Growing up in Latin America, Gabriela Ponce said there was a lot of value placed on body image. So, she thought she had an idea of what women should look like: hourglass figures with thin waistlines.
But the magazine covers of slender models, diet culture and celebrity high-energy fitness workouts of the '90s began to influence her. Ponce developed an eating disorder as a teen.
"It was so embedded in the culture that it was hard to escape," she said.
She struggled with bulimia and anorexia into her mid 20s before she sought treatment, which involved a team of psychologists, nutritionists, medical providers and other experts.
Since entering eating disorder recovery over a decade ago, Ponce, who lives in New York City, has become a mother and an athlete, and prioritizes strength, stamina and happiness. She's embraced body positivity and is constantly working on her emotional and mental health to stay in recovery.
But her approach to wellness and life was rocked a couple years ago when she started noticing a cultural shift back toward weight loss and thinness with the explosion of GLP-1 medications.
"To start seeing friends who I'd never considered were overweight … going on these GLP-1s, having access to them, shrinking their bodies in like record time, I found it really triggering," Ponce said.
Now, magazine covers feature professional athletes like Serena Williams, someone she had admired for her success in tennis and different body shape, now the face of a popular telehealth company that prescribes and advertises glucagon-like peptide-1 medications for weight loss, sexual health, hair growth and more.
Ponce's social media feed these days is filled with advertisements from various companies selling the drugs, some with limited medical and mental health screenings or follow-up care.
It presents a dangerous situation for people in the eating disorder community and those who are at risk of developing an eating disorder, advocates and behavioral health experts say.
"There are people who, unfortunately, if they do take these products, it might cause tremendous harm," said Samantha DeCaro, who has a doctorate in psychology and specializes in eating disorder treatment at The Renfrew Center in Philadelphia. "And paired with the accessibility of these products, it's very concerning."
Treating eating disorders in the age of GLP-1s
Historically, GLP-1 agonists have been used to treat Type 2 diabetes and lower blood sugar levels, chronic obesity, certain cardiovascular issues and metabolic complications.
More recently, some drug brands and formulas have been approved specifically for weight loss, and have exploded in use among celebrities, public figures and the public.
Ponce has witnessed first-hand how these medications can make a difference. Her husband takes a GLP-1 for diabetes and health issues related to chronic weight management issues, "and it has transformed his life."
"His transformation has been incredible, and it's all in the name of health. And he is someone who had a medical need to go on it," she said.
Her husband's care is regularly monitored and managed by a health care provider. He has also sought additional social and behavioral health support while taking the medication.
But Ponce fears this is not the case for many other people who may be taking these drugs as a quick or temporary solution to "fix" weight or body image issues.
"This is an area that I think that he is not like everybody else. He is someone who, because of his relationship to me and my history, he's hyper aware of the changes that can happen when our body shifts so much," she said.
For people with eating disorders, DeCaro said these weight-loss drugs could exacerbate their clinical diagnosis, which often includes co-occurring mental health disorders, trauma, substance use issues, social isolation, emotional dysregulation and more.
She's already seeing patients at Renfrew after they've tried GLP-1 medications when they may have been better supported by therapists, dieticians and medical providers versed in eating disorders and disordered eating.
"They're either unhappy with the amount of weight they've lost, they are still struggling with food, whether it's restricting or binge eating," DeCaro said. "There are people who I think maybe had hopes that the product would help their eating disorder or cure their eating disorder, but they end up coming into treatment."
There's also a lot of fear among these patients about coming off the medications, "which complicates things," DeCaro said.
"There's a lot of fear about gaining weight back. There's fear of what will happen to their hunger if they come off these medications," she said. "There's this additional layer of anxiety and fear that we're working with."
Some people may pursue weight-loss drugs instead of seeking treatment for an eating disorder, providers said. Shira Collings, a telehealth licensed professional counselor based in Philadelphia, has recently noticed a drop in the number of patients seeking therapy for eating disorders.
Collings likes to take a "healthy-at-every-size," or "fat-affirming" approach to therapy.
"I think it's more common that if someone is struggling with their relationship with food and especially if they're at a higher weight, now it's just more likely that they would start with a GLP-1 or just say, 'Yeah, that's gonna fix it,'" she said.
But for people with a clinical eating disorder diagnosis, this just delays evidence-based care and the opportunity to achieve meaningful long-term recovery from the disorder, Collings said.
"It prevents people from fully addressing the psychological drivers of eating disorders where the goal is definitely body acceptance, letting your body kind of naturally do what it needs to do, making sure someone is at a weight that their body kind of naturally gravitates to, when they're eating enough and moving in ways that are fun and enjoyable," she said. "And obviously, GLP-1s really go counter to that."
A call for more research, body acceptance and support
Eating disorders are understudied as is, DeCaro said, but at this moment, there's a crucial need for more information and research on how GLP-1 medications can affect people with eating disorders, positively or negatively.
While the drugs could pose a danger to people who are at risk of an eating disorder, or make it more challenging for people in recovering, the psychologist says some patients report the medications have helped them in managing urges to binge eat, and food noise, a mental drive to eat even when they aren't hungry.
"So now we're asking as eating disorder providers for even more research, weight-neutral research, so that hopefully we can really understand how these products might help people or how they might target the brain, the ways in which they might impact biology that might actually be able to help some people with eating disorders," DeCaro said. "But we just don't have the research yet to make recommendations."
For people in eating disorder recovery like Ponce, being surrounded by others using or advertising GLP-1s can be tough, she said. But added that it's also an opportunity for people to check in with support groups, eating disorder specialists, therapy providers, friendships and relationships that strengthen their values of strength, fulfillment and wellness, regardless of the size of their clothing or the number on any scale.
"This is a really good time for anybody who has struggled or is struggling to reach out for help," she said. "Because in community, there's just so much potential for wellness. And I do think that community does a wonderful job in kind of pulling you towards the light and keeping you away from the darkness."