The Use and Misuse of GLP-1’s for People with Eating Disorders

The new GLP-1 agonist medications are a live experiment due to the widespread use, and misuse, of these drugs. Here are my most recent observations and recommendations based on reviewing current research, communication with colleagues and clinical observations of patients with eating disorders.

First, the best approach to the medications is to start low and go slow. Some people even need to start at doses lower than recommended by the pharmaceutical company and often stay at very low doses. The benefits of the lower doses are fewer side effects, more longstanding benefit and time for one’s body to adjust to the metabolic changes. Going too fast leads to more side effects, especially nausea and constipation, which can build over months or even years and lead to necessary discontinuation of the drugs. The drugs work best when the intended use is for gastrointestinal hormonal imbalance.

Second, people on these medications need to have normal hunger cues and be able to eat regular meals. When hunger is suppressed, people end up restricting food and losing weight due to having less food than they need. This strategy is never sustainable as anyone knows who has an eating disorder. Food restriction leads to ongoing medical issues and rebound hunger, if not binging, thus perpetuating the binge and restrict cycle.

Third, the medications are ultimately hormonal in nature, not specifically weight loss drugs. They work by affecting hormones and adjusting how the gastrointestinal system works. At doses that are too high, they can lead to food restriction and severe weight loss with no long term benefit. The mentality one uses to approach the GLP-1’s is critical. They are medical interventions to be used judiciously, not miracle weight loss drugs.

Last, it’s very important that people with eating disorders don’t use these drugs to remain at weights lower than their body can manage. The end result is slower GI system, muscle wasting and many other effects of drug-induced anorexia.

These conclusions reflect my current understanding of the guidelines most useful for people with eating disorders considering GLP-1’s. There is no doubt these drugs are here to stay so a thoughtful, curious and cautious approach is necessary to use them safely. More information is on its way in the coming months.

The Existential Part of Eating Disorder Recovery

The expansion and monetization of eating disorder treatment has led to a primary focus on concrete steps and goals in recovery. Insurance companies demand practical goals for reimbursement, and the corporatization of treatment means less individualized care.

I believe strongly that behavioral therapy is a necessary component of early recovery and has a role in later stages as well. However, in the current jargon, full recovery indicates freedom from food and body thoughts without addressing the element of identity. If treatment doesn’t involve steps to separate oneself from the illness, it’s impossible to be free to live life fully.

Eating disorders encompass disordered eating, compensatory behaviors, body image thoughts and the all consuming experience of one’s mind being taken over by these demands. Recovery needs to help people find themselves beneath the all consuming nature of the illness.

Early recovery must normalize eating to insure one’s body gets the food it needs throughout the day while also minding the emotional and psychological turmoil that ensues. This part of getting well is always hard and is a necessary first step but is just that: a first step.

Treatment that began early in the eating disorder epidemic took the history of mental illness into account and recognized the existential component of treatment. Eating disorders grew out of the cultural imperative to be thin combined with the advent of mass media outlets spreading images of thinness throughout the country.

No one could predict the effect that sanctioned dieting combined with the idealization of thinness could have on a society. As social media made it easier to spread images and messages that propagate dieting and thinness, eating disorders have become endemic.

The nature of eating disorders and the media machine driving them necessitates a deeper dive into one’s identity for true healing. An eating disorder is now considered a widely accepted definition of identity in this culture. It’s easier than ever to eat well enough and be recovered while continuing to base one’s sense of self on the disorder itself.

An existential search for meaning can be painful at times. The work of therapy examines the core sense of oneself and reckons with the underlying thoughts of person, motivation and meaning. This exploration points the person in a direction of how to live life and what truly matters.

The process of pulling away from the safe identity of the illness and identifying the less sure but more genuine idea of being a full person allows someone to fully get well. Without the need for the eating disorder as a pillar of identity, there is much less reason for the eating disorder to linger.

If treatment ignores the key existential step in recovery, wellness simply means eating enough but still creating self around the empty meaning of food and weight. There has to be more to life than that.

Don’t Lose Sight of What Works in Eating Disorder Treatment: Part II

The current eating disorder treatment protocol is focused on weight, meal plans, higher level of care and, sadly, liability. People seeking help confront a tricky dynamic in which their health and well being are not always primary.

In addition, the capitalist effect on mental health treatment affects eating disorder treatment too. Various therapy services and even text therapy allow for easily switching therapists and substituting a professional friend for true therapeutic work.

In this climate, the value of the therapeutic relationship is easily lost. Much has been written for decades about the value of a therapeutic relationship with clear boundaries of time, role and intention. The relationship is open and connected but allows for vulnerability and exploration that modern life rarely affords. In this relationship, the openness allows for the type of therapy that is very helpful for recovery.

Eating disorders, especially anorexia, represent a source of safety and comfort for many people. Food restriction often serves as a means of security and certainty in a world that is anything but. Following the food rules, monitoring effects on weight and making decisions based on the eating disorder represents a source of calm, something that often feels impossible to resist.

Early studies into treating people with anorexia focused on developing a therapy relationship that might circumvent and eventually disempower the eating disorder. Finding new sources of calm through relationships and connection, so the theory goes, could begin to compete with the emotional security of the illness.

Much evidence supports this idea, yet the eating disorder treatment community continues to move towards solely cognitive based therapy or reflexive inpatient treatment for people not sick enough to merit that level of care.

The effect of more surface level care combined with unnecessary residential treatment sends people the wrong message. Full recovery doesn’t entail embracing the illness and creating identity through treatment. Instead, being well needs to encompass identity outside of recovery or illness. Identity can come from within and develop through connectedness in the world.

The treatment community can offer a more complete and fulfilling idea of recovery by returning to some of the basics of helping people with eating disorders. Understanding what people with eating disorders need to get well is a necessary part of treating this group of people.

Don’t Lose Sight of What Works in Eating Disorder Treatment: Part I

All the changes in the eating disorder treatment field distract clinicians from the basic, most effective ways to help people with eating disorders. While access to care and outcomes matter, all those in the field still need to rely on therapy approaches that work.

With that in mind, I think it’s worth revisiting the tried and true ways to treat people with eating disorders lest we forget what types of therapy really help people get well.

Any type of binge eating disorder, including Bulimia Nervosa, Binge Eating Disorder, Compulsive Overeating and Night Eating, responds best to Cognitive Behavioral Therapy (CBT). The first studies that proved how effective CBT is for these disorders were in the 90’s, and nothing developed since is more helpful.

CBT entails writing a detailed log each day of what one eats, whether or not the eating is disordered and, most importantly, the thoughts and feelings around each time one eats.

The log is the centerpiece of the treatment. Assessing the log each session unearths a multitude of critical information about the eating disorder and charts a path to recovery.

First, looking in detail through a day can reveal what thoughts, behaviors and feelings foreshadow a binge. The most likely causes are undereating through the day, emotional triggers or situational triggers. Even though patterns of eating that lead to binges are often similar, each person learns how their individual eating disorder works.

All this new information makes clear the options to circumvent binges. Adding food at certain times of day or acting on feelings in advance are the most common examples of what can change the course of the day. Each step forward empowers the person to see they are not trapped in the binge cycle indefinitely.

Once the eating pattern normalizes, CBT gradually transitions towards the working in new thoughts and feelings around each meal as binging subsides and in everyday life. The therapy can both curtail binging while assessing what someone needs to face other parts of life without returning to the eating disorder. Awareness of thoughts and feelings enables people to learn about themselves and how to cope in new ways.

The path of recovery may seem straightforward from the above summary, but there are always ups and downs in eating disorder recovery. CBT gives a direct route to getting well and makes clear the steps to get there.

All clinicians in the eating disorder field need to remember that CBT works for any binge or overeating disorder and not get distracted by all the new programs. The focus needs to be on helping people get well.

A Brief Cultural Exploration of Eating Disorders in Modern Life

The history of mental illness is inextricably linked to cultural norms of the time. The symptoms of any specific disorder don’t change and have existed as long as we know about the illness. The understanding, interpretation and pathology attributed to those symptoms change with the times.

Eating disorder symptoms are first documented centuries ago, often related to religious-based fasts and asceticism. The existence of anorexia specifically as a reaction to prolonged, forced food restriction is a genetic adaptation that appears to be a reaction to famine.

Cultural understanding and norms shifted the coining of eating disorder diagnoses in the 1960’s and has grown in our social conscience in the subsequent decades with the skyrocketing incidence of eating disorders. Social movements such as pro-Ana or body positivity combined with the expanding treatment industry represent cultural manifestations of eating disorders in our culture.

In recent years, eating disorders captivated the imagination of many subcultures, largely in the western world, and spread quickly through media and then social media. For instance, the apotheosis of thinness idealizes anorexia as an aspirational goal or, at levels of extreme emaciation, demonizes anorexia as a horrifying sideshow. None of these interpretations represent the personal experience of the illness.

All of these reactions to bodies may have some superficial meaning but are also at times a shameful collective experience of appropriating women’s bodies. During the initial rise in eating disorders, treatment took a clear feminist bent and recognized that eating disorders were the latest cultural phenomenon intended to subjugate women as they gained authority. No woman could be as potent when battling their daily lives at the same time as they confronted the endless fight against negative body image.

Once disordered eating, and the eating disorders which ensued for many, leapt from a new epidemic sweeping our world into a mainstream way of coping with the daily stress of living, the treatment industry capitalized on potential financial gain and created a money-making machine cynically based on greed and not the more worthy cause of helping people heal from mental illness.

What is so striking about eating disorders more than many mental disorders is the fundamental connection between cultural norms and the understanding of these illnesses.

Recovery is firmly rooted in identity, culture and politics. Normalizing eating patterns and the return to a healthy body ensures physical health, but true recovery always demands looking deeply inward. Shirking off the need for eating behaviors to define oneself means learning a new way to see identity, find self-worth and indeed create some sort of meaning to daily life. Treatment has as much in common with the philosophical pursuit of being human as it does with psychotherapy.

The overwhelming social media about eating disorders sometimes miss the point of getting better. The idea is not to join an eating disorder community that establishes identity through the illness. On the contrary, meaning grows from escaping the tyranny of body and food.

I have no trouble seeing how these disorders serve as a metaphor for our daily struggles to be human. Sometimes I wish we could see how eating disorders become a way of silencing new voices that need to be heard. Wasting so much time and energy on food and body is never productive. That energy can be used in so many other parts of our daily lives. Recovery almost always means valuing self and relationships to learn how to live better lives and be better people.

Residential Eating Disorder Programs are a Part of the problem in Recovery

The expansion of residential treatment for eating disorders in the last decade transformed the scope and clinical decision making for these patients. The number of programs increased by multiples. Many more patients go to programs than in the past.

It’s questionable whether the steep increase in residential treatment was warranted.

The driving force to expand treatment was financial. Private equity interests supported the expansive growth in programs and transformed access to higher levels of care. Large sums of health insurance money was a clear incentive. Substance abuse treatment provided a model for easy access to insurance dollars that could turn a profit. The quality or even need for so much treatment does not seem to be the top priority.

I had written in this blog about the need for more access to care for years prior to the treatment program boom, but I never could have predicted the capitalist forces that might take over. The number of programs, often staffed by minimally trained clinicians, is not based on need but instead on greed.

At this point, outpatient eating disorder treatment increasingly relies heavily on access to, and the threat of, institutionalization much more than in the past. It’s too easy to ship off patients not making much progress in recovery without any thought about the repercussions of residential care.

The myriad concerns about forcing adolescents and young adults into eating disorder treatment loom large. The flaws and potential abuses in the system are treacherous and damaging. The risk of derailing these young people on their life trajectory is high. Access to more programs isn’t always the answer, and, in fact, there is little substantiated data that supports residential treatment as a means for success. More thought must be given to the pros and cons of treatment programs for young people in an individual basis.

Clinicians can provide the semblance of adequate care by threatening the patient with a program if outpatient treatment does not “work.” However, eating disorder treatment is notoriously challenging. One must expect ups and downs and not resort to drastic alternatives just because progress is slow or uneven. Referrals to higher level of care must be used judiciously and thoughtfully.

Sending a patient off the typical road of their peers has inherent risks. It’s much harder for them, even after one program, to return to the same path as those around them. They struggle to explain how and why they went to treatment. Although some can overcome this new hurdle, many see themselves as defective or unable to progress in their life. The eating disorder becomes too central after devoting months to a treatment program. The separation from typical life itself becomes an obstacle, if not damaging, for many people.

Why have clinicians not taken the helm of treatment decisions for people with eating disorders? The sad truth is that many of the esteemed providers have collaborated with the finance industry-based initiatives to create the glut of programs. The eating disorder treatment community is not coherent enough to resist the influx of this kind of money. Capitalism has power in the medical field to stop even clinicians from doing the right thing.

The path forward clearly includes access to programs. However, treatment providers need to stop being lured by financial gain and the ease of shipping people off to treatment and instead focus on the hard work of helping people recover from their eating disorder.

The Current State of Using GLP-1 agonists for People with Eating Disorders

On first pass, the use of GLP-1 medications for eating disorders was doubtful at best. How could medications meant to suppress appetite and lead to weight loss cause anything but worsening symptoms or relapse?

Over time, this new class of medications has proven to be useful in eating disorder treatment when used judiciously. Following the original guidelines of ramping up to high doses quickly leads to significant worsening of eating disorders, but there seems to be a place for using GLP-1 agonists in some cases.

The most effective use has been for people with binge eating disorder or compulsive overeating. Low doses of this class of medication can curb binge urges and change the hormonal control over metabolism that helps manage urges and cravings. For some people, hunger and fullness cues are more acute on these medications, and the endless need for larger amounts of certain foods is more limited.

It’s crucial to know that many people with these eating disorders have limited or no response to GLP-1’s so the effect is far from a panacea. In addition, there is no way to predict who will respond to the medications and who won’t.

There is much less information using these medications for other people with eating disorders. It is possible that the GLP-1’s can change thoughts about food which may have longer lasting effects on eating disorders, but the risk is also very high that even a low dose of them could lead to relapse. As of now, there is little evidence to even consider these medications for any other eating disorders.

Even for people with binge eating or compulsive overeating, the risk is high that the medications will lead to food restriction and only flame the desire to lose weight by increasing the dose.

The only people I have seen do well on GLP-1’s long-term already have done a lot of work in recovery. They have normalized eating, learned about hunger and fullness and neutralized eating disorder thoughts. For this cohort, the medications help ease persistent urges and food thoughts.

People who haven’t done much work in recovery struggle to eat enough and tend to push for higher doses to seemingly cure their disorder. Instead, they end up with side effects, need to stop the medication and are typically end up in a worse mental and physical place in recovery.

The GLP-1 agonists have opened doors to a possible metabolic cause for some eating disorders. Time and further research will elucidate these connections. Replacing eating disorder treatment with these medications is dangerous and likely to only worsen the illness and delay any true recovery.

Obsessive Compulsive Disorder and Eating Disorders

Eating disorders and obsessive compulsive disorder are often diagnosed at the same time. The different ways these disorders interact can have a vastly different effect on treatment.

One effect of food restriction is the increase in obsessive thinking about food. Our brains are designed to focus more on food when our intake is limited—an adaptive mechanism to survive periods of famine.

The longer the period of restriction continues, the more the OCD behaviors can spread to other parts of life not connected with food.

Many eating disorders involve periods of food restriction. Even if someone binges or overeats at times, any consistent restriction of eating can trigger obsessive thinking about food.

This type of OCD typically responds to normalizing eating. As the body and mind get used to regularly, obsessive thoughts around food, and other things, tend to diminish.

For some people with eating disorders, OCD is an independent disorder that may be exacerbated by, but not a consequence of, the eating disorder. These people have OCD thoughts and behaviors prior to the eating disorder. The obsessions may be about food and also about many other things. Sometimes the OCD itself is the primary issue which focuses solely on the eating disorder at its height and switches to other obsessions through recovery.

For these people, OCD treatment is a necessary part of recovery. If the eating disorder and medical state are severe at first, then the eating disorder needs immediate attention. Once enough stability is achieved, OCD treatment becomes essential.

Medication for OCD largely entails high doses of antidepressants. This treatment can decrease symptoms significantly but is much more effective with concomitant therapy.

Two types of OCD therapy are common. The first is exposure therapy which encourages facing the obsessive fear directly and leads to decreased anxiety around the obsession. This treatment is the gold standard for OCD and is very effective for many obsessions but is harder to do for eating disorder thoughts. Facing the fear of weight gain directly typically is not very effective.

A second type of therapy is called Inference Based Therapy (IBT) which confronts the thought process and lack of logic in OCD. This type of therapy highlights the self-doubt caused by OCD and instead reinforces the idea that there is no real world evidence for the obsession because these thoughts are illogical. This approach can be helpful for OCD related to food thoughts as well.

Distinguishing types of OCD for people with eating disorders increases the likelihood of recovery. Eating disorders are very prevalent and come in all shapes and sizes. Thus, recovery and treatment need to focus on the myriad paths people follow toward health.

Are Ultimatums About Eating Disorder Treatment Ever Ethical

Concurrent with the idea of full recovery is the concept of clinicians giving patients ultimatums about recovery if they are not “fully committed.” At what point is it ethical for a clinician to stop working with a patient because that person is not making progress? Is that decision ever ethical?

When the idea of full recovery is a therapeutic goal, the bar for treatment is set very high with rigid parameters for success. In this paradigm, only people who are committed to recovery, willing to adhere to a meal plan and show up regularly to do the emotional work are acceptable as patients.

However, eating disorders are psychological illnesses with medical consequences which can be severe or even life threatening. Ambivalence about getting well, fear of losing the emotional support provided by the disorder and body image distortion all make recovery very challenging to contemplate, let alone to remain steadfastly committed. Even if the medical consequences frighten clinicians, the professionals need to ensure the safety of the patient and have enough support to feel comfortable doing their jobs.

Any realistic treatment needs to take into account the ups and downs of treatment and the times someone may slip backwards. The vagaries of recovery don’t disqualify people from clinical care, no matter the medical severity. I don’t believe it is ever right to end care without an acknowledgment that the clinician is a part of what isn’t working and with a clear transition to a new treatment team.

But what about the people unable to keep moving forward? What about those in need of emotional support who don’t have the wherewithal to commit to getting well at all? Should they be discarded as if they don’t deserve care? Should they be punished for the severity of their illness?

No matter how one answers these questions, the reality is that many of these people are dropped by providers because they are supposedly not committed enough to treatment. Clinicians should be able to admit the case may be too difficult to manage. The onus is on the clinician to admit their limitations, not blame the patient, and find alternative care. Setting an ultimatum a patient can’t reach only exacerbates the shame already baked into any eating disorder.

Kindness and compassion are necessary components of any recovery. Creating more shame due to supposed clinical ethics is only cruel.

These concepts of “full recovery“ and the “ethical” decision to drop patients both need to reassessed. It’s clear to anyone trying to treat people with eating disorders how difficult that work can be. Clinicians need to own their limitations, set reasonable goals for recovery for each patient and be sure to approach every interaction with kindness and compassion to the best of their ability.

Reckoning with the Idea of “Full Recovery”

There are forces in the eating disorder treatment world promising the idea of “full recovery.” According to the original definition, this term meant getting well and living your life not dominated by the eating disorder. In recent years the term has morphed into an idealized state of life completely free of the eating disorder with everything one could ever want.

Clearly, this concept is a fantasy.

The altered definition of full recovery stemmed from two sources. First, the proliferation of treatment programs staffed by young, inexperienced clinicians promised the unattainable to many people early in treatment as a means to lure them to follow the treatment plan. Second, social media latched into the idea of full recovery as an easy hook for views but not a realistic idea in treatment.

The fundamental purpose of this term is well meaning and intended to give hope and motivation to someone in the weeds of recovery. Even if misguided, “full recovery” helps people struggling in the daily grind of a path to getting well continue to see the purpose and meaning in this process.

Ultimately, anyone familiar with recovery from an eating disorder knows there is a period when the person is in consistent emotional pain as they try to get through the chore of eating each day and facing difficult emotional hurdles. The urge in this time to return to the eating disorder is strong. Continuing recovery at that stage is a leap of faith. One needs to believe there is a different life ahead when the struggle won’t be so great and the growth of new directions in life will begin.

That’s exactly what will happen in recovery. However, the other side is still part of the human condition not utopia. Life can bring amazement and wonder, joy and connection but also hardship and pain, failure and sadness.

Recovery gives someone the chance to live a full life not dominated by the eating disorder. Recovery won’t insulate a person from the vagaries of being human.

“Full recovery” in its current definition may only be an idealized notion—a hope really—for whatever we all wish life might be like. But the term does remind anyone working hard to get well that things can get better and that life not consumed by the eating disorder offers hope for a depth and meaning hard to find in throes of this illness.