Identity Transformation at the Center of Eating Disorder Recovery

Most chronic illnesses, medical or psychiatric, have a significant impact on a person’s quality of life. Coming to terms with an illness not easily managed or cured changes how someone sees their life trajectory and future. Although an illness can become a part of the lens through which one sees the world, eating disorders are unusual in how they become tightly woven into one’s sense of self.

No matter how the eating disorder starts, the symptoms, self-image and behaviors around food become paramount. All decisions center around the convenience or difficulty of eating or around what the eating disorder seems doable or acceptable.

Inevitably, the way one thinks of themselves and leads their lives depends largely on the eating disorder. Social events, professional choices and any personal plans revolve around what is best for the eating disorder.

Since eating disorders—or at a minimum eating disorder thoughts—start at a young age, psychological and emotional development occurs with the strong eating disorder thoughts influencing every decision. One’s identity and eating disorder grow up together, connected in the overarching experience of learning about oneself.

At its core, eating disorder treatment isn’t just normalizing eating behaviors and regulating body function, nor is it simply relearning new ways to think about hunger and fullness.

Recovery involves breaking down one’s own identity and building a new identity from scratch, no matter your age or personal situation, based solely on one’s own self and not the tenets of an illness.

It’s hard enough to take the steps towards recovery let alone imagine that recovery involves such a profound and painful emotional process, one that adults rarely if ever need to consider.

Time and again, clinicians working with people with eating disorders see this trajectory. Recovery is hard work starting with eating the food and handling changes in one’s body. Understanding the internal transformation that ensues is the next big step followed by a willingness and ability to forge ahead and find that true self, separate and free of the eating disorder.

One Key Limitation to Expanded Eating Disorder Care

Eating disorder treatment and recovery isn’t just about mind over matter. Access to so many types of clinical care, in person and online, doesn’t change the intractability of an eating disorder—illnesses that are physiological as well as emotional.

The psychological draw of an eating disorder can be powerful in many ways, for example the emotional numbing through the release from overeating/binging or the protection from traumatic symptoms via restriction. Over time, the repeated disordered eating behaviors can engender a physiological response in the body’s gastrointestinal system which adapts to the new disordered eating. Once their bodies get used to this new pattern, people have a much harder time escaping the entrenched behaviors.

Many people use food in emotional ways, but not everyone is wired so that the initial manipulation of food becomes a full-fledged eating disorder. For some normal eating returns, and for others the behaviors lead to an eating disorder.

Any treatment needs to take into account the necessary steps to normalize food, track the healing and regulation of various organ systems and engage the resiliency of the gastrointestinal system both for digestion and for hunger/fullness. The physical healing almost always precedes the emotional healing. The body needs to function first for the mind to follow.

Most of the newer support systems focus on the emotional and psychological healing. In many ways these programs are modeled on the older, more established network of treatments available for substance abuse. The treatments are very educational; patients and families alike are much more informed about eating disorders than ever before. But the programs need to include the medical aspect of eating disorder recovery as well.

Without the focus on physical healing, the risk in treatment is for many people to make emotional strides and remain physically sick, unable to make consistent progress with normal eating and gastrointestinal function.

Treatment programs help to a point, but too many people experience programs as intrusive, as if people have to endure forced eating which they can reverse once discharged back into their lives. All the more recent chatter about weight loss drugs and surgeries in recent years only reinforces the glorification of thinness.

Expanded access to treatment has greatly improved the education about necessary emotional and psychological strides for recovery. These illnesses are known to be intractable for a reason, and the entrenched physiological effects are a major cause. It’s the job of any clinician to recognize this fact and be sure to include physical and psychological needs in any treatment.

What Treatment Loses with Telehealth

Telehealth in therapy is here to stay. The abrupt transition to remote treatment in eating disorder work during the pandemic was noteworthy. There won’t be a return to mostly in person appointments. That ship has sailed. We all—clinicians and patients—have agreed to this new method of treatment.

It’s clear what has been gained from telehealth: increased access, convenience and new programs for in home treatment.

The practical considerations of treatment work well remotely. Monitoring food, cognitive tools to combat eating disorder thoughts and even group sessions for people with similar recovery experiences are all effective in this new modality.

However, another equally important question, one that few people are asking, is what have we lost?

Eating disorders require secrecy, isolation and obfuscation to remain powerful in a person’s life. These behaviors aren’t nefarious. In order to stay sick, people with eating disorders need to hide what they are regularly doing. Remote treatment can’t address the secrecy easily.

The screen provides an easy means for people with eating disorders to hide. They can hide their bodies. They can hide their thoughts and feelings. They can hide their behaviors. They can hide their true selves and create enough of a persona to slide by unnoticed.

And that’s what people with eating disorders find themselves doing. They remain unseen in the world and feel safe and protected. The thoughts and behaviors that structure their lives stay omnipresent, and the remote work means no one can ever really spend time with them, can fully see them.

I am an advocate for at least some in person sessions, especially with a therapist. Telehealth will work to a point. Symptoms will improve, but the fundamental emotional and psychological work will lag unless the therapy relationship has an in person component.

The Effect of Social Media Exposure in Eating Disorder Treatment

Social media has changed eating disorder diagnosis and recovery greatly in recent years. Long before seeking help, most people these days are aware of their eating disorder, have read, listened to or watched media that explained not only the disorders but various symptoms and the path of recovery. Thus, education about eating disorders is now largely delegated to online platforms so therapists can both clarify what people learn online and individualize treatment for each person.

Patients used to start treatment often more confused about the diagnosis and without much knowledge of treatment. Now any clinician in this field must assume a new patient is aware of diagnoses and has a lot of information at their finger tips. And since social media posts about eating disorders are very specific about thoughts and symptoms, people are often aware of subtle and specific elements of their disorder.

Treatment needs to incorporate this added knowledge into the therapy relationship and also to respect the vantage point of all patients seeking help. They enter the relationship with a lot of exposure matched with the personal knowledge of their own eating disorder. In fact, their experience needs to dictate treatment much more than ever before.

A therapist can tailor the information the patient has and use their own experience to guide therapy while simultaneously recognizing that this person’s knowledge must play a vital role going forward.

In many ways, this new entry point into eating disorder treatment is preferable. It levels the playing field. The therapy is immediately a partnership—a crucial element of most successful recovery.

There are a few caveats. Not all information online is true, but that can be easily discussed. Younger people and adolescents may need more guidance to assimilate the social media exposure into effective therapy. More information to assuage fears of what treatment looks like will be useful to counter the recovery stories with more difficult outcomes.

Ultimately, the therapist needs to respect the knowledge, exposure and introspection that precedes starting treatment. The effect of the availability of information about eating disorder can and should improve treatment and outcomes.

What will the Ozempic World Look Like? Part 2

The recent posts in this blog hypothesize about changes in our relationship with food and our bodies after the advent and proliferation of GLP-1 agonists like Ozempic and Mounjaro. To be clear, many beneficial purposes for these drugs exist: diabetes and metabolic issues, to name two important ones.

But this new class of drugs also lands squarely in the camp of life enhancers, not just medications to treat illness. What I mean by this term is drugs with benefits people deem attractive but not necessarily therapeutic. Stimulants like Adderall are a good example of a drug people use for extended hours of focus or appetite suppression and not always for the medical indication, ADHD.

Right now the craze for these drugs is largely based on how new they are and how inaccessible they can be. Over time, they’ll become cheaper and more available. Doctors will prescribe them even more freely. Like it or not, GLP-1 agonists are going to be part of our culture.

We need to expect and accept that people won’t have clear hunger cues, will lose and gain weight easily and repeatedly and will raise children who, in a post-GLP-1 agonist world, believe hunger and weight are malleable and controllable factors of life.

Granted, we all have been living in a world trending in this direction for years. There used to be room for changing norms of body shape and size. Industry and capitalism have hardened the glorification of thinness in ways that are going to be next to impossible to undo. With these new drugs and doctors’ obsession with weight loss, the pharmaceutical and medical industries mean these norms are here to stay.

A concomitant result is the permanence of eating disorders. The nature of these disorders will continue to grow and change in cultural ways as they have in recent decades. Eating disorders caused by GLP-1 agonists are the new frontier.

Since dieting and food restriction are the primary risk factors for eating disorders, we collectively have decided to allow the overvaluation of thinness to continue to condemn people to develop eating disorders.

Going forward, the goal is to catch and treat eating disorders early and aggressively. The clinicians who treat these illnesses can’t contain external factors but can increase education and awareness.

What will the Ozempic World Look Like?

Hunger is one the most powerful and essential ways our bodies communicate with us. Put simply, hunger prioritizes the need for food as sustenance and for survival.

The meaning of hunger has changed greatly due to a transformed food supply for many countries in recent decades. After centuries of food scarcity as the obstacle to survival, humans created societies with bountiful food, more than can be eaten and often with a huge amount of waste.

We aren’t designed to know how to handle excess food. Hunger is an acute feeling intended to focus all senses and thoughts on procuring food. Subtle hunger cues can be harder to assess, but the plentiful food for many people obfuscates hunger cues altogether.

The new world of excess food opened the door to many new approaches and industries aimed at manipulating our dulled hunger cues with the supposed intention of improved health but mostly aimed at weight loss.

These factors include diet culture, the obsession with thinness, unsubstantiated nutrition suggestions and ill-researched medical recommendations. Almost all of these ideas infer that our hunger cues are actually misleading. Instead, these new guidelines purport to show us the best way to eat.

Even though medications have suppressed hunger cues for decades, the new GLP-1 agonists practically turn off hunger for prolonged periods of time. No previous intervention has been so powerful. The advent of the medications—in addition to the over-valuation of thinness and limited attention to adequate nutrition—is posing new hazards to our well-being.

Typically, suppressed hunger led to significantly increased appetite, binging and weight gain. The body overreacts to long periods of undereating with a strong hunger response meant to promote survival. Older medications, Bariatric surgery and dieting all triggered subsequent increased and often uncontrolled hunger. Although people experience this reaction when going off these new drugs, what happens if they stay on them indefinitely?

The jury is out at the moment about long-term outcomes. If there are no unforeseen side effects that lead to pulling these drugs off the market, the GLP-1 agonists and the even more powerful medications coming down the pike are here to stay.

As physicians, we are likely to see people with similar medical consequences as with Anorexia or with other appetite suppressing interventions. Slowed digestion and gastrointestinal functioning is an inevitable and often a permanent result of decreased eating. Chronic malabsorption of various minerals and micronutrients can cause a host of diseases rarely seen in medicine and thus hard to diagnose. Slowed cognitive functioning almost always results from decreased nutrition. And this is just to name a few.

My best guess for the results in a society using this new medication routinely is a generally thinner population with chronic medical and psychological effects from the long-term effects of malnutrition. As much as medicine continues to conflate weight and health, we as a population will talk about getting healthier while in many ways we get sicker. It will be up to the country at large to decide if the sacrifice is worth it.

Hunger in the Ozempic Era

People with eating disorders are usually afraid of hunger. The advent of the long acting GLP-1 agonists like Ozempic and Mounjaro not only reinforce this fear but create an environment for a more widespread aversion to this basic human function.

Hunger cues represent one crucial way our bodies can communicate with us. The cues can be subtle like a feeling of emptiness in our stomachs or an increased interest in food, moderate like feeling a bit weak or irritable or strong like lightheadedness or a gnawing need to eat now to the exclusion of any other thoughts or desires.

No matter the level of urgency, hunger cues allow our bodies to tell us what they need. Hunger increases our cognitive focus on food and, historically, ensures an increased likelihood of survival.

If society values thinness over many other necessities of life, hunger takes on a very different meaning. Hunger can feel like a nuisance, a weakness, a temptation or even a sign of loss of control. People very focused on weight will attempt to find ways to tolerate, avoid or negate hunger without eating.

To an even greater degree, people with eating disorders seek any way to neglect and ignore hunger cues at all costs. As I have written many times in the blog, people with eating disorders eat what and when they are allowed by the illness, not according to hunger cues.

There have been many pharmacological and surgical attempts to mitigate hunger, but none of have been nearly as successful as the GLP-1 agonists. Thus far, this new class of medications can suppress hunger for long stretches of time leading to periods of undereating and weight loss without allowing our biology to override the medication with rebound hunger. The jury is out about long term effects, but these medications have introduced a new dimension of medical intervention into modulating hunger.

Although there are many ways our attitudes about hunger, food and weight will change in this new world, my concern in this post is about hunger. The idea that hunger cues can no longer play a large role in daily life for many people is a monumental shift in daily functioning and in eating disorder recovery. Tolerating hunger and learning to read body cues have both been critical parts of eating disorder recovery. Many people may now choose medication over an essential part of recovery.

Just as concerning, children brought up in the world of GLP-1 agonists will believe hunger is a feeling that can be medicated away, not a physical sign that the body needs food.

Fear of hunger is very different from the ability to medicate hunger away. Is it safe to ignore signs of hunger? What are the risks of ignoring such a fundamental aspect of being human? That will be the basis of Part II in the next post.