Eating disorders are on the rise. GLP-1s could make things worse.

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EXECUTIVE SUMMARY GLP-1 weight-loss drugs are one of the biggest biotech breakthroughs of the last decade. But to some clinical psychologists, they can represent something more sinister—a potential trigger for eating disorders. A new report suggests that the global incidence of anorexia nervosa and bulimia nervosa shot up between 1990 and 2023—by a whopping 71%. By 2023, there were an estimated 18.1 million people living with one of these two disorders. What’s worse is that the number is likely to be much higher than that once we factor in other eating disorders. And, disturbingly, those in the field are already starting to see GLP-1 weight-loss drugs exacerbating the issue.

执行摘要：GLP-1 减肥药物是过去十年中生物技术领域最大的突破之一。但对一些临床心理学家来说，它们可能代表着更险恶的东西——一种诱发饮食失调的潜在因素。一份新报告显示，1990 年至 2023 年间，全球神经性厌食症和神经性贪食症的发病率激增了 71%。到 2023 年，估计有 1810 万人患有这两种疾病中的一种。更糟糕的是，一旦考虑到其他饮食失调症，这个数字可能会高得多。令人不安的是，该领域的人士已经开始看到 GLP-1 减肥药物正在加剧这一问题。

Cheri Levinson is a clinical psychologist at the University of Louisville in Kentucky who has specialized in eating disorders for almost 20 years. She says she’s now seeing more patients with more severe symptoms than at any other time in her career, and that many of them are misusing GLP-1s. “This is the worst I’ve seen things,” she says. Eating disorders are mental health conditions in which people’s eating behaviors impact their health. They include anorexia nervosa (defined by a fear of weight gain), bulimia nervosa (in which people binge and purge), binge eating disorder, and others. It’s thought that some people have a genetic predisposition to certain eating disorders, but that some external factor is what triggers their onset. That might be stress, or social pressure to be skinny. Often, simply restricting food intake can trigger an eating disorder, says Levinson.

Cheri Levinson 是肯塔基州路易斯维尔大学的一名临床心理学家，专门研究饮食失调近 20 年。她说，她现在看到的患者比她职业生涯中任何时候都要多，症状也更严重，而且其中许多人正在滥用 GLP-1 药物。“这是我见过最糟糕的情况，”她说。饮食失调是一种心理健康状况，患者的饮食行为会影响其健康。它们包括神经性厌食症（表现为对体重增加的恐惧）、神经性贪食症（表现为暴饮暴食和催吐）、暴食症等。人们认为，有些人对某些饮食失调症有遗传易感性，但某些外部因素才是诱发因素。这可能是压力，或者是追求苗条的社会压力。Levinson 说，通常情况下，仅仅限制食物摄入就可能引发饮食失调。

Eating disorders—along with the pressure to look thin—were already prevalent in the 1990s (the heroin chic era springs to mind). To find out how things might have changed since then, Ruhai Bai at the Children’s Hospital of Nanjing Medical University in China and his colleagues pulled together data from studies and surveys conducted on populations around the world. The team used statistical models to fill in any data gaps. That research allowed the researchers to estimate the annual incidence of two eating disorders—anorexia nervosa and bulimia nervosa—for each of 204 countries and territories between 1990 and 2023. They also estimated the impact those disorders had on global health by calculating their disability-adjusted life years (one DALY represents a year of healthy life lost).

饮食失调以及追求苗条的压力在 20 世纪 90 年代就已经很普遍了（让人想起“海洛因时尚”时代）。为了了解自那时以来情况发生了怎样的变化，中国南京医科大学附属儿童医院的白如海（音译）及其同事汇总了全球范围内针对不同人群进行的研究和调查数据。该团队使用统计模型来填补数据空白。这项研究使研究人员能够估算出 1990 年至 2023 年间 204 个国家和地区中两种饮食失调症（神经性厌食症和神经性贪食症）的年发病率。他们还通过计算伤残调整寿命年（一个 DALY 代表损失一年的健康生活）来评估这些疾病对全球健康的影响。

The findings, published in JAMA Psychiatry on Wednesday, are unsettling. Between 1990 and 2023, there was a 71% increase in the incidence of those two eating disorders, the team found. Those conditions had a huge impact on global health, too. In 2023, they “cost the world the equivalent of about 3.83 million years of healthy life,” says Bai. Bai and his colleagues expect these figures to continue to rise. In 2023, an estimated 18.1 million people had either anorexia nervosa or bulimia nervosa; by 2050, the team predict, the two conditions could affect 21.8 million people. It gets worse. Those two conditions represent less than half of all eating disorders, says Levinson, who was not involved in Bai’s study. The true impact of these disorders is “probably three times the rate that they’re reporting,” she says.

周三发表在《美国医学会杂志·精神病学卷》上的研究结果令人不安。研究小组发现，1990 年至 2023 年间，这两种饮食失调症的发病率增加了 71%。这些疾病对全球健康也产生了巨大影响。白说，2023 年，它们“使全球损失了相当于约 383 万年的健康生活”。白及其同事预计这些数字将继续上升。2023 年，估计有 1810 万人患有神经性厌食症或神经性贪食症；研究小组预测，到 2050 年，这两种疾病可能会影响 2180 万人。情况更糟的是，未参与白的研究的 Levinson 表示，这两种疾病在所有饮食失调症中占比不到一半。她说，这些疾病的真实影响“可能是他们报告比率的三倍”。

Bai and his colleagues didn’t explore the reasons for this rise (although Bai points out that it can’t be entirely explained by population growth). So how did we get here? Social media may have played a role. “Social media comparisons, influencers, challenges, diet trends can all be precipitating … events for an eating disorder,” says Cynthia Bulik, a clinical psychologist at the University of North Carolina, who was not involved in the new study. Bulik has been studying and treating eating disorders since the early 1980s. “Between 1990 and 2023 there has clearly been an upsurge of those types of environmental exposures,” she says. Many social media users are exposed to filtered and modified images of skinny influencers who may have undergone cosmetic surgery or extreme dieting and who are promoting “thinspiration” or “fitspiration” content.

白及其同事没有探讨这种增长的原因（尽管白指出，这不能完全用人口增长来解释）。那么我们是如何走到这一步的呢？社交媒体可能发挥了作用。未参与这项新研究的北卡罗来纳大学临床心理学家 Cynthia Bulik 说：“社交媒体上的比较、网红、挑战、饮食趋势都可能成为饮食失调的诱发事件。”Bulik 自 20 世纪 80 年代初以来一直从事饮食失调的研究和治疗。她说：“在 1990 年到 2023 年间，这类环境暴露显然有所增加。”许多社交媒体用户接触到的是经过滤镜处理和修改的苗条网红照片，这些网红可能接受过整容手术或极端节食，并正在推广“瘦身激励”或“健身激励”内容。

But users with eating disorders appear to be more likely to engage with this content—and to be fed more of it as a result. When researchers at the University of Melbourne investigated this phenomenon a couple of years ago, they found that the algorithms of TikTok users with eating disorders delivered 4343% more “toxic eating disorder videos” than those of users who didn’t have the disorders. They also got more content focused on dieting or exercising. Many were fed over 1000 problematic videos per month. Bulik describes social media as “quicksand” for people with, or at risk of, eating disorders. The covid-19 pandemic—and the social isolation that accompanied lockdowns—also appears to have contributed to the rise in eating disorders.

但患有饮食失调的用户似乎更容易接触这些内容，并因此被推送更多此类内容。几年前，墨尔本大学的研究人员调查了这一现象，他们发现，患有饮食失调的 TikTok 用户的算法推送的“有毒饮食失调视频”比没有这些疾病的用户多出 4343%。他们还收到了更多关注节食或锻炼的内容。许多人每月被推送超过 1000 个有问题的内容视频。Bulik 将社交媒体描述为患有或有饮食失调风险的人的“流沙”。新冠疫情以及随之而来的封锁导致的社会孤立似乎也促成了饮食失调的增加。

Research conducted in 2021 found that the number of people hospitalized with eating disorders in the US doubled between 2018 and 2020. Researchers don’t yet have good data on how trends in eating disorders might have progressed since 2023. But anecdotally, things seem to be getting even worse. “There are more eating disorders, more severe eating disorders… and we’re seeing earlier ages of onset,” says Levinson. “We’re seeing eight- and nine-year-olds with eating disorders.” “From what I’m hearing and seeing, I am not going to be surprised if that number isn’t at least doubling again,” she adds.

2021 年进行的一项研究发现，2018 年至 2020 年间，美国因饮食失调住院的人数翻了一番。研究人员目前还没有关于 2023 年以来饮食失调趋势如何发展的好数据。但从轶事来看，情况似乎变得更糟了。Levinson 说：“饮食失调症更多了，症状更严重了……而且我们看到发病年龄更早了。我们看到八九岁的孩子患有饮食失调症。”她补充说：“根据我所听到的和看到的，如果这个数字没有再次翻倍，我一点也不会感到惊讶。”

Levinson particularly worries about the impact of GLP-1 weight-loss drugs, which have exploded in popularity in recent years. A Gallup survey conducted earlier this year suggested that 15% of Americans had used one of these drugs for weight loss. And they’re becoming more accessible—drug companies are working on new formulations that are both easier to take and more effective, and many people can buy versions of these drugs from compound pharmacies or dubious online sources. In a small study published earlier this year, Levinson and her colleagues found that 30% of people with eating disorders had used GLP-1.

Levinson 特别担心 GLP-1 减肥药物的影响，这些药物近年来人气爆棚。今年早些时候进行的一项盖洛普调查显示，15% 的美国人曾使用过这些药物来减肥。而且它们变得越来越容易获得——制药公司正在研发更易服用且更有效的新配方，许多人可以从复合药房或可疑的在线渠道购买这些药物的仿制品。在今年早些时候发表的一项小型研究中，Levinson 及其同事发现，30% 的饮食失调患者曾使用过 GLP-1。