On today’s episode, Dr. Karen Nelson is joined by Dr. Kate Kardell, primary care physician here at Melrose. Karen and Kate will discuss what supportive medical care looks like for patients who are suffering from an eating disorder.
On today’s episode, Dr. Karen Nelson is joined by Dr. Kate Kardell, primary care physician here at Melrose. Karen and Kate will discuss what supportive medical care looks like for patients who are suffering from an eating disorder.
Click here for a transcript of this episode.
Dr. Karen Nelson: [00:00:00] Eating disorders thrive in secrecy and shame. It's when we create a safe space for honest conversation that we'll find the opportunity for healing. Hi there, I'm Dr. Karen Nelson, licensed clinical psychologist at Melrose Center, welcoming you to Melrose Heals, a conversation about eating disorders. A podcast designed to explore, discuss, and understand eating disorders and mental health.
On today's episode, I'm joined by Dr. Kate Kardell, primary care physician here at Melrose. Kate and I will discuss what supportive medical care looks like for patients who are suffering with an eating disorder. Now, before I begin, I invite you to take a deep breath and join me in this space.
[00:01:00] Welcome to the podcast, Kate.
Dr. Kate Kardell: Thank you. So happy to be here.
Dr. Karen Nelson: I'd love it if before we get started, you could introduce yourself and tell us about your role here at Melrose.
Dr. Kate Kardell: Sure. So I am Dr. Kate Kardell. I am a family medicine physician who's been working at Melrose for seven years. I work out of our St.
Paul location in our outpatient setting primarily, but also do some work in our inpatient setting.
Dr. Karen Nelson: Well, as we kind of transition today and just talk about, our topic actually is medical care for eating disorders, really appreciating kind of the nuance and the diagnosis of that, and then absolutely understanding the follow up and how you help your patients move through recovery. I think it is important to acknowledge best practice as recommended by the American Psychological Association states that a team approach for eating disorders really is the best approach.
Dr. Kate Kardell: Right.
Dr. Karen Nelson: Meaning multidisciplinary care. And so let's maybe start [00:02:00] there. What does that mean? Those are big words, right? What does that mean to have a multidisciplinary team?
Dr. Kate Kardell: It's unique of eating disorders to have a very real psychological component, but also a very real whole medical component. These can be life threatening, and so we need to address all of those facets of the eating disorder. So when you come to Melrose, we typically will schedule you with a medical physician, a dietitian, and a therapist. Plus or minus psychiatry or occupational therapy, so there's lots of different avenues that we support.
Dr. Karen Nelson: There's this team approach to care and treatment that you're not just seeing a therapist or I'm not just seeing a medical doctor. It's this team of people that really moved me to that place of recovery.
Dr. Kate Kardell: Right.
Dr. Karen Nelson: Tell me your perspective of just the advantage of working on a team here at Melrose.
Dr. Kate Kardell: Yeah, I think each member of the team looks and [00:03:00] thinks about things a little bit differently. And so just as a clinician, it's amazing to be on a team, too, where I can learn from other people, and they can learn from me. But then also at the patient level of, ‘This is what I'm seeing, are you seeing something differently?’ So, they might be saying they're doing well, and their physical readings might not.
Dr. Karen Nelson: That's right. Kate and I are smiling at each other because we're like –
Dr. Kate Kardell: Right.
Dr. Karen Nelson: Sometimes we do hear differing stories, right? They may come to therapy and say, ‘No, I'm not using any symptoms.’ Then they check in with you as their medical provider and you may find, oh, the data is telling us a different story.
Dr. Kate Kardell: Right.
Dr. Karen Nelson: As part of your practice, you do initial assessments or diagnostic assessments for eating disorders in our St. Paul Clinic. I would love it if you could help our listeners know, how do you go about assessing or diagnosing if someone has an [00:04:00] eating disorder? And are there specific tests that you may use?
Dr. Kate Kardell: Yes. So I love doing initial assessments. I love kind of hearing people's stories and the path that's led them to my office that day. So there are two purposes of the initial assessment. It's one to establish a diagnosis. Is this an eating disorder? And then also to establish medical stability. Which would direct us into, so what do we do about it? What level of care makes the most sense? So a lot of it is just conversation and chatting and just kind of hearing the story of how things have developed and how people are feeling about their eating patterns and their exercise patterns and other potential symptom use. Then we also do an EKG, which is an electrocardiogram or a test that can give us lots of information about the function of a heart.
Sometimes something's about the structure of the heart, and that's where we could see. [00:05:00] The low heart rate, one thing we're looking for, and then also a specific electrical interval that we look for called the QT interval. And then we are doing lab work to look for signs of undernutrition or malnutrition.
Dr. Karen Nelson: Maybe help our listeners know, are there specific things that happen, like to the heart or to our physical body if we are engaging in restriction or purging?
Dr. Kate Kardell: Yeah, we can certainly see some signs. And again, if we don't see them, it doesn't mean they're not happening. But yeah, with restriction, things that we can see in the labs. So when we look at anemia or low white cell count, another way the body compensates is by kind of down regulating their bone marrow, and so they're just not producing white blood cells and red blood cells, and that can translate to anemia or low white blood cells. Sometimes we see elevated liver enzymes, and so anytime your liver [00:06:00] enzymes are elevated, we can be termed hepatitis, and what we see is usually it's called starvation hepatitis. So if the body isn't getting enough energy or nourishment, it starts to kind of take things into its own hands and almost like digest its liver for energy. And so we can see elevated liver enzymes because of that.
Dr. Karen Nelson: Tell us about purging. How might that potentially impact our body?
Dr. Kate Kardell: Yeah. So there can be impacts on the structures of our body, right?
So the stomach and the esophagus, because that's where purging is happening. So you can have irritation of the lining of your esophagus, so your food tube and your stomach, because stomach acid isn't supposed to be going that way. Those cells aren't built for that. And so you can get sometimes small tears in the esophagus and have some bleeding with purging. In extreme cases, you [00:07:00] can have that esophagus tear open, which is often fatal. You can be more prone to reflux symptoms or heartburn just because the sphincter that's supposed to stay closed all the time between your stomach and your esophagus gets weaker because it's – you're working against it to purge and you're forcing it open.
And so often that means that there's more opportunity for acid to go back up. And then we see the effects from losing the gastric contents. So potassium is the biggest thing that we're worried about. So someone who is vomiting or using laxatives and having a lot of diarrhea from that, they can lose potassium, which can be really dangerous. I think that's the probably one of the most life threatening complications is low potassium because our cells need potassium, our heart cells need potassium, and if they don't have it, that's when we can see some fatal [00:08:00] consequences.
Dr. Karen Nelson: Dangerous stuff. Well, I like how you acknowledged that the body does tell a story, right? There can be definite health issues that are apparent and overt. And, I think sometimes, like you beautifully stated, sometimes we may not be seeing body dysregulation and someone does still have a diagnosis of an eating disorder. Quite frankly, many of my patients. Sometimes it's how the eating disorder convinces the patient that it's not a big deal, that, ‘Well, you know, my labs were fine, so I must be fine.’ Well, and I'm engaging in a lot of these symptoms or using a lot of eating disorder behaviors. How might you talk to your patients about that? Right.
Dr. Kate Kardell: I mean, it is a conversation that I have. I like saying the same thing of like, the body is amazing at compensating. And so I'm glad that your body appears to be compensating right now. And some of these [00:09:00] lab changes can happen pretty quickly. And so I'll say your labs are normal until they're not. And sometimes we don't get a lot of warning before that, right? So if someone is binging and purging all weekend, their potassium at that point might be critically low. Four days later, it might be normal when they come to see me, when they were actually that previous weekend at risk for serious complications.
Dr. Karen Nelson: I mean, we just know eating disorders can be and are very dangerous. We want to take them very seriously. We're not using just one data point to assess wellness or recovery. It's again, the need for that multidisciplinary team, for both the medical doctor, therapist, dietitian, occupational therapist, physical therapist, that we're all connecting to assess and assure that we're moving that patient into recovery. When someone does receive that diagnosis of an eating disorder [00:10:00] and they are recommended to go to inpatient – so the intensive residential unit – they typically do start a refeeding or weight restoration process. I'd love it if you could maybe help us first of all kind of know what that means, and then what things might need to be addressed medically as someone is inpatient to restore weight?
What might that look like?
Dr. Kate Kardell: Yeah, so the initial focus definitely is re-nourishing our patients, so nutritional rehabilitation. When you do look at the research and read, it is refeeding, which I think sometimes isn't the best term.
Dr. Karen Nelson: Right. That's a hard term.
Dr. Kate Kardell: Patients don't want to hear that they're being re-fed. So I'll often refer to re-feeding syndrome as re-nourishing syndrome. And so that's where it is a double edged sword, too, a little bit. There are significant risks to malnutrition. There are some risks to re-nutrition or [00:11:00] re-nourishing, and that's what we are monitoring for. So some of those can look like electrolyte changes, like phosphorus is the most common. And so when somebody hasn't been eating and then they increase their intake and the body has to respond to that. And just one of the pathways that does that is that phosphorus, which is another important element in lots of different functions in the body, gets pushed into cells, so the body doesn't have access to it. And so that can cause weakness a lot of times in muscles and heart muscle and things like that. So what we are often checking labs for is the phosphorus and potassium levels. And so if somebody's on our unit, on our intensive residential unit, we will do labs every three days to make sure that happens. Because they can be a big deal. And also we can catch it before it's a big deal. And so that's where sometimes being in a residential setting is the [00:12:00] safest place to be.
Dr. Karen Nelson: You bet. And just having that aspect of specialized care, right? That you specifically kind of know what to look for. We're responding, and we use evidence-based care here at Melrose, and you just are moving people through that recovery in a safe, you know, supportive manner.
It's so important to name that.
Dr. Kate Kardell: Right, right. And saying, often, I see your heart rate is low. Often, that can tell me that your body is trying to conserve energy. Sometime there could be another reason for that, but just saying ‘often’ and putting it on other people too. Like, ‘Often I see patients who have labs that look like this and it means that they are using laxatives. Is that something that you are engaging in?’
Dr. Karen Nelson: I love that. To just, again, not that I'm accusing, I'm just being curious and saying those curiosities out loud.
Dr. Kate Kardell: Right. Oh, for sure.
Dr. Karen Nelson: Tell us [00:13:00]about if there is maybe an adolescent who may be struggling or is potentially suspected of struggling, what would you tell parents about your concerns? Or how might you bring that up to parents of if you're seeing something in an adolescent that may be questionable or concerning?
Dr. Kate Kardell: Yeah, I think I would look at the facts that I have and use them and say, ‘So this, I see your child has shifted down on their growth curve. I see that their heart rate is low. I see that they have these lab abnormalities, and that is telling me that their body's not getting enough nourishment, and I'm concerned about that. And we need to do some more evaluation around that.’
Dr. Karen Nelson: So, more curiosity, sharing the facts. It really is an important word. Rather than being judgmental or accusatory, I'm just going to be curious and notice that I can't make up the facts, right? Our bodies are going to show [00:14:00] us things. And so, you as the physician – it sounds like you're just maybe reporting it and being like a detective a little bit. Of, ‘Huh, I'm noticing these things. Any insight you can give me, mom or dad, of what might be happening?’
Dr. Kate Kardell: Right. And it can be a double edged sword, too, of the body is amazing at compensating.
Dr. Karen Nelson: Whoa, good point.
Dr. Kate Kardell: There are no physical signs. If their labs are normal, that doesn't mean that somebody isn't physically compromised from their eating disorder.
Dr. Karen Nelson: Wow. Absolutely. Do you think it can be hard for parents to hear expressed concerns about their child maybe struggling? What have you noticed about that?
Dr. Kate Kardell: Yeah, it can be difficult. And I think it depends on the family situation. There are some parents who have noticed changes in their eating patterns and weight and are very concerned. There are some who, as parents themselves are engaging in different diets or eating patterns or they want the family to eat [00:15:00] this way. And not intending to cause any distress to their child. So I think sometimes there's shame and guilt from parents too. Of, yeah, ‘I first was, you know, encouraging them to lose weight or to exercise and now it's in a place where it's dangerous and unhealthy and there's some shame around that.’ That said, parents do not cause eating disorders.
Dr. Karen Nelson: Thank you. That’s right. I was just going to jump in with that one. Never are we ever placing blame, but again, just being curious. As we were talking about some of those symptoms that may happen as someone is potentially struggling with an eating disorder, I think an important one for us to touch on is changes in menstrual cycles for women.
Dr. Kate Kardell: Right.
Dr. Karen Nelson: And so I'd love it if you can, you know, help us understand what that means or how that comes to be and how you may talk about that or treat that.
Dr. Karen Nelson: Yeah. So it is very common in someone with a restrictive eating [00:16:00] disorder and weight loss to lose their period or their menstrual cycle. And it is another kind of compensatory thing that the body does.
And an evolutionary type of thing, too, of when the body is in starvation mode, thinks it's in a famine, that's not a great time to get pregnant and have a baby in caveman times.
Dr. Karen Nelson: That's right.
Dr. Kate Kardell: Right? Or in famine times.
Dr. Karen Nelson: We're conserving all the energy.
Dr. Kate Kardell: Yes. And I often will say that not having a period concerns me for two reasons. One, something's wrong. Something's not working. It's a red flag. But then also it can be concerning because it can affect future bone health. So often if you don't have a period, then that translates in this setting to your estrogen level being too low. And we need estrogen, females do, to develop their bone density.
And where that becomes really important in this is, [00:17:00] we have a few short years to get our final bone density. So peak bone density is between seven. teen and like 22 years. And after that you have what you have. There can be little changes. So you can imagine if that is when somebody is restrictive and they're not building strong bones. So they can develop true osteoporosis or low bone density. And so, that's where we really focus on, ‘Yep, let's restore weight and get your period back because we want you to have strong bones.’
Dr. Karen Nelson: I think it's also important to kind of acknowledge, again, like how a patient may minimize that. You know, I've had many college students, you know, share, like, ‘Well, it's not a big deal. And my period's annoying anyways. And, you know, that I thank heaven it's gone.’ And it's like, ‘Oh, there's a very real reason why we get a menstrual cycle.’ And I love that you're identifying [00:18:00]it. This isn't just about ‘Oh, that annoying period is gone.’ Something is going down in our body.
Dr. Kate Kardell: Right. And, you know, another minimizing thing is like with athletes, like long distance runners. They say, ‘I always lose my period during the season.’ And they shouldn't. Right? Even, I mean, they don't have to have an eating disorder per se. Not having your period does not mean you have an eating disorder, but it's an energy deficit. So if somebody is running a lot. And not eating enough to fuel that, it's the same process of the body kind of downregulating or shutting down that pathway. So it is not normal to not have a period just because you are running many miles a week.
Dr. Karen Nelson: For sure. We've been focusing our attention, Kate, on kind of most specifically restrictive type eating disorders. Specifically anorexia, bulimia, otherwise specified. Let's maybe shift our attention and just talk about medical care [00:19:00] for binge eating disorder. What do you think about that aspect of, binge eating may have its own medical concerns? How may medical care at Melrose, is it integrated for people who are diagnosed with binge eating?
Dr. Kate Kardell: Our patients with binge eating is often to counteract what their outside physician might be saying. So they might present with pre diabetes and are told to limit your sugar intake or limit your carbohydrate intake. When the reality of that, in someone who's struggling with binge eating, might mean that, then they start binging more. And so my message is usually the most detrimental thing to your health right now is your binge eating disorder. So let's get that in check and then before we start doing other restrictive kind of interventions. Often, our patients with binge eating [00:20:00] disorder already have an established primary care doctor. Often, they're adults, and so they've established, you know, an ongoing relationship that we want them to keep. And often, there are other medical diagnoses like high blood pressure and things like that that really are not within the scope of our care at Melrose.
Dr. Karen Nelson: So we would do a lot of that coordination then. Let's maybe talk about as someone is moving through treatment for an eating disorder, if their care had included an inpatient stay and now they are in an outpatient setting, they're doing kind of follow up care with their therapist, dietitian, tell us about what that might look like as far as medical care goes. How might that show up for our patients?
Dr. Kate Kardell: Yeah, so after discharge, we often in the outpatient setting want to see them fairly regularly, because they go from seeing a doctor every day to not. So I like to see patients who have been recently discharged weekly [00:21:00] and just make sure that they are tracking with weight stability or weight restoration, making sure that any lab abnormalities that were persisting from residential care are improved, and then over time that frequency probably spaces out. But the medical appointments are where we get to often get the vital signs, get the heart rate and the blood pressure and the weight and can kind of track and monitor and make sure that they're not going backwards and that they are remaining stable. I often will say the role in outpatient is to make sure that our patients are stable enough to stay in outpatient.
Dr. Karen Nelson: We heal in community and your treatment team is part of that connection and community. You get a three for one at Melrose, right?
Dr. Kate Kardell: Right.
Dr. Karen Nelson: Your team, you got a medical doctor, a dietitian, a therapist, maybe even more, you know, practitioners who are there to just help you move towards that place of recovery.
Dr. Kate Kardell: Right. And I just try to call it out too. I'm like, I know this isn't your favorite [00:22:00] appointment.
Dr. Karen Nelson: This is hard. Yeah.
Dr. Kate Kardell: This is hard.
Dr. Karen Nelson: For sure.
Dr. Kate Kardell: So I'm just acknowledging that. And it's hard and you still have to come and see me.
Dr. Karen Nelson: Right. So let's maybe talk about, as patients are maybe initially moving into that place of diagnosis, they have been diagnosed with an eating disorder, if they already have a primary doctor, do they then like switch care and see medical care here at Melrose? Or help us know about that.
Dr. Kate Kardell: Yeah, we look at it as a partnership, I guess. So, patients who are seeing the medical doctors or providers at Melrose, we are really focused on the medical complications of the eating disorder. And we need them to continue with their primary care doctor outside of Melrose. So, if they have a sore throat or are sick, they still need to have a primary care doctor. But our focus is more on making sure that they are medically stable from the eating disorders perspective.
Dr. Karen Nelson: And so [00:23:00] what does that look like as far as like maybe frequency? Or what is recommended frequency of seeing a medical provider within eating disorder treatment?
Dr. Kate Kardell: Yeah, it really depends on how somebody is doing and what somebody is struggling with. If somebody is using symptoms a lot, or depending on what that is, laxative use or, you know, purging, we would see them maybe even every week or two. As patients move on and start moving towards recovery, they might see us every six weeks. So it kind of depends on if there's things that we need to monitor closely and how they're doing.
Dr. Karen Nelson: I like how you acknowledged kind of the collaboration that happens as a primary care doctor within the eating disorder facility and team, but then also, are patients maintaining potential contact with an established primary care doctor. Just wondering, what would you hope general [00:24:00] primary care physicians might know about eating disorders? Or any insights there? Maybe?
Dr. Kate Kardell: Yeah, I mean, because when I started at Melrose, I mean, I didn't know that much about eating disorder medicine. And I think back of like, how would I have approached my patients differently with the knowledge that I have now. So I think there are things that weren't on my radar as a primary care before Melrose. You know, menstrual irregularities, especially in teenagers and just kind of saying, ‘Well, you know. It's a teenager thing. Your body's figuring itself out.’ And not really diving down to see what is their nutritional status? How are they doing there? And then just talking about weight in general. I know we had a fantastic podcast with Dr. Funk about this. But yeah, how we approach talking about weight and healthy behaviors and really focusing on the behaviors part versus you know, losing weight does not make you healthier.
Dr. Karen Nelson: I love that. The pieces that I'm [00:25:00] really hearing is, if I maybe don't have a kind of deliberate lens of acknowledging eating disorders, may have some covert symptoms happening. They can be overlooked, or what do you think about that?
Dr. Kate Kardell: Yeah, I think they are overlooked often. When people come to our initial assessments, we can look back and identify, ‘Oh, there were lots of visits for fatigue or constipation,’ or things like that. When we can look back and say, no, that was probably secondary to and eating disorder.
Dr. Karen Nelson: Absolutely. So you have evidence that they are overlooked and notice that maybe those questions weren't asked in a certain way to kind of elicit the information from the patient of, ‘Is there any maybe behaviors happening with food?’ I mean do you think a lot of our patients, they've never been maybe asked in some of those settings do you think?
Dr. Kate Kardell: 100%. I think they're not asked [00:26:00] or they're asked in a way that would not necessarily elicit an honest response.
Dr. Karen Nelson: Tell me more. Tell me more.
Dr. Kate Kardell: So yeah, I've had a patient before who, you know, lost a lot of weight – lost maybe 20 pounds. And this was an adult patient and the doctor just came in and said, ‘Nice work. I know you've been trying to reach this milestone.’ And at that point, he's not going to say, ‘Well, that's because I'm throwing up all the time and, you know, limiting my intake to 500 calories.’ He just says, ‘Well, thank you.’
Dr. Karen Nelson: Wow.
Dr. Kate Kardell: And so I think it's important, especially in what I tell my colleagues when I do give talks, is to be curious before you give an opinion about it.
Dr. Karen Nelson: I love that.
Dr. Kate Kardell: ‘I see your weight has changed. Tell me about that.’ Instead of, ‘Good job.’
Dr. Karen Nelson: Such a different approach. Absolutely. That assumption, any type of weight loss is good.
Dr. Kate Kardell: Right.
Dr. Karen Nelson: Wow. What a good point. And I think [00:27:00] also too, the eating disorders kind of by design are really secretive. There’s often a lot of shame attached to the behavior. And so it makes sense if I'm getting even a vibe from my provider that, ‘Hey, they think it's a good thing that I lost weight.’ I don't know. I mean, do you think that does impact how someone may talk about it?
Dr. Karen Nelson: I do. I do. And I think it impacts, sometimes – it might not be the cause of the eating disorder, but it reinforces the eating disorder. There's lots of cases or patients that come to us who have experienced a lot of stigma, even from their regular doctor of lots of things. Your knee pain would be better if you lost weight. Your back pain would be better. Your blood pressure would be better. And so that's what they hear is, ‘Okay, how do I start and how do I do that? How do I lose weight? Because they're just going to tell me that's what I need to do and not [00:28:00] sometimes address the actual physical issue.’
Dr. Karen Nelson: Very true. And appreciating that if I'm just looking at the external symptom of weight loss happening, like you said, not being curious or, I'll say that in a different way, making sure that we are curious to assess the pathway that I got there.
Dr. Kate Kardell: Right.
Dr. Karen Nelson: Because could be really dangerous is what I'm hearing.
Dr. Kate Kardell: Yeah, there are lots of potentially life threatening complications that can come from either caloric restriction and weight loss and or purging behaviors.
Dr. Karen Nelson: I love that. Really good to identify that. Well, as we finish up here, Dr. Kardell, I would love it if you, if there's any kind of final messages you have to our listeners? Or if someone is struggling with an eating disorder, any final thoughts that you may have?
Dr. Kate Kardell: Yeah, I think that recognizing that eating disorders, they have a psychological component and that physical component again. And they can be very serious and life threatening, and it [00:29:00] can affect all aspects of our physical health. But then also that the body's resilient, and it can come back from most of those things. And so continue to work towards recovery, and then your body will start working as it should.
Dr. Karen Nelson: You said it perfect. Well, thank you so much.
Dr. Kate Kardell: Thank you for having me.
Dr. Karen Nelson: I just really appreciate you and this conversation.
Dr. Kate Kardell: Thank you.
Dr. Karen Nelson: That's it for today. Thanks for joining me. We've covered a lot, so I encourage you to let it settle and filter in. And as I tell my patients at the end of every session: Take notice, pay attention, and we'll take it as it comes. I'll talk to you next time. To learn more about Melrose Center, please visit MelroseHeals.com.
If you or a loved one are suffering from an eating disorder, we're here to help. Call 952 993 6200 to schedule an appointment and begin the journey towards [00:30:00] healing and recovery. Melrose Heals: A Conversation About Eating Disorders was made possible by generous donations to the Park Nicollet Foundation.