After the GLP-1 meds - You Tube bonus!
Some thoughts on working with this in the eating disorder space.
Watch the YouTube video HERE.
What happens after the GLP-1 meds?
A compassionate deep dive from the therapy room.
According to the recent BBC iPlayer documentary, GLP-1 use is more prolific than ever.
1.5 million people in the UK are using weight loss injections.
This is 1 in 46 people (2% of the population).
When you take the meds, you are likely to experience rapid weight loss, at least initially, the average patient losing 15% of their body weight in the first year.
GLP-1 use is likely to increase further as the meds become available as pills, rather than a gruesome injection, in the near future.
Watching the recent documentary, detailing what happens when people stop using weight loss injections, confirms much anecdotal evidence seen currently in the therapy room.
It’s important to acknowledge that for many people, the weight loss injections are a valuable tool on their health journey.
But it’s not an easy ride and they can also come with hefty financial burdens (some selling household items to fund the meds), and health costs such as hair loss, stomach pains and poor sleep.
Several people report feeling extremely unwell when taking the meds but overriding these symptoms due to the colossal weight loss experienced.
The pull to lose weight is understandable. For some it is genuinely motivated by health benefits. But societal pressures remain higher than ever, with smaller bodies meaning acceptance and fitting in.
It’s common practice to take the meds for 4-6 months (this can vary for individuals) but then to stop, due to side effects, financial pressures or maybe reaching a weight plateau.
In the therapy room, I am seeing increasing numbers of clients who were taking Mounjaro, Ozempic, Saxenda or Wegovy but have now stepped away for these reasons.
They are understandably struggling in the aftermath, as their bodies readjust and normal physiology returns.
Food noise returns and it’s challenging to sustain the significant weight loss
“Food noise” describes the persistent, intrusive thoughts about food, people have, even when they’re not hungry.
It’s the constant mental chatter about what, when, and how much to eat, which bubbles through daily life.
One of the celebrated benefits of GLP-1 meds is the decrease in food noise.
This is an understandable and welcome relief, for anyone who is usually food obsessed from dawn till dusk.
GLP-1s increase feelings of fullness and satiety, slowing digestion and reducing hunger cues.
Food cravings and food noise dissipate to a gentle background hum.
For some people the removal of food noise allows a body reset and improved relationship with food, even post-meds.
But for others, who have likely had a life-long difficult food relationship, the meds offer a temporary food-focus respite but are like a plaster, sticking over a gaping wound.
Coming off the meds, some people are experiencing an avalanche of food noise which can feel overwhelming. It has been described as a ‘Switch going back on’.
Even though hunger signals have been significantly reduced whilst on the meds, the body has essentially been in a state of restriction and an extreme calorie deficit, essentially starvation. Naturally, substantial weight loss results.
The tricky thing about dulling down food noise
From many years of working in eating disorders and disordered eating, we know that food noise is often a symptom of past or present undereating – involving mental or physical restriction.
Physical restriction can include: - not eating enough, eliminating food groups or delaying eating.
Mental restriction can include: much judgement around food and not allowing full permission to eat the foods genuinely enjoyed. Someone may be eating a full range of foods but the inner critic is chatising every mouthful. There is still a sense of deprivation.
The Minnesota Starvation Study (1950) demonstrates the potent power of restrictive eating.
The men were starved of food in this post-war experiment and became psychologically obsessed with food, with some starting to binge eat.
Physically, they were also severely compromised with energy levels, libido and temperature regulation impacted.
In fact, several of the men wished to retrain as chefs post-experiment, this being the extent of their food preoccupation.
If food is restricted for humans, it is challenging to sidestep the food fixation that follows.
This doesn’t just happen with people who are underweight.
You can be under-eating in any sized body.
We know that people with eating disorders usually do experience a lot of food noise.
Whereas, if having a healthy relationship with food, preoccupation will be far less. It will be around 20% of the day maybe and will fluctuate depending on lifestyle and habits.
Spending 40-50% of the day food obsessing is potentially a dangerous amount.
With bulimia and binge eating, food preoccupation can be even higher.
And clients with anorexia nervosa can experience up to 100% plus of food noise in their day, as they are even dreaming about food at night.
So although turning off food noise might feel beneficial short-term and it may genuinely help some people reset hunger and fullness.
For many people, this is overriding the body’s natural signals around hunger and appetite.
Post-meds, hunger returns and it can feel terrifying. Any weight gain can feel like intense failure.
For the first time, someone might feel that they have the body they have longed for.
But it is inevitable that some weight gain might happen, as the loss has been profound and possibly unsustainable.
In the therapy room, I am seeing that clients are vulnerable to resorting to behaviours they may not have used previously, in a desperate attempt to keep the weight off.
They become driven by an understandable compelling, addictive need to pursue the weight-loss outcome, never mind the costs.
Binge eating, compulsive over-exercise, purging through vomiting and/or laxatives, chewing and spitting - these behaviours creep-in, in a desperate attempt to hold on.
And any underlying self-worth issues can be amplified through this whole process.
Weight loss becomes the life focus and barometer of success and wellbeing.
Weight loss becomes the life area to control and feel safe.
Weight loss becomes a distraction from other emotional issues going on.
But the danger is that weight loss never feels enough. There is always more weight to lose and the goal posts move continuously.
This is why it is so vital to have some psychological support alongside the meds.
Post honeymoon period
When taking the meds, people will likely experience rapid weight loss at least initially, the average patient losing 15% of their body weight in the first year.
The ongoing impact is more varied.
Some of my clients find themselves eating, despite the lack of food noise, once the honeymoon period passes.
Or when plateauing with weight loss, they become disillusioned and return to food for comfort.
An obsession with weight and numbers can also begin.
My experience from the therapy room thus far, is that the meds are a tool, but they don’t necessarily fix underlying issues with food, beyond the novelty early days.
Rapid weight loss results in loss of muscle over fat, which is not so beneficial for body composition.
It is suggested that people lift weights alongside the injections but some people report feeling too unwell to practically implement this.
Research studies from the documentary indicate that in one to three years post meds, 60-80% of weight loss does return. Again results between individuals vary considerably.
Post meds, body physiology must readjust, with the pancreas struggling to regulate its own GLP1 production. The body may also go into survival mode, trying to reestablish its familiar set point.
Rapid weight loss is always risky and potentially unsustainable.
Research from ‘The Biggest Loser’ TV show six years on, showed that the contestants’ metabolic rates had never recovered, due to their accelerated weight loss experienced.
Working with the drugs in the eating disorder space and supporting clients in coming off them
From the documentary, the advice is to reduce the dosage gradually and with medical support, rather than an all-or-nothing approach.
An ‘exit strategy’ needs to be implemented from the beginning, to plan the longevity of use and create an overall mindset around behaviour and habit change.
Lifestyle shifts are essential alongside, including portion control, healthier habits and strength training.
And relationship with food is key in the mix. Emotional or binge eating is unlikely to disappear permanently through the medication alone.
Poor mental health prior to using the meds may exacerbate potential obsession and fixation over weight loss, self-sabotage and low self-worth issues.
Final thoughts
As a therapist, I believe that it’s important to recognise the presence of GLP-1 drugs, putting aside personal viewpoints.
GLP-1s are not the magic elixir or the devil either. They can certainly be a valuable tool for some.
We need to reduce shame and have open conversations about GLP-1 use. Clients will be tempted by the meds whatever their shape and body size. Fundamentally, everyone has autonomy and choice with their body.
When working with clients, it’s helpful to balance psychoeducation and a harm reduction perspective.
Collaborations between eating disorder services and weight loss drug providers would be incredibly helpful, with guidelines and protocols around best practice.
As the industry is largely unregulated now.
GLP-1s are here to stay and their presence needs addressing with openness and compassion.
What’s your experience with GLP-1 medications? Do share in the comments. Thank you.
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Online 10 Steps to Intuitive Eating - a course to help you heal your relationship with food.
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Eating Disorders Training for Professionals - training for therapists in working with clients with eating disorders.
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Podcast - The Eating Disorder Therapist
I had an appointment with my doctor yesterday. I gave her a letter outlining my complex history with anorexia. My goal was to make sure she had a complete picture before we discussed possible medical reasons for my continued weight gain despite ongoing restriction. She suggested possibly micro dosing with a GLP1 to “kickstart my metabolism.” Ugh! I will be discussing this with my eating disorder therapist!
Thank you for sharing this. I'm starting to see more and more news stories about the increase in eating disorder cases attributed to GLP-1 use. I feel like this was inevitable, given the societal pressures to lose weight and a drug that is essentially causing starvation while reducing hunger signals. You very clearly outline what is happening in a way that I don't think the media has been able to articulate.