National Eating Disorders Association

The Role of Medicine in Eating Disorder Treatment

Margherita Mascolo, MD, CEDS

Thank you to Alsana for sponsoring this blog post. 

Medical support has long been a pillar in the treatment of eating disorders; however, historically, this medical support has been delivered in the form of psychiatric care. While psychiatric care is fundamental to eating disorder treatment, medical care should also encompass nursing care and care by an internist or family practitioner familiar with the medical complications of eating disorders. In the age of ever-growing insurance denials and increasing acuity at lower levels of care across the medical spectrum, it is important to develop a robust medical program to best support clients, and ensure their safety and treatment success. It truly takes a village to deliver such care and I conceptualize medical care of these clients as a trifecta of medical, psychiatric, and nursing; all three aspects equally important and equal contributors to the total care of the client.  

The figure of the nurse is pivotal as nurses really play a dual role in the care of eating disorders. Medically, nurses are the physician’s eyes and ears on the ground. In residential treatment centers, nurses are in the facilities 24 hours per day, are able to assess changes to client’s status, and effectively communicate with the attending physician. A strong and well-trained nurse can pick up subtle changes to the client’s medical and underlying psychological status which can serve as a guide to the multidisciplinary team. The second aspect of the nurse’s role is in the power of the bond they develop with the client. Nurses become both enforcers of the boundaries set by the physician and the team as well as the keepers of a safe and nurturing space for the clients to express their vulnerabilities.  

The second aspect of the trifecta medical model is the role of psychiatrist. Eating disorders are primary psychiatric conditions (even though they can have so many physical manifestations) that present with a host of psychiatric comorbidities such as mood disorders, personality disorders, and sleep disorders. Its is crucial for the psychiatrist to recognize and treat the underlying psychiatric co-morbidities in order for the client to receive the most benefit from eating disorder treatment.  There is so often an association between treatment and the prescribing of medications which leads to prescription drug polypharmacy. So often, these clients come to treatment with 15 medications they take on a daily basis for a number of different conditions. While mood disorders and other underlying psychiatric conditions often require prescription medication, it’s important to recognize that many of the psychiatric and physical complaints can be treated with non-pharmaceutical interventions, and as Benjamin Franklin pointed out, “The best doctor gives the least medicines.” Refeeding after a prolonged period of starvation is painful both psychologically and physically; and while a few meds can be helpful, investing the necessary time needed to establish trust with a client can be a powerful tool to help minimize excess medications and ensure clients’ success with treatment. Sleep is often neglected prior to entering treatment (as well as while in treatment) and studies have shown that lack of sleep can lead to poor memory, poor performance, and worsening of underlying psychiatric conditions.  Sleep assessment is therefore crucial in the treatment of eating disorders and instead of reflexively before prescribing medications for lack of sleep, it’s important for the psychiatrist to evaluate sleep hygiene in these clients and set a treatment plan accordingly. 

Lastly, the internist or family practitioner is responsible for delivering the medical care of the trifecta model. As William Osler stated: “The good physician treats the disease; the great physician treats the patient that has the disease.” This quote rings true for the medical providers of eating disorder treatment. While they stem from an underlying psychiatric condition, eating disorders have medical complications that affect the body head to toe and from the inside out. We should all strive to be great physicians as there are many complex physical manifestations of eating disorders, and one can easily become so focused on treating every single problem or complaint that they can neglect the underlying psychiatric disorder and psychological suffering of the client. The medical provider must be trained in the recognition and management of the medical complications of eating disorders — from the complications of extreme restricting to those of extreme bingeing — in order to support treatment.  For example, while gastroparesis from restriction and weight loss is fully reversible with weight restoration, it can take months to weight restore enough for the condition to be reversed.  During this time, as the client has entered treatment and been placed on a progressive nutritional plan, they can suffer from the symptoms of gastroparesis including fullness and nausea which can impede progress and re-enforce eating disorder behaviors. Recognition of gastroparesis and medical management during the acute phase of weight restoration can alleviate suffering and support the client during treatment.  

In conclusion, the comprehensive delivery of medical care for clients suffering from eating disorders is based on an interplay between nursing, psychiatric and medical care. We must not forget however that this trifecta works best in the setting of a multidisciplinary team that is dynamic, supportive of each other, understanding of the psychiatric and physical manifestations of eating disorders, and focused on the care of the whole client: mind and body. This is best summarized by Hippocrates, “Wherever the art of medicine is loved, there is also a love of humanity.”

Dr. Margherita Mascolo is the chief medical officer at Alsana, leading the medical component of the Adaptive Care Model. Dr. Mascolo is board certified in Internal Medicine, has published multiple peer reviewed articles on the medical complications of eating disorders, travels nationally and internationally to speak on these complications, and has earned her certified eating disorder specialist certification.