A Message of Hope for Eating Disorder Recovery

Many of the posts in this blog reflect my concerns about current treatment practices for people with eating disorders. Perhaps, progress in the field is less conspicuous in these reflections.

A wider lens makes clear how far the treatment of eating disorders has come.

Access to care is the most widespread and significant change. The number of treatment centers—and thus the number of providers familiar with eating disorders—has increased dramatically in recent years. In person and virtual care allow anyone in the country to find trained providers. The clinical options used to be a handful of programs run by a few dedicated clinicians and now are too numerous to count.

Similarly, information available about eating disorders comprises of a few books and only a few perspectives. Now the range of sources to learn about eating disorders is vast. It’s almost impossible for someone to feel completely alone with their eating disorder anymore once they started looking for others like them.

With more people vocal about eating disorders, the broadening of social acceptance of all body types has grown as well. The body positivity movement ranges further into our culture than ever in recent years. Even if the pendulum is swinging back at times—now due to the use of GLP-1 medications—progress is still evident.

More treatment also opens the door to new ideas about therapy and recovery. Different ways to approach therapy and recovery give patients many ways to find the right path for them. Treatment is no longer one size fits all.

The burgeoning medical interest in eating disorders, spurred in large part by patients on social media, promises a future with concomitant treatments in addition to therapy. Various medical illnesses connected with eating disorders, elucidated in detail in recent posts over the last few months, are going to provide avenues for recovery for many people in the future.

I wanted to end the year with a message of hope. There are many ways to seek help and recover from an eating disorder, more than ever before. It’s ok to be picky and find the treatment that fits. Once that happens, hard work and commitment will help many people find peace and well-being in the recovery from their eating disorder.

A Philosophy of Treatment for Chronic Anorexia Nervosa

Treating chronic restrictive anorexia remains difficult and greatly unchanged in recent decades. Other eating disorders morph over years of an illness into new iterations of symptoms with varying types of treatment and leading to more successful outcomes. Chronic anorexia seems like a different illness altogether.

The disorder only really has one symptom: severe food restriction. These people continue to restrict over many years and decades. For some people, the long period of being malnourished leads to extreme hunger that takes over and leads to binging or eating/purging over time. A small percentage of these patients—the ones I’m talking about—only restrict and can’t stop no matter the severity of the medical illness and even when faced with imminent death.

There is no sense of vanity about weight or size but simply an inability to overcome the thoughts to restrict which function more like commands than how one perceives typical daily thoughts. The thoughts are to be obeyed.

Over the years, numerous studies focused on a wide variety of medications and treatments without benefit. Doctors have studied procedures as well such as Transcranial Magnetic Stimulation and ketamine infusions alone others. Nothing works.

Recently, links between this type of Anorexia and Autism, PTSD, ADHD, mast cell activation syndrome and metabolic disorders have been suggested. There is no research yet definitively connecting any of these disorders and no treatment options known to be helpful. However, new ideas about restrictive anorexia have spawned theories about the underlying causes and possible treatments.

My approach with people with this type of chronic anorexia is to create highly individualized treatment plans. The plan is to work with a team of clinicians who are right for this person, address any medical issues that come from chronic anorexia, clarify goals and above all create treatment based on medical knowledge, understanding, kindness and compassion.

A plan that incorporates all these facets ensures that the progress is appropriate for each person and focuses on the needs and goals of each individual. No plan can prioritize other ideas such as legal protection for the clinicians, the punitive approach of residential treatment or unrealistic goals. The purpose of treatment needs to center on the person’s life and well-being.

The approach to help people with restrictive chronic anorexia is different from other eating disorders. I suspect one day there will be a clearer medical explanation for this illness and new types of treatment. However, there is enough knowledge now to often help these patients get a lot better.

Eating Disorders Are Not (And Have Never Been) About The Food

Recent blog posts reflected on the receding body positive movement, the collective idealization of thinness and the promised land of medications that will fix all our problems. As too many of us flock like moths to the fire, we forget there is no magic cure to our food and body woes. The myriad reasons weight loss, food obsession and eating disorder behaviors run so rampant in our society won’t change with one miracle.

The most common and powerful adage in eating disorder treatment is that it’s not about the food. The onset and diagnosis of eating disorders start with behaviors, weight and health. Long after these symptoms normalize, the underlying cause for the eating disorder emerges.

There is no question that normalizing eating and nourishing one’s body consistently is a foundation of treatment; however, eating disorders stem from emotional, existential and psychological struggles. Pretending otherwise only ensures lifelong discomfort and unhappiness.

We are all susceptible to the cultural pressures for thinness, but not everyone develops an eating disorder. Some people have a genetic predisposition. The large majority have psychological and emotional underpinnings—elucidated at length in this blog—that transform disordered eating into an eating disorder.

The marketing of magic drugs to turn off food noise conveniently avoids and ignores the emotional needs for people with eating disorders. Since regulating food and weight through recovery never leads to truly getting well, medications won’t be any more effective. The cynical conclusion is that eating disorders and disordered eating are just about the weight and food. Feelings will be ignored at our own peril.

The result is likely to be a strong and prolonged backlash of weight gain and compensatory eating after the medication-induced food restriction. As more people need to go off medications due to side effects, rapid weight gain and the flooding with old feelings are going to affect many more people in severe ways.

The solution is not to lose track of emotional needs or allow the thinness obsession to obscure deeper meaning in life. No drugs will really affect our need to be human and attend to our emotional selves.

The Paradox of Having Too Many Treatment Programs

Ten years ago, I was still writing about the lack of treatment programs available and how damaging this void was for people with eating disorders. Now, the opposite is true. There are so many programs, it’s hard to keep track.

No longer are people languishing at home desperate for more help. The broader issue now is that there are so many spots available in these programs that treatment is an easy decision for an outpatient provider or patient to choose.

A clinician needs to assess the pros and cons for each person to go into residential treatment. When someone is struggling and battling the internal struggle with the eating disorder thoughts, a program is not always the best option. Treatment or not, each person who is in recovery will have long periods of battling these thoughts and trying to move forward. Every moment of struggle doesn’t merit a treatment program.

Working with someone through the recovery process means tolerating the difficulty of progress and struggle. Of course, the patient bears the burden, but clinicians also need to tolerate difficult periods and allow the person their own struggle. Jumping to treatment ultimately shows a lack of trust and confidence, not always a sign of caring.

For some people, programs don’t really help. The outcome might be temporary improvement in medical symptoms but no change in the psychological part of the eating disorder. It’s just as important to realize that some people need outpatient treatment even while they struggle because that’s the way they can get better. The alternative of available programs doesn’t mean residential treatment is the right answer for everyone.

The explosion of programs has greatly improved access to care which was a significant barrier to recovery in the past. Clinicians who treat people with eating disorders are thankful for the change. Now, the provider also needs to weigh when treatment is appropriate and be sure to consider what is best for each person.

Relying on a program when things get hard in therapy isn’t always right either. Recovery is hard, looks different for everyone. The best definition I have for recovery is being able to live a life not dominated by the eating disorder.

Recovery is not the promised land of happiness. It means living your life with minimal impact of the eating disorder. Treatment is a part of the process but not a panacea.

The Nuances of Food Noise

Food noise is a novel term propagated by social media. It may have no clinical relevance but there is a groundswell of laypeople who identify with the concept. However, as with most social media phenomena, clinicians need to recognize the term and create clinical meaning for it.

Food noise represents the unwanted and persistent thoughts about food that some people experience and which are purportedly diminished or eliminated by GLP-1 agonist medications like Ozempic.

The most significant problem with the term is the implication that anyone with thoughts about food and weight has food noise and that this experience is similar for everyone.

Using a colloquial term to describe the experience of thoughts about food and weight is helpful. When people have an easy way to describe their internal stress, they feel less alone and less afraid of the reason their thoughts are so pervasive. Certainly, the glorification of thinness and fear of fat in this country create both anxiety and fear about eating regularly which leads many people to have these types of thoughts.

There is a big difference between concerns about food and intrusive, distressing eating disorder thoughts. These thoughts can be so consuming it is hard to function at school or at work. The thoughts can be so loud that people struggle to engage with anyone in their lives since they have no ability to focus on anything else. The severity of eating disorder thoughts typically exceeds the concept of food noise by many orders of magnitude.

The last concern about food noise is the promise that new metabolic hormone medications will make the thoughts go away. The promise of a magic fix for eating disorders and disordered eating that plague our society is too good to be true. These new medications are more likely to line the pharmaceutical company pockets rather than solve a cultural epidemic.

As I have written extensively in this blog, many people with metabolic dysfunction benefit greatly from these medications, as do people with diabetes. On the other hand, anyone who takes a high enough dose of these medications won’t feel hungry or have food thoughts, for a while, essentially until their body demands more food or shuts down from a lack of food.

Once the dam of hunger breaks or the body breaks down, some people will be back in the same place they were, struggling with food thoughts and likely hungrier than before due to an extended period of time undereating.

The concept of food noise has significant benefit by helping people normalize their experience around hunger and body image. Food noise makes the most sense as a spectrum of severity of symptoms. Understanding the various ways these thoughts can diminish, not just from the new medications available, is the underlying goal.

For the large majority of people, regular meals through the day and cognitive work on body image thoughts will have more success than any other treatment.

Prescribing Ozempic and Mounjaro just for Weight Loss is Unethical

The GLP-1 agonists have been commercially successful primarily as weight loss agents. Although the medical and diet industries are bent on making this class of drugs solely about weight, I believe in time we will see this period of wanton prescribing for weight loss as unethical except in the most extreme cases of very high weight and concomitant serious health concerns.

These drugs are the first widely used class of drugs which alter the hormonal control over metabolism ranging from blood sugar levels, hunger/fullness, digesting and absorption and utilization of energy.

The powerful effects of the drugs range widely through the body and in ways we have yet to understand. The variety of medical effects already mentioned in this blog are only the earliest signs of what these drugs can do. As our knowledge of metabolic hormones and our experience with these medications grows, we will better understand the potential uses of the GLP-1’s.

Some people have clear beneficial effects which include regulation of metabolism and hunger, normalization of blood sugar, decreased inflammation and control over compulsive urges to name a few. For many of these people, there is associate weight loss, often to a lesser degree. For some, weight does not change or changes minimally even when health clearly improves.

Many people who take the GLP-1’s solely for weight loss experience something very different. They take a larger dose typically and have significant decrease in hunger and increase in fullness. Over time, they eat very little, lose weight rapidly and develop signs of malnutrition.

Often after a couple of years, they stop the drug due to the inability to digest food and severe constipation. Off the medication, they usually gain weight rapidly. It appears that these people don’t have a metabolic disorder helped by this class of medication. Instead, the drugs decrease food intake and weight but only to harm one’s health.

From my vantage point, these patients often see online doctors or primary care doctors who ramp up the dose quickly for the immediate desired effect without paying attention to the medical consequences. These patients should not be on these medications since there is no medical indication. In the end, they experience only damage to their body.

GLP-1’s need to be prescribed to treat medical conditions like diabetes or metabolic dysfunction. Using them just for weight often causes long-term harm. It’s hard not to believe the weight loss indication was a reaction to the societal and medical myth that larger bodies are a sign of poor health. Instead, let’s use these drugs for medical benefit, not for the problematic focus on weight loss.

In Person Sessions are a Necessary Part of Eating Disorder Recovery

The further the pandemic recedes, the more our lives are virtual. So many aspects of daily life had digital components in 2019, from work to personal to social. Virtual professional meetings or conferences, virtual time with friends eating or watching movies or playing games, virtual appointments were already common. It’s clear the pandemic accelerated the transition to digital lives to the new way we live.

I wrote several posts about the pros and cons of virtual treatment for eating disorders during the pandemic. In the short term, the pros and cons balanced each other and didn’t seem to decrease the opportunity to work on recovery and get well.

Now, several years later, virtual treatment is also the norm. Many therapists, forgoing to hassle and expense of office space, have fully remote practices. Many treatment programs offer virtual outpatient options. Some new treatment programs are solely virtual.

As with all eating disorder treatment, no systematic studies exist to study various forms of treatment to figure out if virtual options are even effective.

Patients who have struggled with residential treatment or who are ambivalent about recovery choose virtual programs because they are easier to attend. Similarly, patients more ambivalent about care choose virtual therapy for the same reasons.

The transition to this type of care still offers easier access and convenience for everyone while focusing on the promise of equally good care. However, my initial assessment was based on two factors during the pandemic that don’t apply now. First, most patients were continuing care established in person. Previous in person care already broke down barriers towards progress and ways patients with eating disorders hide that strengthen the illness. Second, we were all sequestered so sessions occurred usually without many distractions.

Now people seek treatment solely virtually without ever meeting the therapist in person. They are distracted by many things in life and even on their screen. It’s too easy to show up for therapy but never fully engage. Being in person forces the kind of intimacy that can be overwhelming but also insists that the conversation addresses the fundamental issues of recovery. Virtual sessions enable the eating disorder to remain hidden.

Weaving virtual sessions into recovery can and will always be useful. Allowing people with eating disorders to enable their illness by using the virtual room to hide does people a disservice. However, balancing in person and virtual sessions can be the norm.

As I have written extensively in this blog, recovery necessitates finding things in life as or more important than the eating disorder. That process always involves personal relationships as well, the therapy relationship representing the first step towards engaging in the world. A virtual relationship alone won’t be enough to make that transition.

The Failure of the Body Positivity Movement

The thinness bias and privilege remain strong and ever present in our culture. As much as various groups try to promote body positivity and the general notion that we are all built differently, thinness is still considered central to status and achievement.

The societal fallout from the thinness bias are mainly two things: low self esteem in young people and the high prevalence of eating disorders. The need to be thin means people never feel thin enough and scrutinize their bodies, and themselves, with a negative view. The urgency of being thin also determines the large number of people looking to lose weight. Restricting food is the number one risk factor for developing an eating disorder.

Only a couple of years ago, a turn for the better in popular culture through body positivity seemed imminent. The opening signaled the broader acceptance of varied body types and a turn away from vilifying larger bodies. Language started to change. The fashion industry started to shift. Some people tried to take back the word fat from a slur to use it literally and unemotionally. These steps were promising.

Yet the tide turned quickly. The pressure for thinness quickly overtook popular culture, and body positivity was just another failed attempt to normalize body types.

It’s easy to blame new trends. The most obvious change was the introduction of the GLP-1 agonist drugs (Ozempic et al.) which elevated weight loss as the number one goal and became the newest holy grail to magical changes in our bodies. People more focused on health and well being were inundated with ads for the new drugs. Social media zeroes in and people losing weight. Family and friends talked endlessly about the new drugs and marveled at their magic weight loss. A developing trend couldn’t withstand this cultural juggernaut.

These medications reflect not just the newest weight loss promise but the battle between attempts to shift cultural norms about body shape against capitalist pressures to make a buck on our fears. We live in a world where corporate demands triumph over our well being time and again. If new money making ventures exist, there is no one protecting our medical and mental health.

Weight is a very vulnerable part of our psyche. We have been programmed to focus on thinness as health and success and are susceptible as a culture to any promise of that achievement. Even when movements attempt to circumvent the pressure to lose weight, new options and advertising win each time.

The marketing of the GLP-1’s easily overtook a burgeoning social movement and has lined the pockets of the pharmaceutical companies and all the side businesses that cropped up around it, online doctors, pharmacies and compounding pharmacies.

I have written extensively about these drugs as the first of a series of gastrointestinal hormonal agents coming out in the next decade. We don’t really know what these drugs do yet but they’re not really weight loss drugs. Cynically, the pharmaceutical companies knew that’s where the money would be. These drugs will turn out to be very helpful but in ways we can’t yet understand.

People need knowledge and protection from big industry. Doctors need to inform patients about the true nature of weight and health and the risks and benefits of the GLP-1’s. People in the United States may often have access to top notch care but at what expense. I don’t know that these trends will change any time soon, but the healthiest patient is not only the one prioritizing health over weight but also the best informed.

Please Stop Saying “Just Eat” to Someone in Eating Disorder Recovery

Despite the increased awareness, ignorance about the cause and treatment of eating disorders still runs rampant. Recovery, while very possible for many people with eating disorders, is still difficult and prolonged. The age old mantra of “just eat” is still surprisingly prevalent.

For people without eating disorders, eating is an automatic part of life. If you’re hungry, eat a meal. If it’s lunch time, eat lunch. Being hungry, eating and then becoming full is part of any normal day, several times per day. Even for people with disordered eating or overly concerned with weight, for the most part they still eat regularly enough throughout the day.

Eating disorders create an entirely new set of rules about eating. The rules involve not eating, delaying food as long as possible or eating strictly small amounts, to name a few. The rules are not logical or reasonable but are fixed in stone. If the rules are broken, there is punishment: binging, purging, over-exercise or starving, to name a few.

Just as importantly, the rules are so fixed because the foundation of the eating disorder is most often psychological. Following the rules can create order and structure when life feels unmanageable like for people with post traumatic stress disorder. The rules might be due to Obsessive Compulsive Disorder so they are almost the law. Or the rules are the only way a person knows how to manage living like for people who first developed their eating disorder at a young age.

For people trying to support someone in recovery, saying “just eat” feels upsetting for a number of reasons. First, they feel misunderstood, not heard and alone. They hope the people who care about them understand that they need reassurance, comfort and support, not an ignorant statement that just makes them feel worse.

Second, supporting someone in recovery means understanding that the psychological and emotional trials of recovery are the hardest part. Eating may be hard, but support that reflects understanding and knowledge always feels more comforting.

Third, saying “just eat” feels as demeaning and punishing as the eating disorder itself, which is often very harsh. People need calm and caring support that counters the eating disorder, not another critical voice to manage.

Education about eating disorders is so important to support people in recovery. People who are trying to support someone with an eating disorder need enough knowledge to be supportive in the most effective way possible. “Just eat” will never be helpful. Instead, “I am here for you” or “How can I help” will always work. Kind and caring words will always make a difference.

The Treatment and Outcomes of Chronic Anorexia

The last few posts summarized new directions for diagnosis and treatment of eating disorders, primarily around concomitant psychiatric and medical illnesses. Treating these issues can enhance and improve overall outcome.

However, I don’t want to be misleading. The treatment of anorexia remains prolonged and difficult for many people. Recognizing new ideas for treatment is promising, but research into chronic anorexia in particular has not led to any options that vastly improve outcome.

Of all the eating disorders, anorexia is the hardest to treat with the lowest success rate. Research into these diagnoses tends to focus on anorexia just for this reason.

The improvement in treating anorexia is likely to uncover a variety of causes of the illness from trauma to autoimmune disorders to hormonal dysregulation and more. No one diagnosis or treatment is likely. Anorexia will much more likely be an umbrella for various illnesses and causes.

A significant percentage of people with anorexia seek treatment early and find that the persistent thoughts to restrict food dissipate quickly enough to lead to significant recovery. The increased access to diagnosis and care has helped these patients enormously.

However, there is also a significant percentage of patients who don’t respond to initial stages of care. Often residential treatment only hardens the resolve of the thoughts to restrict and the anorexia becomes chronic.

These patients need an outpatient team which typically involves a doctor, therapist and dietitian and often other group treatment or outpatient programs to maintain stability and build towards a slower recovery.

Fundamentally, recovery for this group involves setting a meal plan and following it. The eating disorder thoughts for some people only get louder and stronger when following a meal plan so often much more individualized care is necessary.

For these patients, recovery inevitably means pushing through a prolonged period of internal struggle between the desire to be well and have a larger life and the extreme internal pressure of the eating disorder to follow the rules of restriction.

This battle between these two sides often feels like an internal war that can be excruciating.

This treatment plan can and often does work over a period of years. The question is not whether this plan is successful but whether each person can tolerate the distressing process. Support from a dedicated and caring team makes all the difference, but the process remains difficult and lonely.

Hope and care are the foundation of success in recovery from chronic anorexia. People absolutely do get well. Continued understanding of the underlying causes will, hopefully sooner than later, offer other options for treatment.