side effects of taking GLP-1 RAs are?

Dr. Elizabeth Wassenaar: 
So GLP-1, RAs are not without side effects. They absolutely have side effects. So as I mentioned, these medications have to be injected, and so you have to be okay with injecting yourself with a small needle at least twice a week as prescribed by your physician or prescriber. And then the medications work by impacting the central nervous system's experience of hunger and fullness. So what people notice is that they feel full sooner. We have been able to notice that people will have a slowing of their GI tract or gastroparesis, especially when they're eating less.

So patients will have gastroparesis as caused by just taking these medications and then when they eat less because they feel fuller, they have more gastroparesis. Gastroparesis is difficult because it makes eating painful. It can make it so that when you eat, you feel uncomfortably full or food will transition through your GI tract really slowly and you can have experiences of constipation, reflux, unpleasant burping is actually a well-described side effect of these medications. It can actually progress to nausea and involuntary vomiting.

I have heard of patients who every time they eat, they throw up and they can't stop themselves and they don't want to. The very difficult thing that we are noticing is that some patients are describing this gastroparesis will persist even if they stop the medications. So that is a very serious side effect I'm really concerned about. Then there are a variety of other side effects that are concerning. These medications are contraindicated in people who have certain kinds of endocrine cancers and may impact the pancreas in ways that we don't fully understand yet. These medications may have influence on your mental health and wellness and have been described to impact experiences of anxiety, depression, and even suicidality.

Ellie Pike: 
Wow, that's a lot and a lot of side effects that I would want to know if I was considering any kind of medication. So I think that when you talk about informed consent being part of the conversation between a patient and a doctor, to me those are the pieces of conversation that are really beneficial. Are there any other amazing resources that would be beneficial for folks if they want to research for themselves and be able to really consent with the information that they need in order to say yes or no, they would like to take this medication?

Dr. Elizabeth Wassenaar: 
The manufacturer is required to have in every single prescription a drug information handout and that lists all of the side effects that have been described or noticed by the manufacturer, the studies and the FDA. So if you are prescribed this medication, you'll have a fold-out sheet in your prescription that will have a very extensive list of those side effects. Those are also available online and I think that that's a really good place to start. It is actually part of the responsibility of a physician and prescriber to review with their patient the side effects as listed on that medication information sheet.

Those side effects are also going to be listed on any kind of reputable drug resource. So Lexicomp or drugs.com or something like that are going to take that information verbatim and have it on their website as well. So there are good resources. I think that the impact on your experience of diet culture and perpetuating the idea that if you are thinner, you will be happier. That's not something that is listed though because that is not necessarily something that we are capturing as a side effect of this medication or any medication.

So being able to understand how this medication might influence your experience of your body is something that there just isn't really a good resource for. Those of us in the eating disorder field I think are trying to talk about it as often as we can and get this message out so that people can find this information if they go online and they look up impacts of GLP-1 RAs on body image, etc. But I would say it's a message that needs to be brought to the forefront more intentionally.

Ellie Pike: 
And would you say that there's the risk of if you take a GLP-1 RA of really inducing or triggering eating disorder behaviors for someone who may not have had an eating disorder before?

Dr. Elizabeth Wassenaar: 
That is such an important question that we don't know the answer to. I have heard anecdotally that some people are noticing that. We know that eating disorders are very often triggered by stress and malnutrition in a brain that has a vulnerability to develop disordered eating. So who has a brain that's vulnerable? People, we know there's genetic history of eating disorders, and so if you have a family history of eating disorders or disordered eating, that can be a trigger. We know that if you have a history of trauma, that can be a marker. That you may have a brain that's vulnerable to develop an eating disorder.

And then if you are in a stressful time of your life, which I think if you look around, who's not in a stressful time of their life? This is sort of the world we live in, there are so many stressors and you are malnourished. And so GLP-1 receptor agonists induce people to eat less and by their nature cause a degree of malnutrition. That is how people lose weight. They become malnourished. So we know that if you overlay malnutrition stress and vulnerability, you have the perfect recipe for the development of an eating disorder. I think it's something that we should be concerned about.

I am especially concerned when these medications are being prescribed to brains that are still in adolescent development because I think we just don't have enough data on what this type of malnutrition can do to the adolescent developing brain.

Ellie Pike: 
So I think it's really important that we just discussed what may contribute to developing an eating disorder, but it's definitely on my mind to consider what about the folks with an eating disorder already? Are there any circumstances where someone with an eating disorder should or could take a GLP-1 RA and it could benefit them? So for example, if someone has an eating disorder and they actually do have type 2 diabetes, would that be a case where it could benefit them and what should they watch out for or is that not a good decision?

Dr. Elizabeth Wassenaar: 
That's such an important question. So I think there's two groups of people that I want to consider for GLP-1 receptor agonists and possible benefit. Patients who have a diagnosis of type 2 diabetes and an eating disorder I think should be carefully considered with their endocrinologist and physician and the eating disorder specialists around if a GLP receptor agonist is the right intervention for them. So there are some people for which GLP-1 receptor agonists are worthwhile to consider in careful conversation with your physician or prescriber and eating disorder team.

So patients who have type 2 diabetes and an eating disorder may have a reason to consider a GLP-1 receptor agonist. However, I have seen people who were prescribed GLP-1 receptor agonists with a diagnosis of type 2 diabetes who had potentially resolution of their type 2 diabetes, but relapse of their eating disorder so severely that they had to come back to high levels of care for treatment. So I think it's something that I want to advise a lot of caution around.

When I'm thinking about using GLP-1 receptor agonists in a patient with a type 2 diabetes diagnosis, one of the things I want to make sure is that there is really strong involvement with a registered dietician that understands eating disorders and can help and monitor regular eating patterns and help someone notice if they are verging into disordered eating or excessive restriction. There is also literature that suggests that the GLP-1 pathway may be important in how we understand compulsive eating or overeating. And I have heard quite a bit of antidote from patients who report that they have a history of non-stop food chatter in their brain and when they take GLP-1 receptor agonists, that quiets down.

I am concerned that if we use these medications without understanding what's driving that food chatter or putting in any other resources to treat disordered eating, that it's kind of like putting a Band-Aid over a wound that's not actually healing. So I think these medications potentially provide us with an important window into understanding this disordered eating pattern of compulsive eating or overeating. And just like you can't just do one intervention for an eating disorder and then be cured, I think the same is true for compulsive eating.

That GLP-1 receptor agonists can't be used in isolation and should always be used in caution for somebody who has the diagnosis of an eating disorder.

Ellie Pike: 
So when you talk about how anyone with an eating disorder who's prescribed an GLP-1 RA should be used with caution. I think it comes with a variety of reasons. And so I'd love to equip our listeners with some tools to know what to pay attention to. So if they have an eating disorder and are taking one of these medications, what are some indications that the medication might be hurting or helping their recovery?

Dr. Elizabeth Wassenaar: 
What I would recommend is first and foremost, if you have a history of an eating disorder or maybe you have a history of disordered eating and you were never diagnosed with an eating disorder, but you suspect you would've been if you would've told somebody all the things that you were doing. You have to be honest with your prescriber or physician. This is so very important to let the person who's prescribing these medications know. Now, as we've referenced, not all physicians and prescribers know what to do with that information, but it is important that they know as they prescribe these medications that you have this history of an eating disorder.

And then if you are going to start these medications and you feel like this is really the best next step for you, you've made a good decision with your prescriber or physician, I really encourage you to make sure that all the members of your team also know. So I hope that you have an eating disorder-informed therapist and an eating disorder informed dietitian and maybe an eating disorder-informed psychiatrist or adolescent medicine doctor. And if you don't, I encourage you to get those members of your team in place. If you have those members of your team, make sure they know you're starting these medications.

And then as you start these medications, I want you to be very aware that this is going to be a time when it's important for you to be very, very vigilant and very, very intentional about meeting your treatment goals. So your treatment goals remain the same as when you were in treatment. You need to nourish your body routinely and you need to take care of your mental health. So you need to make sure that you are in a situation where you're getting adequate nutrition and that you're eating regularly, that you're getting enough water and that you are taking care to notice if your anxiety is creeping up, if your eating disorder thoughts are creeping up, if your body image concerns are creeping up, if your comparisons are creeping up.

And notice not just the negative thoughts, but also notice if you are flooded with some of those old positive lies that the eating disorder told you that, "Oh my gosh, look at what your body looks like now. I wonder how much weight you've lost today." Maybe you're stepping on the scale a little bit more often because it's important to monitor your weight if you're starting these medications, but notice what knowing those numbers does to you and how it starts to wind itself into your brain. So it's a time to be very, very, very vigilant and make sure that your team knows that you are undertaking this journey.

Ellie Pike: 
I think all of those indicators are super helpful. So it's a lot of self-monitoring and hopefully also being aware of what has helped or hurt you in the past. How did an eating disorder start and paying attention if any of those current symptoms are happening? It could mean going into a relapse or lapse. And something that caused me concern when you were describing the side effects of GLP-1-RAs earlier was when you talk about feeling full sooner and having some symptoms of gastroparesis, which if I'm correct, it's the slowing of the GI system and the intestinal tract. Is that accurate?

Dr. Elizabeth Wassenaar: 
That's accurate.

Ellie Pike: 
And so in that process, I'm wondering, I think some of the conversation that's happening in the world right now is that some folks describe GLP-1 RAs as "reducing food noise", and I think I'm a little skeptical about that. Is it reducing food noise or is it actually just silencing their hunger and satiety cues and do we actually know if that's related?

Dr. Elizabeth Wassenaar: 
We don't know. And I think that's such an important question about if it's the core way that these medications impact your experience of hunger and fullness and appetite drives and how that all interacts with your experience of eating and feeling full. I think this is an important thing to bring up, especially for patients who have a history of an eating disorder and especially those patients who've had to go through experiences of refeeding. So you know that if you have been in an experience where you had to increase your meal plan for weight restoration, there were times that you were asked to eat when you may not have felt hungry,

And it was hard and you needed support, but it was an important part of your recovery process and important for your body to heal. And so taking these medications may mimic that experience for you where you feel really full and without the support of a dietitian and an eating disorder-informed team to remind you that you need to eat regularly, you may be vulnerable to fall back into patterns of restriction just based on hunger cues. You don't feel hungry, it feels hard to eat. It may make you feel nauseous again.

The reality is that when you look at the side effects from GLP-1 receptor agonists, this is described as a side effect of these medications and potentially a desirable outcome. That you feel less hungry, you eat less, you have negative cues when you eat, and so then you lose weight. And for those of you who are in recovery from an eating disorder, you know how hard it was to go through the process of getting your body nourished. And I am very, very concerned that these medications may mimic some of those experiences and potentially really trigger a relapse for patients who have that vulnerability.

Ellie Pike: 
And for someone who has an eating disorder who may need a medication for type 2 diabetes, are there other medications that they could consider that might have less of a risk on their eating disorder recovery?

Dr. Elizabeth Wassenaar: 
Absolutely, and that's so important. There are several other medications for type 2 diabetes that are well validated, well studied, and we have not seen them trigger a relapse into eating disorder in the decades that they've been prescribed. And so I think that this is where it's very important to have an informed conversation with your prescriber or physician about your history of an eating disorder. And I encourage you to bring up concerns that I'm worried that GLP-1 receptor agonists might be triggering for me because I have a history of an eating disorder.

What medications can we try first? And so there are definitely options that are less likely to cause someone to have some of these side effects or experiences that could actually trigger that eating disorder.

Ellie Pike: 
So Dr. Wassenaar, I know there's a lot of folks out there that they feel like they trust their doctor, but they also feel competing messages are out there. They might know that thinner isn't always better, but maybe they are feeling like it is sometimes and then their doctor might say, "Hey, you need to lose weight for your health." Can you speak to that?

Dr. Elizabeth Wassenaar: 
Absolutely. This is a area where medicine has truly failed the people that are seeking its help. So we have decades of "research" that seems to find correlation between certain kinds of health outcomes and one's size or shape. However, as we are learning more about the wide diversity of body sizes and shapes and also considering all of the aspects that figure into health and wellness, we are learning that that research is really flawed and incomplete. Unfortunately, most physicians and prescribers are not being educated about the shortcomings of some of that research.

And so you are very likely to hear from people in the health profession that if you lose weight, you will have better health and you will prevent future bad health outcomes. And the reality is that we need to understand more about metabolic diseases and what people are vulnerable to those and what factors might influence someone's vulnerability to metabolic diseases and really tease that apart from just this sort of weight number or BMI number. And so what I encourage you to do if you are getting that message, is to take a step back.

Connect with resources that build you up as a person and remind yourself that health is something that you can define and it is your prerogative to work with providers that can support you on your journey towards what health means for you. So I encourage you to set health goals that matter to you. "I want to enjoy Sunday dinners with my family. I want to be able to take my dog for a walk to the park. I want to be able to get good and restful sleep." And find ways to work towards those health goals that are separate from weight loss as the only intervention. Now, you may have weight changes over time.

All of our bodies change in weight as we get older, as we go through life changes. That is actually what the body is supposed to do. Good job, body. And really what I would like for each one of you is that you not think that if you just get that number on the scale to a certain number, you will be able to have those health outcomes and you will feel happy and healthy and peaceful. That's the lie. So I know it's really hard and I know you're getting competing messages everywhere, and I really want for you that you can take to heart that you are worth so much more than a number on the scale, and your health is so much bigger than any number on a scale or graph.

Ellie Pike: 
I think for any of us to feel really empowered and ask that question about what defines my health or how will I feel good in my body is really incredible. So thank you so much for highlighting that piece for us. Well, thank you so much for joining our episode today. If anyone would like to see you speak live, there's probably plenty of opportunities. But in August, you will be speaking at the ERC Pathlight Foundation Conference specifically on GLP-1 RAs. Is that correct?

Dr. Elizabeth Wassenaar: 
That is correct. And it is a virtual conference, so it is available around the world for you to join us both either live or later when it works with your schedule. I'm really thrilled to be invited to speak on this topic and to continue to promote this message and hope that for each one of you it meets you where it needs to today.

Ellie Pike: 
Thank you so much. Thank you for joining us as we explored the world of GLP-1 weight loss drugs. Our conversation with Dr. Elizabeth Wassenaar provided valuable insights into critical topics like weight stigma, potential eating disorder triggers, and the physical and mental side effects of GLP-1s. I'm so grateful for Dr. Wassenaar's time and expertise in helping us make informed decisions about using such drugs. Remember, while GLP-1 drugs may change the shape of your body, nothing is more important than protecting your health, especially if you are in recovery from an eating disorder. Thank you for listening to Mental Note Podcast.

Our show is brought to you by Eating Recovery Center and Pathlight Mood and Anxiety Center. If you'd like to talk to a trained therapist to see if in-person or virtual treatment is right for you, please call them at 877-850-7191. If you need a free support group, check out eatingrecovery.com/support-groups. If you like our show, sign up for our e-newsletter and learn more about the people we interview at mentalnotepodcast.com. We'd also love it if you left us a review on iTunes. It helps others find our podcast.

Mental Note is produced and hosted by me, Ellie Pike, edited by Carrie Daniels, and directed by Sam Pike. Till next time.

Presented by

Ellie Pike, MA, LPC

Ellie Pike is the director of alumni, family and community outreach at ERC & Pathlight Behavioral Health Centers. Over the years, she creatively combined her passions for clinical work with…

Presented by

Elizabeth Wassenaar, MS, MD, DFAPA, CEDS-C

Dr. Elizabeth Wassenaar is the Regional Medical Director for the Mountain and West regions at Eating Recovery Center and Pathlight Mood & Anxiety Center.  Dr. Wassenaar grew up in central Iowa,…