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Jason Krynicki will never forget how obesity made him a target for vicious bullying from the time he was little. Those memories haunt him even now, even though he weighs a willowy 127 pounds at age 43.
"You try to eat, and in the back of your mind, your mind still goes back to what people said to you 20 years ago," Krynicki says, recalling how he was derided for his large appetite or the food he ate. Other kids — his doctors, even — called him fat, and worse.
Krynicki, an insurance coordinator in Brick, NJ, got bariatric surgery a decade ago, but during the pandemic regained some of that weight. So his doctor eventually started him on Zepbound, a GLP-1 shot. That took 80 pounds off his frame — too much, causing other health effects — yet he fixates on losing still more.
The increased availability and effectiveness of GLP-1s at curbing appetite is adding to the vulnerabilities for some people prone to eating disorders. They're easy to obtain online, with little screening. Meanwhile, eating disorders are very common. Nearly a tenth of people will meet the clinical benchmarks of an eating disorder at some point in their lives. And, experts say, a far greater percentage of Americans have problematic relationships with eating and body weight that fall short of the clinical definition. So far, very little is known about how GLP-1 use — or misuse — affects people who binge or restrict food, despite the prevalence of those behaviors.
Internal dialogue and an anorexia diagnosis
For Krynicki, meals have become a source of internal conflict, and he knows he ought to eat more and regain muscle.
"I've lost hair," he says, and sometimes he feels light-headed because his blood-sugar falls too low. But, he says, "I still go on the scale like every other day."
He's struggling with an anorexia diagnosis, yet he fears quitting his monthly shots. "I'm afraid that if I come off of it, I'm going to go back to that 267-pound person that had all the medical issues, hated his life and everything about myself."
"Two truths"
One of the biggest problems is that most patients are not evaluated for these disorders when prescribed GLP-1 drugs, says Washington DC psychologist Robyn Pashby, who also sits on the board of the Obesity Action Coalition, a patient advocacy group.
"We're at a point where we need to hold two truths: That GLP-1s are legitimate evidence-based treatments for obesity, but that they also sit inside our culture, which has intense weight pressure, weight stigma and eating disorder risk," she says.
There is a long history of abusing drugs or over-the-counter medicines to lose weight – diet pills, appetite suppressants, diuretics, enemas and the like, says Dr. Samantha DeCaro, who heads clinical outreach at The Renfrew Center, which specializes in eating disorders.
But today's GLP-1s are more powerful and wholly different from earlier types of weight-loss drugs, DeCaro says. She is concerned they are potentially more harmful, because they make it harder for people to nourish themselves regularly, or tune into their natural hunger cues.
And, DeCaro says, weight loss itself almost never addresses the underlying psychology of the food-related disorders she treats, which are complex diseases involving emotional, relational, and biological drivers. "It's very rarely just an eating disorder," she says. "We often see eating disorders with severe depression, anxiety, PTSD."
Like many other experts, DeCaro also worries that the heavy marketing and societal embrace of GLP-1 drugs are bringing back a cult of thinness, including among actors, singers and social media celebrities who previously preached acceptance of diverse body types.
"There were people out there that many folks looked up to who were in larger bodies, and there has really been some grief around losing that representation," she says.
A possible treatment, too
There are some cases where GLP-1 drugs might help those with certain specific eating disorders.
Some people genetically produce lower levels of natural GLP hormones, meaning they do not sense when they are full, and end up binge eating, says Kim Dennis, a psychiatrist and CEO of SunCloud Health treatment center in Chicago.
She's seen some instances where GLP-1s address that hormone imbalance, restore the sensation of satiety, and alleviate those symptoms.
A BMI of 16
But in many cases, Dennis says, the use of the drugs are dangerous. The day she spoke to NPR, for example, she received an early morning call from an alarmed therapist. The clinician wanted to admit a patient with anorexia who was taking a GLP-1 drug, despite having an extremely low body mass index (BMI) of 16 – the equivalent of a 5-foot-3 person who weighs 90 pounds.
That patient was acquiring the drugs online by lying about their weight. Dennis responded: "Help them go to the E.R. right now and make sure that they're in a controlled setting so that they're not taking the medication anymore."
"Atypical" and misunderstood
Of particular concern to Dennis are the many people who are considered "atypical anorexics," or people who starve themselves and meet the clinical definition of anorexia but who are not underweight.
"Those folks in particular are at high risk of being harmed by these medications because many doctors don't know what atypical anorexia is," she says, and therefore might prescribe GLP-1s based on their body size alone.
This is the kind of paradox that Jason Krynicki, the New Jersey man, understands about GLP-1s.
"I still live with the disease of obesity," he explains, meaning his natural tendency to gain weight remains. But that diagnosis can make it hard to recognize he suffers from anorexia, too.
Plus, the added stigma of being a man with an eating disorder meant it took him a long time to admit to himself, and then to his therapists. "Men, we're always told that we can't show our emotions, we don't talk about our emotions," Krynicki says. "We're supposed to be the big, tough male figures."
Today, Krynicki says he's found understanding among peers he works with in obesity care, or who gently encourage him to eat healthy portions to sustain him.
He says he's recovering by building the kind of trusting friendships that eluded him in childhood. "I think if it wasn't for my friends, I wouldn't be here today," he says, "I probably would be in either rehab or I would probably be dead for starving myself."
That support, he says, has been the most powerful antidote.
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