GLP-1 Receptor Agonists May Reinforce Restriction in Patients With Eating Disorders

Patients with eating disorders should be carefully assessed if using glucagon-like peptide-1 receptor agonists (GLP-1s), according to Leslie Heinberg, PhD, MA. Those who had anorexia nervosa or bulimia nervosa may be motivated by a pathological pursuit of thinness and those with binge eating disorder potentially motivated by symptom reduction.¹ Preliminary studies in patients with obesity and binge eating disorder found fewer binge eating episodes, lower body weight, and less preoccupation with food, although Heinberg noted that long-term effects and outcomes after GLP-1 discontinuation had not been studied.² The medications delayed gastric emptying and appeared to reduce appetite and food-related reward, effects that may reinforce restriction and the drive for thinness in patients attempting to limit their intake. Heinberg recommended a brief eating disorder screen and record review before prescribing, referral to eating disorder specialists when an eating disorder was suspected, and assessment for disordered eating before initiation, during treatment, and after discontinuation.

Psychiatric Times: Why might patients with eating disorders be drawn to GLP-1s?

Leslie Heinberg, PhD, MA: Eating disorders present along a wide continuum and include diagnoses such as anorexia nervosa, bulimia nervosa and binge eating disorder.Many individuals do not fall neatly into those categories and may have atypical presentations (Other Specified Feeding and Eating Disorder—eg, someone who may meet all criteria for anorexia except low weight). Eating disorders such as anorexia and bulimia are characterized by a pathological pursuit of thinness often accomplished by severe dietary restriction and/or compensatory behaviors like purging by vomiting, laxatives or excessive exercise. For these individuals, seeking obesity medications such as GLP-1s may be driven by the pathological pursuit of thinness. The pervasive media and social media coverage of dramatic weight loss related to this medication class may make pursuing prescriptions even more compelling.

Conversely, some preliminary studies of GLP-1s in patients with both obesity and binge eating disorder find reduced binge eating episodes, reductions in weight and less preoccupation with food/food noise. Those with binge eating may be seeking benefit to reduce their symptoms. However, long-term impact on binge eating disorder hasn’t yet been studied and what happens after GLP-1 discontinuation hasn’t been evaluated either.

PT: Which eating disorder presentations concern you most when a patient is using a GLP-1?

Heinberg: Weight loss that is much more rapid than would be expected, endorsement of purging, restriction, and/or excessive exercise. Increasing preoccupation with food and weight rather than declines while on the medication. A steadily declining weight goal (eg, wanting to lose another 15 lbs and another upon reaching the goal) is another concerning sign.

PT: How can GLP-1 use reinforce restriction or other eating disorder behaviors?

Heinberg: GLP-1s facilitate weight loss by delaying gastric emptying which results in a greater sense of fullness or satiety. Additionally, evidence suggests that they act on the reward centers of the brain reducing appetite and food-related reward.This may relate to the subjective experience of reduced food noise (thoughts about food that are experienced as pervasive and distressing). For individuals who are attempting to restrict their intake—a primary symptom of their eating disorder—these medications may reinforce the ability to do so, and the resulting weight loss may reinforce the pervasive drive for thinness—another component of their disorder.

PT: How should clinicians screen for an eating disorder before a GLP-1 is prescribed?

Heinberg: Before prescribing a GLP-1, providers should consider conducting a brief screen for eating disorders. Additionally, a review of the patient’s record is indicated to identify if there has been a recent rapid weight loss, electrolyte imbalances or past eating disorder diagnoses). Referrals to eating disorder specialists for additional evaluation and treatment are warranted when an eating disorder is suspected.

PT: How can clinicians ask about GLP-1 use obtained outside the healthcare system without patients feeling judged?

Heinberg: A focus on all medications and supplements (not just GLP-1s) that a patient takes can help providers identify the wide variety of things patients may be taking from other providers, from online providers or simply ordered off of the Internet, can help reduce defensiveness and feeling judged about weight loss medications.

PT: How do you distinguish expected appetite suppression from eating disorder psychopathology?

Heinberg: GLP-1 medications for weight loss prescriptions should be augmented with recommendations on healthy eating, protein recommendations, kcal goals that are not overly restrictive and initiation/continuation of weight bearing exercises to avoid lean muscle mass loss. Difficulties following these recommendations may indicate that additional screening for eating disorders is necessary and/or referral to multidisciplinary providers in behavioral health and nutrition that may help further evaluate and treat the patient.

PT: What should a clinician do when a patient with an eating disorder is already using an unregulated GLP-1?

Heinberg: Recommend that the patient seek specialized, multidisciplinary care and educate on the potential risk of use in those with eating disorders and that these medications are contra-indicated for them.

PT: What are the biggest gaps in the evidence on GLP-1s in patients with eating disorders?

Heinberg: Well controlled randomized trials for GLP-1s for binge eating disorder are needed along with studies that can identify which patients may derive the greatest benefit. Ongoing studies of GLP-1s should evaluate the incidence of de novo eating disorder symptoms, recurrence of eating disorders in those with a history and frequency of sub-threshold disordered eating symptoms.

PT: What would you say is the most important thing for practicing clinicians to keep in mind about GLP-1s and eating disorders?

Heinberg: Patients with eating disorders are seeking out GLP-1 medication and clinicians should assess for disordered eating prior to initiation, during treatment and post-discontinuation of these medications.

Dr Heinberg is vice chair for psychology in the Center for Behavioral Health Department of Psychiatry and Psychology. She is a professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

References

1. Bartel S, McElroy SL, Levangie D, et al. Use of glucagon-like peptide-1 receptor agonists in eating disorder populations. Int J Eat Disord. 2024;57(2):286-293.

2. Radkhah H, Rahimipour Anaraki S, Parhizkar Roudsari P, et al. The impact of glucagon-like peptide-1 (GLP-1) agonists in the treatment of eating disorders: a systematic review and meta-analysis. Eat Weight Disord. 2025;30(1):10.