Written by Cheri A. Levinson, Ph.D.
First, I need to disclose how my perspective is formed, based in both lived and clinical experience and scientific training. I am an eating disorder therapist and researcher. My livelihood is dedicated to alleviating suffering for those who have eating disorders, both through the development of new and better treatments and through treating patients with a variety of eating disorders across the weight spectrum. Perhaps more importantly, is that I am also a reformed dieter. I spent my life from the ages of 19 to 30 on diets, constantly trying to lose weight, beating myself up about how “fat” I looked, and bouncing back and forth between a “normal*” weight and “overweight.”
I now know because of my scientific and clinical training that I should have been diagnosed with atypical anorexia nervosa (read about A-AN here), but I never was despite seeing several therapists for anxiety and stress throughout this time. Why? Most likely because I was never officially “underweight” or if so, not for very long. I have not made this public knowledge until now.
Now, at 39 years old, I am considered “obese” by outdated, yet widely-referenced medical standards. I am not on a diet, I eat a wide diversity of foods that I enjoy and savor, I’m happy, healthy (yes you can be healthy at any size!), and I love my body (truly- it happens!). My body is currently growing my third baby girl and I am grateful every day for what my body does for me. Like so many people with similar lived experiences, I would need a book to document my life’s journey finding body acceptance (someday!), but that is not the point of this post.
The point is to reflect on the growing trend happening in the weight management area with the use of Ozempic (semaglutide, wagovy, glp1s). This reflection is informed by both my professional and personal experience. My current opinion on Ozempic is that I am highly skeptical regarding its use for weight loss. I would not use it. In fact, I would stay far, far away from Ozempic. I expect it will cause a lot of damage before we have conclusive data one way or the other. The history of the weight loss industry tells us that routinely, when one approach (e.g., Weight Watchers, Bariatric Surgery, Intermittent Fasting, etc.) either goes out of style or is debunked, another will replace it. Each of these methods have left harm in their wake, especially for those with eating disorders (read more here: article by Levinson et al.).
I sincerely hope that I am wrong about Ozempic and it does not turn out to be the latest “fad diet” and can instead be a helpful medication (for health [not weight loss] purposes). I would love to find an easy cure for the endless negative thoughts present in eating disorders. But history has yet to find a ‘magic’ bullet for mental illness and it will take a very, very lot of well-conducted research, including assessment of long-term potential harms, to convince me that Ozempic is not the latest weight-loss fad (again, this is not a comment on its use for other areas, such as diabetes).
Second, I want to thank Dr. Cynthia Bulik for her thoughts here: Reflections on Writing About Ozempic for “Science” | Exchanges (uncexchanges.org), many of which have inspired my thoughts expressed below. She writes about many pros and cons of the rise of Ozempic, many of which I will discuss here. I also want to be clear that this post concerns Ozempic for weight loss and in particular the impact it may have on eating disorders. I am not familiar enough with the diabetes, substance use disorders, or other areas that Ozempic may be used for to comment on those areas.
The Eating Disorder Landscape. Eating disorders are at an all-time high in terms of prevalence rates. It is estimated that up to 20 percent of Americans will have an eating disorder during their lifetime. Yearly economic and loss of well-being costs are estimated in the 400 billion range. As a mother of two (almost three!) young girls, what scares me the most is the growing trend that life-threatening eating disorders are starting at age 8 or 9. Eating disorders are not getting better – in fact, they are getting worse. They kill someone every 52 minutes. At the same time, diet culture, anti-fat bias, and fad-diets (with many names) are widely promoted in society. Most women (up to 95%) report being dissatisfied with their bodies and wanting to change them. Foods are labeled as unhealthy, (e.g., “fattening,” “empty”) and immoral (e.g., “bad,” “naughty,” “guilty pleasures”), when in reality, food has no morality and what is deemed “healthy” is subjective. Medical doctors widely promote the message that to be healthy you must be a certain weight, when weight actually tells us very little about the health of an individual. Countless pediatricians suggest that children should lose weight (a shared experience by many individuals who later develop eating disorders) during a period when bodies are supposed to be growing and expanding. Through research, clinical practice, and lived experience, the connection is clear: Dieting, restriction, food rules, food labeling, and weight bias are all major players in the development and maintenance of eating disorders in all ages.
Propagation and Advertisements of Ozempic for Weight Loss. Dr. Bulik starts her post by mentioning the advertisements that are currently bombarding users of Facebook urging them to try Ozempic to lose weight. I think we need to take a minute and reflect on how truly alarming it is that we are all being flooded with advertisements for this new drug. I too have seen ad after ad for Ozempic pop up across multiple of my social media accounts. I am currently in my second trimester of pregnancy and Facebook is suggesting that I start taking weight loss medication. If that does not ring as truly devastating to you, well, let me spell it out: I am growing a human being in my body, and taking weight loss medication would be harmful to both me and my unborn child.
Now, I know that if I am seeing Ozempic ads and Dr. Bulik (a leading eating disorder expert) is seeing Ozempic ads, our patients with eating disorders and many people with eating disorders who do not know or recognize that they have eating disorders, are seeing these ads. And to date, there is no data out there suggesting that these medications would be helpful for those with eating disorders (at least 20 percent of the population at some point during their life). Indeed, most eating disorder experts are strongly warning against the use of these medications given the potential for harm (any negative energy balance or restriction can set off or re-trigger an eating disorder).
As Dr. Bulik writes, perhaps to me, the most compelling statement in her blog post, “The second issue relative to eating disorders is the potential for abuse. As an eating disorders specialist, this scares me enormously. I cannot overemphasize the vigilance that clinicians and carers should maintain about the misuse of these drugs. It is not a stretch to anticipate them having serious if not fatal consequences in very underweight individuals.” Though I would argue this applies to all individuals with eating disorders regardless of if one is “underweight” or not, especially given that most research finds that those at higher weights have as bad or worse medical complications from their eating disorder, go unrecognized (see above re lived experience), and are often unable to access care. Regardless of size, these medications have huge potential to become another harmful way to propagate eating disorders.
Eating Disorders Get Quiet When Weight Loss is Happening. We need to consider the long term. Eating disorders are loud. They scream at you to not eat, to eat as little as possible, that you are bad, ugly, fat [note I identify as midsize/fat- it is not a bad word], and worthless. People with eating disorders will do most anything to quiet those thoughts. They are uncomfortable.
Guess what quiets the thoughts? Losing weight. When weight management researchers report that their “weight loss” treatment improves eating disorder symptoms in the short-term, they are not wrong. Because in the short-term, weight loss quiets the thoughts, which quiets the other extreme attempts (e.g., behaviors) at weight loss. The problem is the long-term maintenance of a harmful cycle. This phenomenon has been shouted loudly from those with lived experience, and researchers need serious thought and work to better document this cycle. Because weight comes back or thoughts come back when you are no longer *losing* weight. It is impossible to lose weight forever without dying. Perpetual weight loss is however, the goal of the eating disorder.
Dr. Bulik discusses that there are reports that Ozempic has “a profound cognitive effect that it is like changing the channel on a TV. The soundtrack of their minds completely changes, eliminating the constant food noise that fed their eating disorder.” I would love for this to be true. But I will remain unconvinced until I see long term data showing that Ozempic can quiet eating disorder thoughts. Because in the short term, of course it quiets thoughts. This is the same mistake weight management researchers make when they interpret a short-term decrease in eating disorder symptoms as a positive. They are only capturing part of the harmful cycle. Which leads us to the harms of weight management treatment…
Harms of Weight Management Treatment and Weight Stigma. The harms of weight management treatment in reference to eating disorders and weight stigma are just beginning to be documented. I am not going to go into an overly-exhaustive explanation of these harms because they were discussed by myself and colleagues here. Suffice it to say it feels like fighting an uphill battle. As soon as there is some recognition of the harms that are caused by weight stigma and the harms of focusing on weight in medical and psychological treatments, a new ‘shiny thing’ comes along promising a new way to lose weight, and **this time** it works (no, really! If you squint hard enough the data is so promising)! Unfortunately, all the prior instances of promising new ways to lose weight have failed and left many individuals suffering. This is why I, and many eating disorder researchers, therapists, and those with lived experience, are so wary. What harm will Ozempic leave as its legacy? Time will tell.
The Role of Individuals Versus Systems. And Access. A very important point about Ozempic is the current food environment we live in and how that impacts outcomes. Issac Ahuvia and Dr. Jessica Schleider wrote a very recent and important article pointing out the fact that interventions that focus on individuals instead of recognizing that the system is actually the problem can promote individual and structural harm. Fatphobia, weight stigma, and the weight loss industry embody the very definition of a systemic problem that is attempted to be treated in an individual manner. Though individuals have very little control over their weight, they are continuously made to think they are to blame (personally, I think people of all sizes are beautiful and that we should not change this- but our society thinks differently). We know that things like poverty, food insecurity, food desserts, and mass production of profit-making foods, contribute to high weight. Yet, we try to change individuals. Ozempic is another attempt at individual change. If we really wanted to improve health (note the distinction between weight and health) we would put efforts into addressing poverty, food insecurity, food desserts, and regulating profit-based food and health companies.
Part of the major problem here is access. Poverty precludes access to diverse foods. If you are worried about whether you can feed your family for the next week, you don’t have the luxury of choosing between more expensive produce and lean protein. And why do we think that Ozempic will change these facts? It will continue to be accessible to those with resources and those without resources will not have access. Continuing to perpetuate a harmful cycle on an individual level without addressing the structural systems that are actually causing the problem. Another band-aid on a wound without treating the infection.
Lifelong Medication Use. When you stop Ozempic the weight comes back. What happens when you become pregnant? Breastfeeding? Need cancer treatment? Or any other reason out there that medications must stop. I would like to see answers to this before I would ever recommend someone start a lifelong medication.
Health at Every Size. Dr. Bulik also thoughtfully points out the fact that Ozempic may have an impact on the growing movement toward health at every size and fat positive groups that are pushing society to look differently on how we view weight. She writes, “Is there still a place for these groups, or will the widespread use of these medications actually lead to a new flavor of discrimination, “Why would someone CHOOSE to remain fat when these medications are widely available?” This is where I start to see a very large problem and gap between how society views fat and how people in these groups view fat people. To me, fat is a body descriptor. Just like thin, brown eyes, long hair, etc., and all of these descriptors are beautiful. They are all expressions of our human bodies that lead us through life. Someone who is fat may be medically healthy. Someone who is thin may be medically unhealthy. Just as though we cannot tell who has an eating disorder by viewing their body, neither can we tell if someone is “unhealthy” by viewing their body. This is the vision these groups promote. I highly agree with this vision and think it leads to healing and both mental and physical health. So why someone would “CHOOSE” to remain fat is not the problem, nor will it ever be relevant. Its highly dystopic to think we will ever live in a world where everyone’s bodies are the same size and fatness does not exist. I certainly would not want to live in a world with no body diversity. Instead, we should be asking, how do we better recognize medical problems and treat those? Can Ozempic improve those regardless of what happens with weight? If we were prescribing Ozempic to improve actual health metrics, I would not be writing this opinion piece.
Weight is the Wrong Target Mechanism. Which brings me to the statement I keep repeating over and over: Weight is the wrong target mechanism. In the mental health field when we develop treatments, we have to first show that a ‘target mechanism’ that is related to our outcome of interest, is impacted by the treatment we are developing. Weight is not the mechanism by which health is impaired. As stated above, you can be thin and have poor health. You can be fat and have poor health. What we actually need is to focus on the underlying mechanisms that lead to poor health if we want to improve health. Not weight. This is probably another blog post in itself. The main point is, weight is a problematic focus, whether that focus is with Ozempic or any other form of intervention to ‘so called’ change weight.
Side Effects. I haven’t delved into this and won’t go into detail. But this really needs to be paid attention to. I’ll just leave you with a post from a mom’s group that I am in. A mom in the group asked for experiences with Ozempic and the overwhelming response was negative. This is not an eating disorder, body positive etc group- it is a general moms group. Most of the time I see a lot of pro-diet culture in this group. But here is a sampling from one mom in response to this issue, “Don’t do it! Yes I lost weight-but I started getting dizzy and passing out almost daily before stopping and developed POTS. I stopped and my POTS went away but my stomach is all messed up, my period is irregular, and I am constantly constipated. If I could go back in time I would say no. The things I am dealing with it are not worth it.” Would you willingly take this medication? Do you know what else causes dizziness, constipation, and passing out? Not eating regularly (i.e., an eating disorder).
What would Really Solve the Issue. Systemic change. Combatting poverty. Regulating Big Pharma and For Profit food and health companies. Universal healthcare. Medical professionals treating everyone equally regardless of their weight. Getting rid of constant societal messaging that we should diet, limit foods, and lose weight. Accepting bodies of all size. Stopping our overfocus on appearance, what someone looks like on the outside, and anti-aging. Promoting food variety and regular eating. Pushing for joyful movement. Practicing body gratitude. All of these things would actually improve the health of our society. I have little hope a little pill (or shot) will be the trick.
*weight categories are always in quotes because they are based on the highly flawed body mass index as a metric
Thank you to Dr. Irina Vanzhula, Dr. Hannah Fitterman-Harris, and Samantha Bedard for providing feedback on earlier versions of this post.