Sept. 25, 2024 -- As a psychiatrist specializing in eating disorders, Kim Dennis, MD, has seen firsthand the complex relationship between obesity treatment and mental health in adolescents.
Now, with the rising popularity of medications like Ozempic for weight loss, she fears she will see more of these young patients.
"We haven't seen patients yet, but I'm sure they are on their way," said Dennis, a professor at the University of Illinois College of Medicine in Chicago. She is also the co-founder, CEO, and chief medical officer of SunCloud Health, an outpatient eating disorder treatment center in Illinois.
Dennis's concerns reflect a growing unease among eating disorder specialists as newer obesity medications, known as GLP-1 drugs, gain traction for adolescent use.
The FDA approved semaglutide (Wegovy) for weight loss in adolescents ages 12 and up in December 2022 and liraglutide (Saxenda) for ages 12 and up in December 2020. One study found that the number of adolescents prescribed GLP-1s for type 2 diabetes and weight management rose from 8,722 to 60,567 between 2020 and 2023 — a nearly sevenfold increase.
"The number of adolescents taking these medications is going up because they work," said Suzanne Cuda, MD, medical director of Alamo City Healthy Kids and Families, a medical weight management clinic in San Antonio. The medications have been shown to treat type 2 diabetes, lower blood pressure, and reduce the risk for cardiovascular diseases.
"The younger you are, the better the outcome," Cuda said.
But experts like Dennis have expressed concerns for teens with eating disorders who are seeking these medications or who have developed a disorder while taking them.
In one recent study,nearly 80% of teens in treatment for obesity reported symptoms of disordered eating. These included signs of binge eating and loss of control.
The randomized clinical trial, conducted from 2018 to 2023, looked at 141 adolescents with obesity doing interventions like low-calorie diets or intermittent fasting. Almost half scored as having a risk for an undiagnosed eating disorder. At the end of the intervention, many continued to have symptoms of disordered eating.
The findings illuminate a significant challenge: Balancing effective weight management with the risk of worsening or triggering eating disorders, said Hiba Jebeile, PhD, a research dietitian at The Children's Hospital at Westmead in Westmead, Australia, and the study's lead author.
Adding weight loss medication on top of the equation can further complicate care.
Treating Obesity in Adolescents: Why Weight Loss Drugs Are Different
How GLP-1 drugs affect adolescents in the long run is not yet clear.
Studies on GLP-1 medications in patients with eating disorders have shown mixed results. Some suggest that the drugs decrease binge episodes for those with binge eating disorder or bulimia nervosa. But these studies looked at a small number of people and measured only short-term effects, leaving long-term outcomes and risks unknown.
Traditional treatments for eating disorders emphasize regular eating patterns, body acceptance, addressing weight stigma, and improving attunement to hunger and fullness cues.
GLP-1s, on the other hand, suppress appetite, alter metabolic signals, and may unintentionally reinforce weight loss as a primary goal, creating a potential disconnect between the aims of recovery from eating disorders and the biologic effects of the medication, experts said.
"One of the concerns is the extreme reductions in calories that could be induced by [GLP-1s] in children and adolescents," said Cuda, who has cared for adolescents with eating disorders who are seeking GLP-1s.
Unlike adults, adolescents use calories not just for physical activity but also for growing and developing. "They can’t catch up on that growth and development,” she said.
The National Eating Disorders Association raised concerns about the possible misuse of these medications and their potential to exacerbate eating disorder behaviors in people at a higher risk. That includes those with mental health disorders or stress, dieters, and people who’ve experienced weight-centric bullying.
Also vulnerable are patients with less obvious eating disorder symptoms, such as picky eating, insomnia or difficulty sleeping, or, for girls, irregular menstrual periods, Dennis said. These patients may be more likely to go undiagnosed or be misdiagnosed. Research also suggests that people of color are less likely to be diagnosed or receive specialty care for eating disorders.
Obesity treatment is a crucial opportunity to screen and monitor for disordered eating. But Dennis said that does not universally occur. Validated screening tools like the EDE-Q and the Center for Epidemiologic Studies Depression Scale Revised, 10-Item Version can help.
But regular check-ins with your doctor throughout treatment are also important, Cuda said.
Building Your Weight Loss Management Team
The Obesity Medicine Association (OMA) has stressed the importance of a collaborative approach involving connections with mental health professionals specializing in eating disorders and dietitians.
Consulting with an obesity medicine specialist may also be helpful, said Cuda, who co-authored the OMA statement. "It's impractical to expect a primary care physician to do everything: Screen for dietary disorders, do a full dietary counseling, follow up on their activity."
Bottom line: Focusing on healthier lifestyle habits (as opposed to restrictive diets) is the best approach, the experts said.
"I think a weight-agnostic approach where the focus of care is not weight loss but increase in health protective behaviors and nutritional intake is safest for all kids,” Dennis said, “especially those with eating disorders or eating disorder risk factors.”
