GLP-1s & eating disorders: a complicated relationship

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According to a poll from the Kaiser Family Foundation, about one of the first. One in eight U.S. adults are currently taking a GLP one. They've been described by a lot of people as a miracle drug. They're used to treat high blood sugar and diabetes. But they've also shown promise as a treatment for addiction and metabolic conditions like PMOS, formerly known as PCOS. But a lot of Americans are taking it for one reason, weight loss, which actually doesn't happen for everyone on a GLP1.

But for people with eating disorders, that weight loss could be dangerous. Layla Taylor, one of the cast members of the Secret Lives of Mormon Wives, made headlines earlier this year when she opened up about getting on a GLP1 to fuel an eating disorder. And a lot of people started chattering online when a recent piece in the cut went viral about women in eating disorder recovery who cut off a friend going on with Govee. I've been thinking about these two moments a lot. Because like eating disorders are fairly common. According to the National Eating Disorders Association,

about one in 10 Americans will have an eating disorder in their lifetime. And even for those who don't, I wouldn't say our culture promotes a very healthy relationship to food and our bodies. So even though GLP-1s are a miracle drug for many struggling with certain health conditions, what does it mean that they're becoming incredibly available to everyone? And how do we reckon with its place in a culture that prioritizes thinness, sometimes to the point of real danger to someone's health? To get into it, I'm joined by Allegra Broft, a psychiatrist and an assistant professor at Columbia University Medical Center who specializes in eating disorders. Welcome, Allegra. Thank you for having me.

And Hannah C.O., an independent journalist who wrote about GLP1s and eating disorders for The Guardian. Hi, Hannah. Hi, thank you for having me. I'm so happy to have you both.

Hello, hello. I'm Brittany Luce, and you're listening to It's Been a Minute from NPR. a show about what's going on in culture and why it doesn't happen by accident. And a reminder, if you love It's Been a Minute, which from the sweet comments y'all have been leaving, it sounds like maybe you do. Be sure to follow or subscribe to the show on your favorite podcast app. That way, you get new episodes the moment they drop. Alecra, let's start with you. How have GLP-1s changed the world of eating disorder treatment? What have you seen?

In some ways, I feel like it is just sort of the latest societal innovation that represents things that have already been present. For example, when I would meet eating disorders patients, I always have things that I ask about what they're doing to, you know, sort of control, manage shape, and weight, right? And some of the things are vomiting, laxatives. And then diet pills, you know, is next on the list. And so in reality, this is the latest, greatest, next diet pill.

And yet, they're also so much more potent maybe in a way, one injection. You don't even have to think about it again. It goes, you know, lasts for a week. I think some amount of that kind of reward reduction, you know, that gets talked about in the media. Like food became much less, I don't know, kind of enticing, you know. More neutral? More neutral. More neutral.

Is that kind of the way? You know, which it's sort of the double-edged. sword, right? It becomes more neutral. That's a win for some. There's a reduction of joy around it or that's, you know, what other people describe. You know, one person's game changer is another person's, you know, albatross or kryptonite or whatever, right? So this is sort of the dilemma. You don't really know how it's going to go until someone takes the medication. Hannah, how, how easy is it for a person with an eating disorder to get on gLP once? Oh boy. In my reporting, I found that it is unreasonable. reasonably easy to get your hands on a GLP1. As part of reporting my piece, I did try personally to, you know, get prescribed semi-glutide. And I used a popular telehealth platform. I did the intake form. And the only sort of safeguards that I could detect in my process of trying to get my hands on this medication was there was a little survey that said, you know, do you have a history of, you know, problematic or restrictive eating behaviors? And I just clicked the no option.

Oh, so it's like self-report. Yes, exactly. And then it also asked me to submit a photo. I think what this was, the reason for this, I think, was because they wanted to see if I was, like, dramatically underweight. And I don't know if I needed to do this, but I spent two minutes sort of, like, photoshopping myself to look a little bit more overweight than, like, just to see. Like, unambiguously for the purposes of the... Yeah, I just wanted to be sure that I could get it. Submitted my picture and was, like, approved for semi-glutide through this telehealth platform.

And so I don't even know if I was, if I needed to edit my photo. Also, it needs to be said that people can have a history of anorexia and restrictive eating at any size, right? And so just checking to see if someone is underweight is not going to, you know, be a protective safeguard for a vast majority of people who have this history. I wonder, Allegra, what do clinicians and experts like you think about the potential for this kind of use? You mentioned to our producer Liam that there's a lot that we don't know about eating disorders. And sometimes they get triggered in the brain by like an innocent foray anti-dieting, which I mean like I don't know the statistics, but I would argue that probably most Americans have been a diet at some point in their lives. Do you think that the same risk or a significant risk might apply to, you know, getting on a GLP one for people who don't already have a history of disordered eating? eating disorder? So actually, there is a little bit of data I came across recently to that point. This kind of discussion is nicely timed with, I think it was an editorial or some kind of piece that was written in the New England Journal of Medicine that came out like within the past couple

of weeks. Amanda Banks, I believe, is the name of that author. She noted there was retrospective data now from a large pooled sample that suggested that the development of a new onset eating disorder in retrospective chart review of folks taking GLPs was something. like 1.3%. It's tricky because, like, I mean, there is a lot of people, but when you compare that to the number of people who are taking the drugs overall and the benefits that that broader group may see, then I could see how it's one of those sort of tricky questions that you have to weigh. Hannah, for the people you spoke to for your story, what did they have to say about how their GLP1 use interacted with their eating disorders? Something that's important for people to know that I

think that a lot of the general public don't necessarily know is that eating disorders often don't fit into these neat categories that we know that are out there, whether it's like anorexia, bulimia, binge eating disorder. Like a lot of the times and eating disorders can shift over time. The main character in my story, her name is Lily. She had a long, long history of anorexia, starting from when she was a very young girl. And she was in various inpatient facilities, and she had care and treatment for this for a long time. And then in her mid-20s developed binge eating disorder. And then for health reasons, her doctor suggested that she get on a GLP1.

And so for her, this was a really interesting and very fraught experience because on one hand, the GLP-1s provided her with this immense instant relief against her urges to binge. That to her was such an immense relief, and she was very grateful for that. But at the same time, the GLP-1s really enabled her patterns of restriction and really brought a lot of those urges back in a way that triggered a relapse for her. She's sort of wedged in between these two urges. And so the GLP-1 really helps with one side of those things, but presents this sort of persistent risk on the other side of things. And right now she's choosing to stay on the GLP-1s for her health as she does have adult onset type 1 diabetes. and the GLP-1s are really helpful for managing that.

But who knows whether that will be like an answer in perpetuity for her. That is a lot to handle. Yeah, and she's handling it as gracefully as one person could. I think what we're getting at is that there is, like how I put it, there are so many different ways to have a relationship with food, so many different ways to have a body and have a relationship with a body. I imagine that it's kind of like impossible to imagine, a GLP1, especially as it does not treat those emotional and psychological underlying issues,

as something that could address every, or even most, or even half of all individual's issues with food. It's like, it may, for a lot of people, help with one really important portion of it. But everyone has their sort of individual fingerprint of like their issues or relationship with food and their body. And that's a very complex thing to address, it sounds like. You know, I think there are some people that probably feel the lived experience of this battle has felt so out of control for me that, you know, now that it feels a little more in control, I have room, you know, to work on the emotional stuff that maybe I wasn't even able to get to before, you know. Yeah, because there was so much just going on in your head about everything else. It's dangerous for me to think too enthusiastically about that, right, because I'm aware of, you know, the potential downside of having restriction triggered. But I think there's, you know, that's a possibility.

It sounds like it's a very delicate balance that we're trying to find. But Hannah, you were going to say something. An expert I spoke to was, you know, cautiously optimistic for GLP-1s as a tool to sort of, you know, reduce the food noise and, you know, curb the binges for, like, in the interim. And in the meantime, you know, teaching people to heal their relationship to the food while they don't have the presence of that, like, oppressive food noise and the, you know, those really intrusive thoughts to binge eat or overeat and saying, you know, maybe there's potential to use this as sort of like a breathing space, like as a tool to give people breathing room to sort of approach the conversation of how to heal the relationship with food in a more sort of emotionally neutral environment. And then eventually if they can be tapered off the

GLP one entirely, then maybe that's like a good way to use this as sort of a transitional space. So I think there are people who are doing a lot of work trying to figure out creatively ways to sort of use this as a tool while not relying on it as like a permanent crutch. Coming up? People forget how much something like an eating disorder can really take over your brain. More when we get back. The fatal shooting of a teenager at a protest in Seattle has gone unsolved for six years. This is open in your face. How are there no answers?

Our investigation has uncovered new evidence and witnesses who say they've never talked to police. Did police ever call you? Not once. Listen to We Keep Us Safe, a new true crime series on the Embedded podcast from NPR. Of all the protests in the summer of 2020, for a moment there, it was utopia. One took a unique turn. Somebody over there, they ain't seen all to use a gun.

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This is weird. Watch or listen to that wildcard. conversation on the NPR app or on YouTube at NPR Wildcard. I also wonder about like all of the, the sort of quagmire of other issues of even classifying and identifying and diagnosing eating disorders. You know, as I said earlier, about one in ten Americans will have an eating disorder in their lifetimes. But I also think that eating disorders, I mean, I personally just, this is just me speaking

from my nearly 39 years of experience. of being a woman. I suspect that there may be more people dealing with eating disorders or at the very least disordered eating than is reported, even if they don't necessarily fit into an eating disorder diagnosis. So there's all that. And GLP-1s are kind of a bomb dropped into this whole ecosystem. How have they changed how people might think about their bodies and relationships to food,

especially when these relationships are already often so complicated. Yeah, I mean, I think GLP-1s, something that I heard a lot from people and from what I saw online, what I've seen online, is that, like, the advent of GLP-1s, I think, is maybe brings about this new attitude that if someone is obese or overweight, like now you have no excuse because you could just use a medication. And that, I mean, that totally discounts the fact that GLP-1s don't really even work for everybody. So, like for weight loss. For weight loss, yes, exactly. But because it's this like potent tool for weight loss, it kind of double downs the sort of personal responsibility that the individual person faces to sort of like, quote unquote, take care of their own health. And by take care of their own health, like implicit in that is like you should be of a smaller size. It's tricky too because GLP ones do have so many like valid and valuable.

effects on health generally, you know, for blood sugar reasons and, you know, all this research is coming out showing that it's potentially really useful for things like addiction, et cetera, as you mentioned. And so, and I think that's a key difference between GLP1s versus like Fen, or previous, you know, weight loss drugs, right? Because those were purely for weight loss. There are no, like, really no redeemable qualities for any of those drugs. But for GLP1s, it's tricky because people are using them in life-saving ways in very, very very very, very valuable ways, but at the same time, it's sort of poking at this like scab that we have in our society or we're all sort of like feeling the urge to be thin and we're sort of, I think it's

easy to sort of take this medicalized route as an excuse to buy into and double down on the diet culture. I want to touch back on this piece from the cut that I mentioned earlier and you have referenced Allegra where the writer who was in eating disorder recovery spoke about cutting off a friend who was getting on Wagovi. You know, there was a lot of backlash to the piece because I think in the piece, a lot of very strong feelings

from the writer came through. And I think the writers still seem like she was at a very fragile place in her recovery. And I do feel empathy for her there. I bring it up, though, because I think it's the start of an interesting conversation about people who are trying to heal their relationships

to food. and their bodies, while seeing others essentially shrink on GLP-1s, whether they're people close to them or, you know, listen, as I've been saying, we all remember the last awards season. A lot of people are looking different than they did like nine months ago. The culture at large seems more thin, like, and thinness obsessed than it has in a long time. Angeline Chappen, who is the features writer at the cut, she called this the era of emaciation. What does it mean to recover from an eating disorder in the quote-unquote era of amaciation?

It's a tough question, but I think that's a lot of people's reality right now. I think a fair number of my patients would say that the era never really left or their reality as they live it was that this thin ideal has been baked in. I mean, even with whatever forces have tried to promote body positivity, what to hit them is still this sort of thin ideal, you know, reality. And so, look, everybody's surrounded, right, by these cultural realities. Relatively few people develop severe eating disorders like anorexia, you know, that I see. So this is just one piece of what makes recovery hard. And that's why I have a lot of sympathy for the woman writing that article that, like, knew that, like, she needs, for her, making a lot of space means being bombarded by certain things as little as possible, right? There was, I think, what people reading that article, you know, in some of the comments I read, I think there was a lot of judgment.

you know, towards her. I was really disappointed by the judgment that I saw in the comments and in reaction to the piece. I also thought it was interesting that a lot of commenters I saw were sort of making assumptions about the sizes of the friend and the size of the writer. And I don't know. I just, I felt it. I felt it was all very ungenerous. But to me, like the main takeaway of that piece was just how hard it is to sort of protect yourself from all of this messaging in today's world. And I think she, either she made the analogy or maybe someone else made the analogy.

But, you know, it's like ideally someone who's recovering from alcoholism would be able to sit at a dinner table with friends while they have glasses of wine. But, you know, that process to get there is not going to be immediate. It'll take some time for anyone. It might not even happen for some people. And in the same way, like someone recovering from a restrictive eating disorder might need like a whole lot of time and a whole lot of help before they can even get to a point where. they can like knowingly interact with people who are on GLP ones. And so I think people forget how much something like an eating disorder can really take over your brain and like lead to these like spirals of like obsession and rumination. Yeah, I think it's so easy to to be like,

oh, this person is a bad friend and is being like not responsible towards her friend and her friend's feelings. But you don't, I don't know, we don't know what's going on in another person's brain, especially if it's a disordered brain. I mean, yes, there are many places. where like something like alcohol or even drugs are socially acceptable and you can expect to see them. But you can go to plenty of places and avoid those sorts of things. But like you got to eat three times a day. You can't avoid food. And it's like I can imagine that the recovery process is extremely difficult because, precisely because you absolutely cannot avoid food for the rest of your life.

I don't see a world in which the pressure to be thin is going away. And definitely not anytime soon. I also don't see a world which GLP-1s are going away. And if anything, I think that they might become even more easy to access. Given that, how do we support people who have disorder relationships to food and their bodies? And is it possible to keep new disorders from developing? You know, I think in an ideal world, right, there would be kind of a model where, you know, there really would be those discussions of, you know, has there been a history of eating disorder that there's a little more than just an online, you know, interface that, you know, you know, is part of the process of making this decision, you know, that these things would get discussed openly.

I always worry, you know, when I have a patient in my practice that is using one of these medications, like, you know, they often say, I'm good. Like, it's not a problem, you know, but is it? You know, like, you know, when people are happy enough with the benefit of something, do they want to look at the downside, you know? I can think of scenarios where maybe I have a patient using medication, like, this where the weight is starting to trend a little bit in that area where I'm like, you know, but the person says, it's not, it's not restriction. I just, you know, I'm, you know, I'm, you know, less hungry or, you know, so like, what do you do with that in a way, you know, and where is that going, right? So how do we support folks? I, you know, so I'm,

I, um, I, you know, obviously I wish everybody, um, could have a therapist, you know, or someone to talk to about this stuff. It is very difficult to find a therapist or a psychiatrist or anybody to work with you without insurance. It can, in some cases, be easier to get a GOP1 medication than to find a therapist. Yes. Without insurance, yeah. 100%. I'm just being honest.

I agree. I do think that stigma plays a big role. And I think if we can reduce stigma and just like about like our histories with, you know, our struggles with food, maybe that could help. I'm of two minds about whether or not we should talk more openly about GLP1 use or not. Because, I mean, like as as this writer's piece showed, like, you know, she's. She wants to avoid all mention of GLP1s. But I think if we could be more open about who was using a GLP1 and how those drugs are affecting various people's bodies, it could in the same way that people want celebrities to be open about their, like, facelifts or whatever. You know, like, it could just, like, set more realistic expectations for how people are managing their health or managing their bodies in a way that can sort of, in a way where, like, the world makes more sense to you, right?

You're like, oh, this makes sense that this is happening to you because you're going through this. and you're talking about this and that's why you're eating like this. If we can talk more openly about health generally, I think that could be really helpful just saying, like, what's going on? Well, I hope for the future that you both have described. But I'm very curious to see how we get there. This has been a really eye-opening conversation. Thank you both so much for coming on the show.

You're welcome. Thank you for having me. Thank you so much. Yeah, this has been a really great discussion. That was Allegra Brof, a psychiatrist and an assistant professor at Columbia University Medical Center, and Hannah Seo, an independent journalist who wrote about GLP1s and eating disorders for the Guardian. This episode of It's Been a Minute was produced by Liam McBain. This episode was edited by Nina Patuck. Our supervising producer is Sheriff Vincent.

Our executive producer is. in Gurdwood. Our VP of programming is Yolanda Sanguini. All right, that's all for this episode of It's Been a Minute from NPR. I'm Brittany Luce. Talk soon. 250 years ago, the nation's founders considered a free press, a critical protection for we the people. Today, the NPR network proudly upholds your First Amendment rights with reporting accountable only to you. It's something we protect together. a truly independent press. Support the NPR network at plus.npr.org.

For three weeks in 2020, part of my Seattle neighborhood was taken over by a protest occupation. We were here to protest police brutality. But it ended in tragedy. The whole space felt darker and angrier. Join me as I investigate the unsolved killing of 16-year-old Antonio Mays Jr. Listen to We Keep Us Safe on the Embedded podcast from NPR. Thank you.