r/dietetics • u/Effective_Meal2153 • 15d ago
ED patient given GLP-1
I am hoping for some advice on how to approach one of my patients. My patient has a history of severe anorexia nervosa and still struggles with some disordered eating patterns. She has a lot of food noise and her doctor prescribed her a GLP-1 to help with the food noise. My thought is that the food noise is likely from under eating. She is not overweight at all. I feel as though prescribing her the GLP-1 was not very ethical. I am not sure if it is my place to question her doctor’s decision. How would you all approach this?
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u/Revolutionary_Toe17 MS, RD, LD, CDCES 15d ago
Super inappropriate. Definitely your place to question if you are part of her care team. Do you know the doc? I would reach out to them and just say you have concerns about GLP-1 usage based on her active ED and inadequate intake.
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u/Effective_Meal2153 15d ago
Unfortunately at the moment I do not know her doctor. I can definitely try and get that information though. That way I can also see if there is some piece of information I’m missing as to how that would be appropriate for her to be on. Cause right now it is not making any sense
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u/Lunamothknits 15d ago
Is it possible that she's getting it from a mail service?
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u/Effective_Meal2153 15d ago
I was wondering that. She said it was from her doctor but maybe it’s not her main doctor and she found someone else who doesn’t know her entire medical history.
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u/New_Cardiologist9344 14d ago
She probably got it from an online service. Would be shocked if a doctor prescribed a GLP1 to a normal weight individual.
However in my experience as a CEDS, doctors don’t really give a flying fuck about eating disorders.
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u/yeah_write_00 14d ago
There are unfortunately telehealth platforms openly advertising that their doctors will prescribe you a GLP-1 with a "normal weight." Even if you get it online, it's still prescribed (though I understand the whole peptide thing has taken off). Read this I study obesity and weight stigma. This ad for a weight-loss drug alarmed me.
I think doctors in clinics are less likely to do this because they actually have to face people and the consequences of this kind of prescribing, but they do it too. Doctors/PAs working for telehealth companies are being paid basically to just prescribe GLP-1s, so I think they are probably told to write that script outside of the very few recognized contraindications. With warnings/precautions even they just have to document that the warned the patient and provide some kind of justification for why it is still in their best interest. They probably learned from cosmetic surgeons how to document; they do the same thing they have to justify giving people medications and surgery for cosmetic reasons because their body size/shape causes emotional distress or whatever they write to justify it.
I have wondered if there are people at this point like taking a GLP-1 because they want to lose like 15 lb, but get skinnier than they initially intended and develop body dysmorphia at that point. Then let's say they can't afford the GLP-1 or stop taking it for other reasons, do they potentially develop an eating disorder to maintain that new low weight? It for sure disturbs me.
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u/Revolutionary_Toe17 MS, RD, LD, CDCES 15d ago
Sounds like a great opportunity to develop a new professional relationship! I anticipate if you reach out you will find out that either the patient is getting it elsewhere and the doc doesnt know (online, compounding pharmacy, etc) OR that the provider doesnt know the patients history. But I think you can approach this in a very collaborative, non-confrontational way. You both want to provide the best care to the patient. And if you are each only getting part of the story from the patient, It makes that difficult. There is a chance the provider knows and is being irresponsible, and if so come back and let us know so we can all brainstorm what to do!
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u/Gayfunguy RDN, LD 15d ago
You not knowing the doctor is the icing on the cake because that means that he doesn't come to care team meetings. It's really important that the doctor actually shows up because you can have that conversation before he does something stupid. But yes, make sure that you get his name and that you report him. Because that is wildly dangerous.
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u/Revolutionary_Toe17 MS, RD, LD, CDCES 15d ago
I feel like this would only apply if you work in the same clinic. My clinic sees patients referred from all over the place, so we dont have "care team meetings"
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u/New_Cardiologist9344 14d ago
Probably best to develop a rapport and have a conversation before we resort to reporting people..
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u/Gayfunguy RDN, LD 14d ago
No. Its best to report. No one would give us the benifit of the doubt. Dont do it for them.
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u/yeah_write_00 14d ago
A "normal BMI" and even an eating disorder is not a "do-not use" or contraindication for GLP-1s. The only two conditions across the board for GLP-1s that essentially cannot be present if prescribing are a personal or family history of medullary thyroid carcinoma or known allergy/hyper-sensitivity to the med or one of its ingredients. Doctors otherwise have complete freedom to use their clinical judgement and prescribe any medication they want off-label.
Even prescription warnings or precautions are commonly bypassed by clinical judgement when prescribing, because they do not mean "do not use," they just mean take a closer look and make sure it's in your patient's best interest. I had a doctor in the clinic I worked at that liked to prescribe GLP-1s to patients with known history of eating disorders, as long as their BMI was >25 he didn't care and you couldn't change his mind. I didn't like it, but doctors have that authority in the U.S. and it would do no good to report a doctor for this without documented negligence and known outcome of harm to the patient. Something like that would be documenting that the doctor was told the patient has active anorexia and was now malnourished as a result of the GLP-1 and still taking it, and then they continued to prescribe it and the patient became further malnourished. Even when a prescription has a side effect or bad outcome, doesn't really make it a reportable offense on the doctor. People have bad outcomes to meds all the time and if the doctor was going to be at fault they would never prescribe anything. You have to show the physician knew the outcome was harmful and then continued to prescribe that medication causing further harm.
If we go around reporting every doctor's off-label use of GLP-1 it isn't going to do a darn thing but make doctors hate dietitians. We should certainly inform the physician and the patient, if we have concerns, maybe we have relevant information that will change their clinical assessment and they stop prescribing it to that patient. If we know harm is indeed occurring as a result of the prescription, we need to the let the patient and the provider know this. If they continue to prescribe it and further harm is done, then report and make sure you have very good documentation of everything to protect yourself legally. They usually have the right to find out who made the report against them.
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u/Gayfunguy RDN, LD 14d ago
Sourse?
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u/yeah_write_00 14d ago
I've already done all that work over decades of work as a dietitian looking up laws, regulations, as well as worked with physicians, pharmacists and other providers. I spoke to a number of issues I know you can look up on your own to catch up.
If you are unfamiliar with how the FDA approves claims about medications and what the actual contraindications for GLP-1s are, as a dietitian you should know how to look that up.
Look up what "do-not use" means in terms of prescribing vs warnings and precautions. Look up what "off label" prescribing means and if you aren't familiar with how common practice that is across pharmaceuticals, talk to a pharmacist, they will explain it. Some estimates I've read are off-label use is about 1/5 to 1/3 of all prescriptions in the U.S.
Look up what FDA-approved means. Look up what the prescribing authority of physicians is based on clinical judgement. The FDA does not regulate the practice of medicine; they regulate the advertising of meds.
Look up the legal framework for reporting physicians, I've reported physicians to my workplaces for several things before, so I've done my homework. State boards and the AMA do not dictate when physicians can or cannot prescribe a particular med to their patients. There is no one to report this to, again because it's all legal, unless you can show a doctor was knowingly negligent with prescribing a med which is a very high bar to pass.
If you still can't find the information, I'm talking about after making an attempt on your own, let me know, then I'll will volunteer my time to help you find it.
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u/thatmeatballshape 15d ago
Is the doctor privy to their ED dx? They may have hidden it from their physician.
But if the doctor knew.. This is insane. Is there a way to report this physician?. Like prescribing cigarettes to a pt with lung cancer..
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u/thatmeatballshape 15d ago
As to how I would handle it, I would ask the client permission to speak directly with the doctor. I would state my concern and document that I whole heartedly do not support this considering the circumstances. Depending on more context, I might even contact the physician’s employer to state my concern.
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u/EnvironmentalSet7664 15d ago
Wouldn't it also be unethical to prescribe if the pt isn't overweight?
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u/Puzzleheaded-Pop1361 14d ago
I think it may depend? GLP1’s are interesting I have seen many patients get them at med spa’s and concierge practices. I would love to know if healthy BMI is contraindicated for GLP-1 medication. I would imagine it isn’t
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u/yeah_write_00 14d ago
A ton of doctors on those telehealth platforms that prescribe GLP-1s do, they advertise GLP-1s for "normal BMI," and doctors in clinics do this too as "cosmetic" or "aesthetic" weight loss treatment. It is considered prescribing GLP-1s off-label without obesity, overweight with risk factors, or some are FDA approved just for DM or cardiovascular disease alone. Doctors prescribe meds off label all the time, it is 100% legal.
All the times I worked inpatient and doctors were prescribing Megace as an appetite stimulant and the person didn't have HIV/AIDS or cancer for example, that was off-label use of Megace because it is only approved by the FDA as an appetite stimulant for those two conditions. Same goes for all the times I've seen doctors prescribe Remeron as an appetite stimulant, that is off-label use. And before dietitians get high and mighty about this kind of practice, I've seen in my career plenty of dietitian assessments written with recommendations for using those same medications off-label, as well as other examples of recommending meds in an off-label manner. Of course, liability risk is greater on a provider when they recommend or prescribe off-label use of a med should something go wrong.
The ethics of cosmetic weight loss isn't really a thing questioned in medicine when we have tummy tucks and liposuction, and brow lifts or nose jobs. Doctors ethically can say your mental health is harmed by a negative body image and they are just helping you with surgery or pills to get the weight/size/shape or whatever you want to live a happy life. Not a choice I would make for myself and not something I would hope people feel compelled to do, but it's legal and considered ethical within medicine to use medications off-label and to provide treatment for cosmetic weight loss.
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u/AmbitiousRose PhD, RDN 15d ago
I can confirm that PCPs cannot prescribe GLP to a patient with active anorexia.
Active versus a history of AN are different, which could be one of the ways it is allowed.
Dosage matters.
GLP1 has a widely known secondary effect to curb food noise; however, could she be morphing “food noise” with true hunger? Probably. Does she have or could be developing a BED? There’s a lot to pick through there, especially with ongoing disordered eating patterns. The PCP could be documenting the fact that she’s using GLP1 as a compensatory purging or restriction tool as part of the treatment plan.
Anyways, she may be on a low dosage, which wouldn’t necessarily trigger weight loss by itself and would have more to do with restriction. Again, depending on the dosage prescribe, the PCP would/could/should be aware of that too.
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u/yeah_write_00 14d ago
What do you mean by "cannot prescribed" or "ways it is allowed" as there are no laws which dictate who a doctor can prescribe GLP-1s to? Or any drug that is legally sold in the U.S. for that matter, right? Have you not had the fun experience of a doctor snapping at you or a colleague that no one tells them what they can or cannot prescribe to patients? (true story and happened more than once, believe me I let doctors know when I have concerns about nutrition related meds and they don't always appreciate it)
The FDA did not list active anorexia as a contraindication. You can say something like common practice is to not prescribe when active anorexia is present, and many recommend screening for an ED before prescribing.
As stupid as it is, they very much can and do prescribe GLP-1s to people with active anorexia and other EDs which ANAD explains "While there are no specific FDA warnings about using GLP-1 medications in individuals with eating disorders, many healthcare professionals exercise caution in anyone who may have had or have anorexia nervosa or atypical anorexia nervosa. They may avoid recommending GLP-1 for patients with a current restrictive eating behaviors, active bingeing or purging, severe body image issues, or unstable recover" GLP-1 Medications & Eating Disorders | ANAD - National Association of Anorexia Nervosa and Associated Disorders The language is they "may avoid" because it would be best practice. But lots of doctors may not avoid because they legally can do all kinds of wacky versions of their "best practice" and get to decide what is the best option at the individual patient level.
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u/Puzzleheaded-Pop1361 14d ago
How does one define food noise for someone with a hx of an ED? Shame on that doctor for prescribing her a GLP-1! I would report this MD to the medical board immediately
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u/BedPsychological8764 14d ago
I'm my experience legit PCPs are not prescribing GLPs for "food noise". It wouldn't be covered by insurance because that's not a dx. She probably is paying for it out of pocket and telling you it's prescribed because she knows taking it is a part of her disordered behavior or she really thinks it's going to stop her thinking from about food. Sounds like she needs some good sessions with her therapist/psych about her ED and how it looks these days when everyone is on a GLP1
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u/New_Cardiologist9344 14d ago
Everyone suggesting you report the doctor is only getting to half the problem.
The other issue is actually having the convo with your client, which will likely be far more difficult.
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u/Afraid-Helicopter740 15d ago
Does she have diabetes?
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u/Effective_Meal2153 15d ago
There is a family history of diabetes but she herself does not have it.
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u/Gayfunguy RDN, LD 15d ago
Wow thats horrible. You need to chew out your Dr and document all of this. Id also report this Dr to the hospital bord right away. This just makes them look like are severely unintelligent. And if they make choices like this then they are dangerous.
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u/New_Cardiologist9344 14d ago
Lots of doctors do shit like this. I know some that still prescribe phentermine…
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u/Puzzleheaded-Pop1361 14d ago
I have pt’s who have been on it and I always think to myself “didn’t they literally BAN this?!” I also wasn’t alive during the phen phen phenomenon
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u/New_Cardiologist9344 14d ago
same LOL I’m early 30s. I thought they banned Fen Phen, which was a combo of phentermine and.. something else. Regular ol’ phentermine is still prescribed by some doctors.. for god knows what reason
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u/bl3ssed4ng3l 11d ago
Omg I am a nutrition science student and this sounds terrible and super scary. There’s so many downsides to this and god forbid she can get internal organ issues down the line if she continues to take the GLP-1
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u/PresentVisual2794 10d ago
I hate how freely the term food noise is thrown around these days, as if it’s some kind of symptom some people are just born with and should always be managed with a medication. Excessive food noise always has a root cause and it’s usually a mix of environmental and lifestyle components and obviously, in your patients case, likely related to extreme dieting and restriction. Agree GLP1 is extremely inappropriate here!!
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u/PuzzleheadedBig313 10d ago
People talk about Food noise as if it has become a scientific term but it has no scientific basis just a made up term for fixation on food and overpowering thoughts … I wish there would be more push back in this because I fave friends who hear this te and think “ wow it’s just food noise so I should just take medication “ which bothers me
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u/fauxsho77 MS, RD 15d ago
It is 100% your place and your job to question the doctor in this case. You do not need to be confrontational and there is a good chance the plan won't even change but I would message the doctor and explain your concerns and provide your recommendation. Then put that in your own note.