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.

Increased Awareness of Eating Disorders has Changed the Process of an Initial Assessment

The last post reviewed elements of a thorough assessment for someone with an eating disorder. There are key pieces to this initial consultation that are necessary to create an appropriate treatment plan.

The first issue is that eating disorders are not a homogeneous set of illnesses. Underlying connected, and sometimes causal, conditions need attention as well. The increased awareness of eating disorders means many people are diagnosed without giving attention to other concerns. It’s easy to just decide the primary issue is an eating disorder without considering many more possibilities as well.

As a result, these days I am more likely to see someone diagnosed with an eating disorder whose main diagnosis is depression. In the past the opposite was much more likely to be true. The takeaway message is that diagnosing someone with an eating disorder without considering all other psychiatric issues is inadvisable and often counterproductive.

The second issue is that potential causes for eating disorder symptoms are not just psychiatric. Many medical conditions mimic eating disorders. Simply making the diagnosis and starting treatment often means people are getting help for a completely inappropriate condition. Many gastrointestinal diseases, ARFID and metabolic dysfunction are some of the most common alternate causes for eating disorder symptoms. However, there are many other options which need to be considered depending on a person’s specific symptoms and experience.

Trauma belongs in its own category of eating disorders. For most of these patients, the eating disorder symptoms are a means to cope with the symptoms of PTSD. The food behaviors can be calming, create order out of chaos and structure daily life. The only way to make change is to address the PTSD symptoms first to enable the person to begin to let go of the eating behaviors slowly and carefully. Traditional eating disorder treatment will be much too dysregulating. Severe PTSD appears to be more akin to a neurological disorder than psychiatric and needs very individualized care.

All of this information shows that people with eating disorder symptoms need a thorough initial assessment. The clinician needs to be able to sort through possible causes of the eating disorder, refer to other specialists if necessary and ensure the path of care is appropriate.

The increasing breadth of knowledge about eating disorders continues to expand treatment guidelines and opportunities while changing the guidelines for an assessment. These changes also demand a comprehensive first appointment before starting treatment.

The Needed Components of a Thorough Assessment of Eating Disorders and Implications for Treatment

The tendency to consider eating disorders as a homogeneous set of illnesses is misleading and frankly incorrect. They comprise a broad set of symptoms that are all include a focus on food, hunger and weight but typically manifest in very different ways.

Broad knowledge of how hunger, fullness, metabolism and weight are maintained by the body and mind is necessary to grapple with the healing process from an eating disorder. However, the treatment recommendations can vary greatly.

In this post I will explain some of the more general ways to differentiate eating disorders and elaborate more in upcoming posts.

Some eating disorder treatment is different based on the concomitant psychiatric diagnoses that need treatment with the eating disorder. The most common ones are Post Traumatic Stress Disorder, Obsessive Compulsive Disorder Disorder, Major Depressive Disorder and Attention Deficit Disorder.

The first key step is to differentiate whether the eating disorder or other disorders are primary and then to prioritize treatment for the eating disorder or other illness treatment accordingly. Sometimes treating the other disorder actually treats the eating disorder as well.

The second necessary step is to consider medical illnesses that might be a part of the eating disorder. These can include general inflammatory disorders, autoimmune disorders and metabolic disorders. Not enough is known about the connection between eating disorders and medical illnesses yet to lead to a clear path to recovery, but these new concepts for treatment are promising. Often searching for more general treatment for these symptoms, even with a clear diagnosis, can be very helpful in treating the eating disorder

Third, it’s important to consider the overall nature of the eating disorder symptoms in planning an approach for recovery. Cognitive Behavioral Therapy is extremely helpful for many eating disorders especially when binging is a primary symptom. Focusing on exploring and identifying emotions is often critical for people with more limited understanding of their emotions. For some, slow and steady work on changing eating patterns remains central to treatment for a longer period. The nature of types of therapy needs to match each patient’s needs.

A better understanding of eating disorders changes the formulation and course of treatment for people with eating disorders. Thoughtful consideration of all factors is necessary for any treatment to be effective. A thorough assessment and consultation will increase the chance of long-term benefit of any treatment.

The Transition of GLP-1 agonists from Weight Loss Drugs to Powerful Metabolic and Hormonal Medications

The introduction of GLP-1 agonists (Ozempic et al.) has completely changed the course of treating metabolic disorders. Even though the marketing of this new class of drugs has focused on weight loss—I believe, cynically, for increased profit, medications that correct metabolic hormonal dysfunction are the future of treating many illnesses, perhaps eating disorders included.

As of now, our knowledge about the broader effects GLP-1’s have on the hormonal system is very limited. Utilization of energy, hunger/fullness awareness, speed of digestion and normalization of blood sugar levels are all clear effects and match our current knowledge of the hormones affected.

But then why are so many people having other powerful effects? The list thus far includes decreased alcohol cravings, curbing compulsive behaviors, lowered systemic inflammation, broader regulation of other non-metabolic hormones and even augmentation in treating depression.

Clearly, there are broader implications of adjusting the gastrointestinal hormone levels which we know regulate metabolism. So the potential risks of taking these medications, and the risk of taking high doses simply to lose weight, are enormous and vastly unknown.

The collective fallacy about the GLP-1’s is that they are very safe and that we know the long-term effects. Through this lens, many people are taking these medications and our knowledge about them will grow quickly.

Over the last couple of years, many doctors have slowed down the dose increase greatly from the original suggestions of the pharmaceutical companies. For people on these drugs longer than three years, side effects appear to become more severe and sometimes lead to needed time off the medications, something that will be shocking for people taking them solely for weight loss. Sudden cessation of the drugs typically leads to weight gain.

The reason people need to stop the drugs is paralysis of the gastrointestinal system. Taking too high of a dose for too long can slow down the digestive system so much that it ceases to function normally. Stopping the drugs helps reverse this side effect, but the jury is out whether long-term use is possible again after suffering such severe side effects.

A few things about the GLP-1’s are becoming clearer. First, the broader effects of this class of medication are still unknown as is the systemic implications of altering metabolic hormonal levels. Second, it’s better to be a lot more careful with dosing and remain on as low a dose as possible. Third, the long-term use of these medications is in question. We don’t know enough yet to see if this is truly possible.

As the hysteria of the GLP-1’s dies down, medicine, and the culture at large, needs to respect the power of this new pharmaceutical step. Rather than kowtowing to the blatant disregard of our well being that weight loss marketing achieved, medicine can instead thoughtfully figure out how and when these medications are best used.

Relationships are the Foundation of Full Recovery

Therapy is central to the treatment of most psychiatric disorders but is even more so to the recovery of people with eating disorders. As trends in therapy focus more time on techniques and tools, the nature of the therapeutic relationship might get brushed aside. It’s crucial to make sure the relationship itself does not lose its place as a part of growth and healing.

Tools and techniques play a large role in eating disorder recovery as well. When someone has an urge to engage in any eating disorder behavior, the ability to turn to another action until that urge dissipates is necessary to make progress. That step is very hard and takes repetition and perseverance.

Similarly, eating regular meals regulate the gastrointestinal system to become accustomed to consistent food through the day. Using techniques to stay focused on eating through the day can be very helpful too. The physical cues for hunger and fullness ensue and give a person in recovery new ways to conceive of eating and thus reinforce the need and ability to continue new behaviors.

However, eating disorders also encroach on psychological and emotional development. At the start of the illness, eating disorder thoughts and behaviors replace all other possible ways to face emotions and reactions to daily life. The eating disorder is so powerful, so numbing, that there is no reason to even search for other ways to cope with being human. An eating disorder feels like a panacea to the travails of life while simultaneously extracting the joy, growth and connection that makes life meaningful.

In many different ways, relationships that are connected and true provide an antidote to the dullness of life with an eating disorder. For many people, the therapy relationship can be the first exposure to that sort of connection.

Any relationship that begins to compete with an eating disorder must, first and foremost, engage with the true sense of the person hidden behind the eating disorder. Only after one finds and connects with their true self can a person in recovery chart a course that escapes the eating disorder’s clutches fully. There has to be something more powerful and more important in a person’s life to consider letting go of a set of calming rules and structure. Invariably, personal connections make the biggest difference.

Recovery involves these two pieces—techniques and relationships—working together to form a new path in life. Once each person starts their new path, the directions splay in all new ways because recovery itself means becoming your own self and living your own journey.

The Financial Industry Interest in Eating Disorders

As I reviewed the last post, I neglected one way in which capitalist tendencies undermine the ability to find eating disorder treatment. The food, diet and health care industries collectively convince us to blame ourselves for any perceived shortcomings about food and body and then to purchase the wares to either remedy the problem or drown our sorrows. I neglected to mention the finance industry which cynically exploits mental illness for financial gain.

Many years ago, private equity companies bought up and expanded substance abuse treatment centers. Although the access to treatment centers improved, the intention of the industry growth was to create profitable enterprises to take advantage of health insurance benefits. Much of the data accumulated show how these clinics make unsubstantiated medical decisions to keep patients longer. The decision making process chose financial gain over patient well being.

The eating disorder treatment center model has started to look a lot like substance abuse treatment and became too tempting for the finance industry to ignore.

Residential treatment centers were, not long ago, places for intensive emotional work, soul searching and a safe place for people, primarily women, to find a path towards healing and recovery. Frequently, the programs were run by people who themselves had recovered from eating disorders and used their own personal experience combined with clinical knowledge to create centers with exceptional clinical care.

The rapid expansion of treatment programs by financial firms reeks of a quick grab for money. Although access to care had been a significant problem for years, opening many programs with poorly trained staff is not an improvement. The growth continues and the benefit from these programs decreases with each step while insurance money lines the private equity coffers. There isn’t enough focus on quality of care and too much focus on profit.

The limited benefit of residential programs makes the path towards recovery complicated. It’s harder to recommend residential programs than it used to be. Online outpatient programs have unclear value even though they do provide a needed service. Outpatient treatment is much easier to find but not sufficient for many people.

The problem of limited access has transformed into a struggle to find appropriate and educated providers. It is perhaps an improvement and also a sign of the times: medical care is increasingly driven by the patient, aka the consumer, who makes semi-educated decisions based on the limited information online. These are the overall trends in medical care but they are concerning for eating disorder treatment.