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.