The Unexpected Opportunity of Government-Approved Low Cost GLP-1’s

Last week the announcement that GLP-1’s would have price caps in 2026 was no surprise. Anyone following the GLP-1 industry knows that these meds are a phenomenon, a capitalist, not medical, breakthrough. With lowered prices and pill versions fast tracked, Ozempic et al. changed the landscape of the profitability of health care and the entire medical/diet/exercise complexes.

Rest assured, these changes are not related to the overall health of Americans. All signs point to a market too large for the current system to handle. Compounding pharmacies and online GLP-1 bodegas swept up the leftover profit with only a faint whisper of medical attention. The online companies have more in common with a smoke shop than a medical office.

No one knew what these meds were going to do to our society. Anyone and everyone feels drawn to the miracle shot and the fantasy, not reality, of a perfect body. From people who were minimally affected by media and thinness to those with lifelong eating disorders, people can’t escape the lure of the magic injectables.

Not only are the medications here to stay, but they also have changed medicine for good. After years of blaming patients for their various maladies due to being overweight, doctors now have a supposed cure at their disposal which is reinforced to patients every minute on social media, pressed upon clinicians by big pharma and suddenly available to most people by the government.

The next step is clear for medicine, even if the goal is a stretch for the zombie-like approach to medical care these days. Rather than follow the pharma company’s and health insurance juggernaut’s recommendations, doctors need to figure out how to use these medications wisely and simultaneously phase out the reliance on blame and shame about weight as an excuse not to practice medicine.

These medications help a large number of people by treating diabetes, regulating the gastrointestinal system, managing metabolism, decreasing inflammation and aiding in sobriety. Many people benefit from much lower doses than recommended, and the benefits of the GLP-1’s can buoy people to look to other ways to improve health. No doctor should treat the medications as a magic fix and absolve them of the responsibility for improved health.

These medications are likely to be the truest test to see if medicine can function with some autonomy from the capitalist system. Health care is a the fastest growing part of the economy. Financial firms are aware of the amount of money available in this industry, as evidenced by the investment in eating disorder treatment, for example. Doctors often work for large conglomerates now and find themselves drowning in bureaucracy and overwhelmed by messages from industries with ulterior motives.

Can GLP-1’s be an entree into practicing better medicine? Can doctors use this intervention to help patients see the benefit of preventative medicine? Can the lure of weight loss, the unabashed panacea of the medical establishment, help doctors speak more openly to patents about their actual health, not just weight?

Perhaps it’s an overreach to imagine such a sea change in health care, but access to these injectables will bring patients into the office and give doctors a captive audience to listen to broader ideas about health. Even more importantly, patents can start to trust doctors and the health care system again.

There is no point questioning the utility of these meds. They are here to stay. Instead, we need to accept the change and consider how medicine can improve from here.

Why is Eating Disorder Treatment an Existential Experience?

After the stabilization of food, attention to meal planning and work on identifying hunger and fullness cues, eating disorder treatment is an existential process at its core.

Eating behaviors are largely unconscious and automatic. Similar to other animals, the human drive to eat and survive is necessary for our species. The conscious ability we have to decide what to eat, when to eat and how to eat pales in comparison to our fundamental need to eat to live. When given the choice between any philosophy about eating and food as survival, the human instinct to persist always wins.

Regulating eating patterns enables us to feed our bodies appropriately. Within reasonable guidelines, our bodies don’t care too much how we eat but don’t like to be subjected to insufficient eating over long periods of time.

What makes eating disorders so intractable is really not about the food. Instead people with eating disorders develop all psychological, behavioral and emotional aspects of their lives around the rules of disordered eating. Disentangling this web feels like tearing apart the soul, an unenviable task for anyone.

Eating symptoms start at a young age and fill the need to learn coping skills in the formative stages of life. At a time when identity is vague, emotions are strong and the need for an anchor overpowering, food and body can become an incredibly stabilizing force.

People often turn to food to manage all kinds of emotions from frustration to sadness to joy. For many, food is an automatic way to experience and tolerate emotion and experience. Eating behaviors obviate the need to look for other ways to cope.

Body shape and eating behaviors are powerful means to create identity. Our world values public food restriction and thinner bodies as true achievements and as signs of moral superiority. In this regard, some eating disorders provide an immediate identity that is very grounding.

In a much more painful context, people who spend years of their young life in treatment can develop an identity as a scapegoat and identified patient in the family. The personal recognition of attention by being sick can create identity that is painful and limiting, but equally powerful.

These are a few examples of how an eating disorder can affect psychological development. The effects on body and eating patterns are profound and the creation of a framework to understand and oneself very straightforward.

Then, after the focus on food, therapy needs to recognize how strong the psychological hold of an eating disorder is and create a path to learn an entirely new way of being. In therapy one can work on finding new coping mechanisms for daily living, experience emotions in different ways and explore a deeper sense of identity outside of food and body.

These are not simple tasks. Learning so many ways to function in the world demands a willingness to remake and rework our fundamental sense of ourselves and to open up difficult and often frightening vulnerabilities.

No other mental illness necessitates therapy on such a profound level to get well. Recovery is so hard because one needs to truly break down the self built on eating disorder beliefs and find new ways to exist in the world. The result of this work is very powerful and meaningful. The path is hard.

Patients who get Stuck in Residential Treatment

In recent years, I have seen more people go to treatment around ages 16-19 years old who proceed to get trapped in several years of an endless cycle of residential and outpatient programs. Although some patients did go through similar experiences in the past, the number of people languishing in this cycle seems to be increasing.

Typically, these are young women with anorexia who have little incentive to change their eating, for either psychological or physical reasons, and who are very vulnerable to the messaging in eating disorder programs. These messages instill blame and shame around not being able to “fully recover,” thus reinforcing the negative self-image at the heart of an eating disorder.

The combination of a sense of failure to follow the guidelines of programs and the shaming about having an eating disorder leave this cohort of people hopeless and alone. Even involved families are convinced that there is no other option for recovery.

These patients are forced to integrate the hopeless and helpless state as part of their eating disorder identity and then feel the pull give up on themselves and their future. The resulting trauma from treatment often overrides even the struggle with the eating disorder itself. To a person, this cohort reports that their self-worth tumbled dramatically after entering treatment.

Some find ways to exit the cycle often through extreme measures such as a feeding tube for regular nighttime formula feeding or avoiding any health care providers who might force them into treatment again. The result is more isolation and increased fear of seeking any help that may lead to being imprisoned in treatment again.

It’s hard for me to ignore the fact that private equity investment in eating disorder treatment seems to encourage a revolving door of patients who provide an unlimited pool of insurance money for these programs. For the group of people in and out of treatment for years, it’s clear that the current state of eating disorder treatment is not working. No one should have to repeat treatment that’s punishing, cruel and ineffective.

That’s one reason I’m looking into other possible medical causes for some eating disorders. Many of those mentioned above have MCAS symptoms, which I have written about in recent posts. Providers ought to include MCAS screening for newly diagnosed people with eating disorders, especially Anorexia, to assess if the difficulty eating is connected to MCAS. Forcing people to eat may very well be torturing them by worsening these uncomfortable, painful and sometimes debilitating mast cell symptoms.

Eating disorder treatment providers need to stop relying on methods that often fail and can be traumatic and instead think outside the box for new ideas. Even referring to higher level of care, which may be clinically appropriate, often causes irreparable psychological harm to people just learning about their eating disorder and starting to get help. Our goal must be to help and heal, first and foremost.

The Hypocrisy of an Eating Disorder Diagnosis

On the one hand, people with eating disorders seem to merit grave concern. Doctors and clinicians worry about the medical effects of any eating disorder, often exaggerate the consequences and easily cross the line to insist on a higher level of care as an ultimatum to stop treatment.

On the other hand, people who lose a large amount of weight are praised for the improvement in their health, how much better they look and are encouraged to be proud of their achievement.

Even more disturbing, people in larger bodies are seen as unhealthy from the start, slovenly, unable to care for themselves and a ticking time bomb of medical illness. Even when larger people heavily restrict their food, rarely do clinicians see any concern about their health.

The hypocrisy around these judgments of people based on size is pervasive, and nowhere is it more prevalent than in the medical field. Doctors who are burdened by an overbooked schedule and demands of endless electronic paperwork rely on losing weight and exercise and the de facto prescription for any illness. Because of the powerful weight bias in our culture, patients always take this suggestion seriously, no matter how unsubstantiated or even absurd.

For many people, eating disorder diagnoses appear to be more about the conflation of weight with morality and inherent personal value in our country than it is about health and well being. The diagnosis applies to certain people in certain situations and not in others. That is not the typical process of obtaining a medical diagnosis.

Young underweight women are much more likely to be diagnosed with eating disorders than anyone else, even with the exact same symptoms. They are also much more likely to be sent on a residential treatment merry go round for months, if not years.

The pressure for profit from the private equity companies, which own most residential facilities, also skews the goals. If profit is number one, then extending treatment for the most vulnerable (who have good insurance) is a reasonable priority. Overall health and recovery don’t factor into these decisions.

Eating disorder diagnoses need to incorporate social stigma, cultural norms and the ever-present media bias towards thinness into a broad understanding of what an eating disorder diagnosis actually confers in our society. Ignoring these trends means turning a blind eye to the fact that eating disorders represent a clinical symbol for our current assessment of the most attractive body.

The diagnostic criteria for Anorexia in the DSM may not change quickly, but clinicians make diagnoses based on cultural norms as much as on the general consensus of a boardroom of a bunch of psychiatrists.

If eating disorders are a bellwether of the state of the cultural messaging about our bodies, then there need to be treatment approaches which meet people where they are, recognize the forces that push them into the treatment world and help them find a way to being well.

Programs run by inexperienced clinicians and owned by financial companies combined with practitioners more wary of their own personal liability and hampered by their own hidden biases only lead to alienating the people who seek help.

The answer is to see eating disorders in all its facets and focus on individualizing treatment. We are not treating a cultural bias applied to humans. We are treating actual people caught in the maelstrom of weight bias.

The next post will address the people who get trapped in an endless treatment cycle and the deleterious effects on their lives.

Does an Eating Disorder Diagnosis Mean Losing Your Humanity?

What happens if someone with an eating disorder chooses to live their life with disordered symptoms? What if they either don’t want to get better or don’t want to go through the painful, and often harmful, treatment process?

Some doctors call this harm reduction or palliative care. Others call it unethical. Which description is appropriate?

Thus far, there isn’t much appetite to talk about these options in treatment. Providers are typically closed minded and even self-protective when it comes to looking into different ways to approach long-term care.

Patients are presented with a standard approach for care which includes therapy, nutrition counseling, psychopharmacology and a primary care doctor. If symptoms are severe, the team will consider higher levels of care: outpatient programs, residential treatment or hospitalization. If patients refuse more care, most practitioners will refuse to continue treatment, ostensibly for the sake of the patient, but largely to avoid liability.

Many of these patients with long treatment histories have either experienced harm in treatment settings or don’t want to comply with the indignities of being locked up in a mental facility. They are entitled to make that choice and still receive more help if they so desire.

Instead, patients who choose not to go to a higher level of care often are abandoned by their support and made to believe their decision is influenced by the “eating disorder thoughts.” In other words, they are not entitled to make a personal decision without blame and shame for making the “wrong” decision. Somehow, the diagnosis of an eating disorder also means losing one’s autonomy.

Why does this psychiatric diagnosis also justify losing independence and the basic human right to choose your destiny?

In my experience, many people with eating disorders are exquisitely attuned to other people, can see emotional and non-verbal cues acutely and accordingly make clear decisions. Other people may not agree with their decisions around their eating disorder but also don’t often try to understand how those decisions might make sense for each individual.

There are other forces connected to eating disorder treatment that seem to be more powerful than simply helping a set of people get better. Financial gain by private equity companies is the best example of exploitation. As I have written many times in this blog, eating disorders are one in a long line of mental illnesses used to justify disempowering a population.

For a country obsessed with weight and thinness, there appears to be some unconscious need to force a group of people to eat large amounts of food against their will while so many other people are lauded for undereating, primed even more by the GLP-1’s.

Only privileged populations are allowed to restrict their food or take medications to lose weight. Others are instead diagnosed with a mental illness and punished accordingly.

Who determines which category we fall into? How can this hypocrisy go unnoticed in our country for decades at this point?

I consider the answers to these questions and more in the coming posts.

Being Judgmental Never Belongs in any Eating Disorder Therapeutic Relationship

In successful eating disorder treatment, a non-judgmental approach is the foundation of therapy. The person seeking help needs to see from the start that the relationship is based on mutual respect, building trust and an immediate sense of being on equal footing.

If the there is even a hint of judgment at the beginning of treatment, then it behooves the person to look elsewhere.

People with eating disorders feel very alone, seek solace primarily, if not solely, from their eating disorder and have come to believe that other people need their help and support but that they need to figure life out themselves.

If there is even an inkling that the therapist will be needy in the relationship, that is also an immediate red flag.

Therapists can show they aren’t judgmental not just through words but through action.

The food journal is an incredibly personal and exposing step for anyone with an eating disorder to take, in all likelihood more vulnerable than any other step in therapy. If the therapist approaches the journal as a collaborative exercise to help learn about both the person and their eating disorder without judgment, the journal becomes not only informative but also a step towards trust.

Therapists also need to take in new and important details of the person’s life and eating disorder with care, concern and compassion. People seeking help are used to clinicians overreacting. Therapists often jump to a safety contract or need for higher level of care when the they feel overwhelmed or scared. It’s a big step towards trust for a therapist to attempt to work together rather than react immediately out of fear.

Third, respect for the person’s autonomy, individuality and judgment builds bridges to trust. Clinicians too often conflate an eating disorder with a lack of reason and functionality as an adult. Much to the contrary, people with eating disorders often have a very astute understanding of the people around them and an acute ability to perceive nonverbal communication. The eating disorder serves as protection from people but not a sign of poor decision making.

Establishing a relationship without judgment leaves room in therapy to explore one underlying experience in most people with eating disorders: shame. Judgment reinforces shame and also hides it from view. No one will allow this painful feeling to emerge in a relationship devoid of trust.

Shame represents the deeper repudiation of oneself and the ultimate fear of being true and real in any relationship. Shame confirms the feeling of not being good enough, not having value, not being lovable. The deepest shame can be hidden under an eating disorder but still erodes any sense of hope and a future.

If judgment pervades a therapeutic relationship from the start, shame forms the bedrock of that relationship and practically eliminates any chance at getting better.

For anyone seeking help for an eating disorder, the first and most important experience to avoid in therapy is feeling judged. I beseech people seeking therapy to pay attention to feeling judged and instead feel able to look for a new therapist who can create an environment moving towards recovery. 

What the Journey of Eating Disorder Recovery Actually Looks Like

Sometimes eating disorder recovery looks like a straightforward, if not simple, path. Work on eating a meal plan, restore health and weight and then waltz off into a well body and healthy life.

Anyone who promises this plan and utopian endpoint is not telling the truth.

Eating disorder treatment is a journey that is deeply introspective with unexpected twists and moments of fear and hopelessness and others of inspiration and joy. In between, there are long stretches of monotony and the mundane.

Recovery looks a lot more like daily life but just more intense. The journey from the reliable prison of an eating disorder combined with the numbness and isolation of that life to the immediate connection to and experiencing of the real world is a lot to handle at first. Being so much more exposed to outside reality and the internal experience of more emotion can be overwhelming, especially since eating and body changes accompany these steps.

Over time, it becomes clear that treatment is a much longer path. It’s necessary to have a companion, aka a therapist, who is knowledgeable, patient and kind. It’s important to try to surround oneself with at least a few other people who care. It’s essential to learn to have compassion and kindness for oneself.

There will be many bumps in the road. The negative thoughts about oneself stay present for quite some time. Moreover, finding things that matter serves a necessary function to show that there is more to life than an eating disorder.

The path is long, usually years long, but it is not a march to an endpoint. It’s a journey that steers life in a new direction, opens up ways to see oneself and the world that were unthinkable before and makes life so different than it might have ever been.

The journey is in fact the point, not recovery itself. The eating disorder was a byproduct of the effects of life and a stopgap measure for survival. Getting well means finding a way to live that matches the true person underneath and her desire to live in the way she wants to live. Recovery is not only playing the long game. It is focusing on one’s life and not just getting by.