CW: discussion of weight, weight loss, weight loss drugs, BMI, and eating disorders.
As dietitians working with eating disorders (ED), we are no strangers to how fad diets and weight loss drugs negatively impact our clients and our society at large. We may spend many sessions reviewing the science, unpacking the harmful discourse, and helping our clients define and seek the best choices for their health and wellbeing. For some clients, this includes ED recovery, body acceptance, and eventually Intuitive Eating. For other clients, the desire for a smaller body is overwhelming, and they may not be ready or interested in a more weight-inclusive approach to nutrition and movement.
As everyone is in a different stage of change, and may have varying health beliefs and goals, we consider our role as one which includes unconditional acceptance of where our clients are in their wellness journey. With our understanding of the nuances and factors that impact our clients’ eating behaviors, we aim to reduce harm and fight weight stigma by providing a more compassionate and inclusive approach. For this reason, we work with clients who may be taking or are considering a GLP-1 agonist (such as Ozempic, Wegovy, and Mounjaro), even if our dietary counseling does not expressly advise on intentional weight loss.
GLP-1 agonists have been gaining attention from the public in recent years. Originally developed for managing type 2 diabetes, GLP-1’s are now increasingly recommended by physicians for weight loss. The reasons for any person making the choice to use a GLP-1 are complex and nuanced, and we support our clients and their autonomy as they make their own informed health choices. At Nourish for Life, we are interested in understanding the “why” our clients make their decisions, helping them navigate “if” a GLP-1 could be a safe decision, and supporting their physical and mental health throughout the process. Further stigmatizing the desire for weight loss by making a client feel uncomfortable approaching these conversations with their dietitian is not helpful and may cause increased harm and break trust.
In this article, we want to share more about these drugs and how we work with our clients to support them - whether they choose to use them, or not.
How Do These Drugs Work?
GLP-1 agonists work by mimicking a hormone called glucagon-like peptide-1, which is naturally produced by our bodies to promote blood sugar regulation, the sensation of fullness, and increase metabolism. They have been approved by the FDA and have been available for use by patients with type 2 diabetes for nearly a decade. Brand names for GLP-1 medications are Ozempic/Wegovy, Saxenda, Mounjaro, and Zepbound (among others). Typically the doses for weight loss are greater than the doses used for managing diabetes.
GLP-1 agonists activate GLP-1 receptors in the body, leading to several effects. They increase insulin secretion (which draws glucose from the blood to our cells) and decrease glucagon release (inhibiting the conversion of liver glycogen to glucose, which is then released in the bloodstream), helping to lower blood sugar levels. They also slow down gastric emptying, meaning food stays in the stomach longer, causing fullness for more extended periods. Additionally, GLP-1 medications affect the brain's appetite centers, reducing appetite and increasing feelings of fullness(1). Herein lies the drug effects that promote weight loss in individuals who take these medications.
GLP-1 Agonist Considerations
Those who are contemplating taking a GLP-1 each have their own individual and personal reasons, and we urge everyone to talk with their care team about these reasons and any potential risks. There is so much chatter and misinformation on the internet, discussing their concerns with a trained professional may help people become more informed. Even though some people may (inaccurately) believe these drugs offer a kind of “easy” path to weight loss, taking these medications can be a challenge physically and mentally. Before starting a GLP-1, here are just a few important factors to consider:
Health ≠ Weight: Weight loss or a smaller body size does not equate to improved physical and mental health(2). We strongly recommend our clients have a therapist to help unpack and process concerns they have about their health and wellbeing. Conversations with one of our dietitians can help clients better understand their health beliefs and ideals, identify gaps in their knowledge about nutrition, physiology, and medicine, and provide emotional support regardless of what they choose to do.
Eating Disorder Screening: Some eating disorders are associated with the desire for thinness. Thus, there is a probability that folks may have been inappropriately prescribed a GLP-1 without being screened for an ED, and people who have struggled with ED may be more interested in exploring these drugs(3). We do not recommend that folks with an active eating disorder begin a GLP-1 medication without communicating any eating or body image concerns they have with their physician and therapist. Intentional weight loss while in treatment for an ED is not appropriate. The potential side effects (discussed below) could complicate the process toward recovery. Also, weight loss does not address the underlying emotional/behavioral issues surrounding the ED and body image disturbances(4). There is also a risk that some folks with EDs may misuse a GLP-1 agonist for the purpose of weight loss(5), as we’ve seen happen in the past with other drugs and supplements, sometimes with severe consequences.
Side Effects: Common side effects we observe in our clients that take a GLP-1 include nausea, diarrhea, vomiting, and constipation. Add to this, that reduced appetite makes identifying sensations of hunger and fullness more difficult. Some people may experience more serious side effects such as hypoglycemia, pancreatitis, gallstones, bowel obstructions, or gastroparesis(6). With rapid weight loss comes the risk of sarcopenia(7) (loss of muscle mass) which can impact long-term health. Anecdotally, we have noticed increased risk of severe mental health side effects in some of our clients, such as depression and suicidal ideation.
Cost: These medications can be expensive, averaging around $1,000 per month(8), and insurance might not cover the costs, especially if the BMI is below 30.
Long-Term Commitment: Studies show that weight loss achieved with GLP-1 medications is generally only maintained while the medication is being taken(9). About two-thirds of the weight lost is typically regained within a year after stopping the medication.
Weight Cycling: Since there is a likelihood of weight regain when stopping a GLP-1 agonist without long-term change in health behaviors, there is also a risk of weight cycling. Studies have looked at the health effects of losing and gaining weight repeatedly over time, and found adverse health outcomes, such as impaired metabolism, worsened cardiometabolic markers, insulin resistance, binge eating, depression, sarcopenia, and higher mortality due to these frequent shifts in body weight (10,11).
How We Approach GLP-1’s in Our Practice
As dietitians that practice from a HAES® lens, we support our clients’ health without weight change as a primary outcome. However, we understand that our society has promoted weight loss as a desirable goal, and sometimes even a moral obligation. So we completely understand why taking a weight loss drug can seem appealing. We also believe that medication stigma can cause harm to our clients. Everyone deserves autonomy without judgment when it comes to their health choices.
If you were curious how we would support folks that are choosing, or maybe already have chosen, to use a GLP-1 agonist, here is a little sneak peek into how we work:
Ensuring proper and adequate nutrition: These medications reduce appetite and increase feelings of fullness, which can further complicate our interoceptive awareness and can lead to inadequate nutrient intake. Our dietitians offer nutrition education and assistance creating an individualized meal plan to ensure clients get the nutrients their body needs without restriction.
Maintaining muscle mass: Any amount of weight loss will lead to muscle mass loss(12). We guide folks on how to maintain muscle mass while taking these medications using nutrition and movement(13).
Managing side effects: Our dietitians are knowledgeable about the common side effects of GLP-1 medications and can provide strategies to manage symptoms like nausea, diarrhea, constipation, and hypoglycemia.
Developing sustainable changes: Beyond managing immediate concerns, we work together to find long-term dietary and lifestyle approaches that support physical and mental health. This can include learning how to understand and respond to hunger and fullness, creating routines around food and movement, processing body image distress, and encouraging self-care activities.
Education: We will weed out the nonsense found on the internet and focus on evidence-based information from the most up-to-date science available on GLP-1 agonists. As trained Registered Dietitian Nutritionists, we take the research and our client experiences into account when making recommendations or suggestions.
Social Justice/Trauma Informed: Topics that are often left out of the doctors office while being asked to “step on the scale” and “do you want to try a GLP-1?” are broader, important issues that affect a person’s perception of their body size and their health outcomes. This includes our culture’s obsession with thinness, food industry, food access, healthcare inequities, “Big Pharma”, safety in our communities, financial stability, and racism (among others). We also understand that some individuals may not feel safe exploring their body in terms of hunger/satiety signaling as this type of connection may evoke feelings of fear and trauma often held in our bodies.
Supporting your emotional wellbeing: As mentioned previously throughout this article, there are so many things that can complicate a person’s healthcare decisions. Arriving at the point of considering a weight loss drug (or being recommended one) means that a person has likely been the target of fatphobic medical care, weight stigma, and body size discrimination. We aim to provide compassionate and supportive space to explore these concepts and the feelings they bring up, and work with you to identify perspectives and standpoints that might help you develop greater resilience.
Eating disorder prevention: To date, there are no solid research studies looking at the effect of GLP-1s on the development of a new eating disorder or relapse of a pre-existing ED. However, we are trained to screen and treat EDs, and consider EDs a potential risk for any of our clients. Everything we do is done with the lens of ED prevention or recovery. We monitor our clients for signs of EDs and collaborate regularly with their care providers to ensure safety and improve health outcomes.
Lastly, we have to acknowledge our own standpoints, positionalities, privileges, and biases to understand how fatphobia affects our clients. Some of us benefit from the social advantages of living in a thin body, being a certain gender, and our race. These privileges are unearned, systemic issues, and are embedded into our society and institutions. We continually engage in self-reflection regarding our privileges by asking questions, challenging our biases, and educating ourselves.
We hope that this article helps you understand GLP-1 agonists, and our nuanced approach to working with clients who are taking or considering taking these drugs. If you have specific questions/comments, or are interested in starting nutrition counseling with us, we look forward to hearing from you!
Works Cited:
1. Smith NK, Hackett TA, Galli A, Flynn CR. GLP-1: Molecular mechanisms and outcomes of a complex signaling system. Neurochem Int. 2019;128:94. doi:10.1016/J.NEUINT.2019.04.010
2. Bacon L, Stern JS, Van Loan MD, Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc. 2005;105(6):929-936. doi:10.1016/j.jada.2005.03.011
3. Bartel S, McElroy SL, Levangie D, Keshen A. Use of glucagon-like peptide-1 receptor agonists in eating disorder populations. International Journal of Eating Disorders. 2024;57(2):286-293. doi:10.1002/EAT.24109
4. GLP-1 Medications and Eating Disorders - National Eating Disorders Association. Accessed October 16, 2024. https://www.nationaleatingdisorders.org/glp-and-eating-disorders/
5. Chiappini S, Vickers-Smith R, Harris D, et al. Is There a Risk for Semaglutide Misuse? Focus on the Food and Drug Administration’s FDA Adverse Events Reporting System (FAERS) Pharmacovigilance Dataset. Pharmaceuticals (Basel). 2023;16(7). doi:10.3390/PH16070994
6. GLP-1 Agonists: What They Are, How They Work & Side Effects. Accessed October 16, 2024. https://my.clevelandclinic.org/health/treatments/13901-glp-1-agonists
7. IKEJIMA S, KONDO S, SAKAI T, et al. Novel Approach to Sarcopenia in Diabetic Patients Treated with GLP-1 Receptor Agonists (GLP-1RA). Diabetes. 2018;67(Supplement_1). doi:10.2337/DB18-673-P
8. Popular GLP-1 Agonists List, Drug Prices and Medication Information - GoodRx. Accessed October 16, 2024. https://www.goodrx.com/classes/glp-1-agonists
9. H Wilding DM JP, Batterham MBBS RL, Davies M, et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Published online 2021. doi:10.1111/dom.14725
10. Rhee EJ. Weight Cycling and Its Cardiometabolic Impact. J Obes Metab Syndr. 2017;26(4):237. doi:10.7570/JOMES.2017.26.4.237
11. Kakinami L, Knaüper B, Brunet J. Weight cycling is associated with adverse cardiometabolic markers in a cross-sectional representative US sample. J Epidemiol Community Health. 2020;74(8):662-667. doi:10.1136/JECH-2019-213419
12. Cava E, Yeat NC, Mittendorfer B. Preserving Healthy Muscle during Weight Loss. Advances in Nutrition. 2017;8(3):511. doi:10.3945/AN.116.014506
13.Ozempic May Make Your Muscles and Bones Weaker. Accessed October 16, 2024. https://www.healthline.com/health-news/ozempic-muscle-mass-loss
