Possibilities and Pitfalls in the Management of Obesity and Co-occurring Psychiatric Disorders (Binge Eating Disorder, Alcohol and other Substance Use Disorders)

Abstract: Obesity is associated with diagnoses that increase morbidity and mortality, including type 2 diabetes mellitus (T2DM), coronary heart disease, and cancer. The mainstay of obesity management is the promotion of weight loss through behavioral, medical, and surgical interventions. Glucagon-like peptide 1 receptor agonists (GLP-1RAs), originally designed to treat T2DM, have emerged as highly effective weight management agents. GLP-1RAs impact food intake through changes in gastrointestinal motility and central satiety signaling. GLP-1RAs are unlikely to eliminate the role for surgical management of obesity in a significant portion of the population to maintain weight loss. Surgical management leads to weight loss through reduced food intake due to anatomic alterations to the gastrointestinal (GI) tract as well as changes in GI peptides produced in various tissues that cross the blood-brain barrier.

Many people seeking weight loss treatment have a history of disordered eating; problematic substance use; or other disorder of reward-seeking behavior. Binge eating disorder (BED) is the most common eating disorder across sexes and is frequently present in individuals seeking weight loss treatment. BED often co-occurs with substance use disorders (SUD): 68% in a recent US-based epidemiological study. BED and substance use disorders (SUDs) share certain behavioral and neurobiological features, including alterations in frontostriatal signaling, reward seeking, and impulsivity. Furthermore, pharmacotherapeutic interventions for both disorders overlap. However, long-term efficacy of currently available therapies is modest.

Increased use of GLP-1RAs in the management of obesity has brought attention to their utility in treating frequently co-occurring disorders, including BED and SUDs. On the other hand, use of medical and surgical weight management strategies may contribute to worsening or emergence of disordered eating and substance use. Siloing of treatment of overlapping disorders, by psychiatrists, endocrinologists and surgeons, may limit collaboration and result in poor outcomes. In this workshop, we aim to review the literature on GLP-1RAs in eating disorders and SUDs and highlight opportunities for psychiatrists to collaborate with weight management experts to optimize holistic care, taking into account the morbidity associated with obesity as well as with frequently co-occurring psychiatric disorders.

Janna Gordon-Elliott, MD, will present an overview of the changes in neuropeptide signaling and circuitry that are thought to result from GLP-1RA administration; discuss how these agents are relevant to the known neurobiology of eating disorders and SUDs; and present clinical case material highlighting the role for GLP-1RAsin the management of BED.

Marra Ackerman, MD will expand upon this discussion with a case of a woman with obesity and BED who developed a restrictive eating disorder following GLP-1RA use and profound weight loss; the case will illustrate challenges in inter-specialty collaboration and communication.

S. Alex Sidelnik, MD, will review the current literature on GLP-1RAs and their potential use in the treatment of AUD. He will discuss existing potential mechanisms of action and potential implications for clinical use.

Mladen Nisavic, MD, will review the existing literature on bariatric surgery and risk for subsequent development of alcohol use disorder, including potential impact on end-stage liver disease and transplant considerations.