A New Drug, An Old Diagnosis

TGIF! It's great to be back!

Let's get into it. GLP-1s are everywhere so its only fitting to write about it. What I'm particularly interested in is that GLP-1s work mostly in the brain to regulate appetite. It also decreases glucagon in the blood and liver so the liver stops producing too much glucose, and it increases insulin by minimizing the delay in insulin release ^[1]. It binds its own receptor on the pancreas and tells it "go ahead and release insulin," but only when there's already glucose around (from eating). So you don't get as hungry (brain), and your brain thinks you're full before you've eaten much.

When I was younger, I think I was watching some reality show or documentary, and saw a story about a girl with diabulimia^[2]. She would avoid using her insulin to lose weight. And this GLP-1 explosion makes me think about how this is a new version of an eating disorder, except instead it's the general public abusing a weight loss drug that was originally created to help people manage appetite in patients with type 2 diabetes.

Just to summarize how T2D actually happens: excess visceral fat secretes inflammatory signals that jam the insulin receptor's signaling cascade, so insulin can bind fine but the message never gets through^[3]. Regulation goes out of whack, glucagon stays high, and hyperglycemia follows. Over time the pancreas overworks itself trying to compensate, and eventually it can't keep up.

The way GLP-1s are meant to help people with T2D is by regulating appetite in the brain and correcting that glucagon/insulin imbalance. So now they're also a tool that's been picked up for the thing those of us who grew up in the "heroin chic era" know all too well. Eating disorders in diabetes patients aren't new. What I think is new is eating disorders built around medications meant to help people with T2D, now being used by people who were never the intended patient.

To break it down:

What's disheartening are the side effects. Bone density loss is one of the more concerning ones. A 2025 Endocrine Society study following 255 patients on semaglutide or tirzepatide found that the more weight someone lost, the more their hip bone density dropped ^[4], and a separate 2025 report from the World Congress on Osteoporosis found a 12 percent higher fracture risk in older adults on these drugs compared to other diabetes medications ^[5]. The evidence isn't entirely one-sided (some newer data actually shows a protective effect in certain diabetic populations), but the current thinking on the negative studies is that it's less about the drug itself and more about the speed and amount of weight loss, similar to what's seen after bariatric surgery or aggressive calorie restriction and not enough resistance training to compensate for body weight lost. Which further makes the point that GLP-1s are just making that kind of rapid weight loss accessible to a much wider population, including people who never needed to lose weight in the first place.

Muscle loss is another side effect. A meta-analysis of 20 randomized controlled trials found lean mass accounted for roughly 25 to 39 percent of total weight lost on these drugs, depending on which one ^[6]. That means a real chunk of what shows up as "weight loss" isn't fat, it's muscle. The SURMOUNT-1 body composition data shows this directly too ^[7]. It’s important to note that plain old calorie restriction causes almost the same amount of muscle loss, the only thing shown to meaningfully protect against it is pairing weight loss with resistance training, which most people chasing a number on the scale aren't being told to do ^[6]. I think with these kinds of drugs, its crucial to be on a nutrition and resistance training plan, especially for women aged 30 and above.

The drug doesn't distinguish between someone who medically needs it and someone chasing a smaller number on the scale. The body pays the same structural price either way, bone and muscle loss, regardless of why someone's taking it.

And this isn't accidental targeting either. A recent Journal of Advertising study looking at gendered GLP-1 ads on Instagram found that when ads did target a specific gender, 95.6 percent of them were aimed at women, even though most ads analyzed didn't target a gender at all ^[8]. Prescription data backs this up. Women have been getting prescribed these drugs at higher rates than men since 2021 ^[9], and nearly double the share of women got them specifically for weight loss, not diabetes, compared to men (18.6 percent versus 9.3 percent) ^[9]. Women between 40 and 64 are the single largest group receiving these prescriptions, right in the window where marketing around menopause and "changing bodies" hits hardest ^[9].

The racial targeting is also an important point. Reporting has pointed out that semaglutide manufacturers have made Black women the face of a lot of their marketing, despite Black communities historically having some of the most limited access to healthcare in the first place ^[10]. And the market has moved past advertising and into product design. SheMed launched as the first GLP-1 brand built specifically for women, with its founder pointing out that women are already the primary consumer group even though no brand had positioned itself around them until now ^[11]. That's not a company reacting to demand, that's a company recognizing there's an entire body-image economy sitting untapped.

Then there's "Ozempic face," a term dermatologists and plastic surgeons started using once patients on semaglutide and tirzepatide began showing up with sunken cheeks, hollow temples, and sagging skin from losing facial fat too fast for their skin to keep up ^[12]. It's not unique to these drugs, any rapid weight loss can do it, but it's become its own cultural shorthand and its own cosmetic procedure market, meaning the same rapid fat loss being sold as the fix is now generating a second industry to fix what the fix did to your face.

None of this is actually new, it's just a new drug wearing an old pattern. Fen-phen, the diet pill combo of the 90s, was pulled from the market after it was linked to heart valve damage and pulmonary hypertension, but not before it had already been marketed hard to women chasing thinness. The packaging changes, the biology of who it's sold to and why doesn't. Now I may be way off base, but these are just the patterns I happen to be noticing.

Cover Photo by isens usa on Unsplash