Tuesday, December 6, 2022
HomePodcast13: Dr. Linda Schack: Disordered Digestion

13: Dr. Linda Schack: Disordered Digestion

Our guest this week is Dr. Linda Schack, and the topic today is disordered digestion and recovery. Dr. Schack provides some medical insight into how eating disorders affect digestion, some of the real consequences of eating disorders, and why she orders specific lab work for all of her patients.

You can learn more about Dr. Schack from her website as well as the work she is doing at the Medical Stabilization Program for Patients with Eating Disorders at Torrance Memorial Medical Center

Full transcript –

Kathy: Hello and welcome to ED matters. I’m Kathy Cortese, your host, and my guest today is Dr. Linda Schack. Good afternoon, how are you doing?

Dr. Schack: Good! How are you?

Kathy: Good. I’d like to start off by sharing a bit of your file. Doctor Linda Schack has been treating teenagers and young adults with eating disorders for more than twenty years. She’s overseen the care of patients with eating disorders in residential, hospital and office settings and is the Medical Director of the Torrance Memorial Medical Stabilization Program for patients with eating disorders. Dr. Schack has been a lecturer at the International Association for eating disorders professionals in the Academy for eating disorders international conferences. In addition to her specialized work with eating disorders, Dr. Schack provides comprehensive healthcare for teens and young adults at her Torrance office. Dr. Schack is one of a handful of board certified at  Adolescent Medicine Specialists in the country having first trained in pediatric at Children’s Hospital LA and then continuing at Children’s Hospital at LA for her adolescent medicine fellowship. Our topic today is probably a little more medically oriented than some of the others that you’ve heard. But this one is entitled “Disordered Digestion and Recovery.” So, we’re going to start with how you started out. You started out meeting with eating disordered patients a good number of years ago and your thinking has evolved over time. I’m curious if you could share some of that with us.

Dr. Schack: Sure. When I started I was of course seeing adolescent and young adult patients, kind of trickling in with eating disorders. I have a general adolescent medicine practice and the eating disorder’s really built up slowly over time. So, occasionally I would see an eating disordered patient and often they would say that they were constipated.  And I would think to myself “Of course you’re constipated you’re not eating anything. So there’s nothing in there.” And I would just move on and I would tell them “When you’re recovered, when you’re eating, the constipation will resolve” and I really believe that. And I think a lot of doctors probably think along of the same ways. And I should also say that when I was admitting patients to the hospital, which I did increasingly over the years as my patient population grew and got — I started seeing sicker and sicker patients, I rarely consult a gastroenterologist on my patients and when I did consult them they would often come in, see the patient be fairly uninterested and maybe write a note and fix something up and never come back.

Kathy: Mmmhmm.

Dr. Schack: In 2008, I saw an extremely sick patient who was in our Intensive Care Unit who had refeeding hepatitis. And I consulted a gastroenterologist who was new in the community who would come from UCLA and had some experience working with the UCLA Eating Disorders program. And she quickly helped me resolve the hepatitis in my patient and I started consulting her on every patient that I was admitting eventually. And she really taught me that constipation is a real thing. So what you see with constipation if you take an X-ray is that in a normal patient, there will be some stool in the X-ray in the left colon, that’s normal. And in a constipated patient you can easily the stool that shows up as kind of a spongy-looking whitish material and it goes up and across and down into the right colon. And that should not be there. And it’s very very easy to see that. And what happens is often radiologists will report that on their report, if you happen to get an X-ray, a radiologist will report that out. So under the findings they’ll say “there is stool to the right colon” or “there is an abundance of stools seen on the X-ray.” But on the impression section of the film, they will say “Impression: Within normal limits” or “no significant abnormality.” And if you’re a physician in your office and you happen to order this X-ray and you’re busy and you just get this across your desk, you’re going to just look at the impression that says “no abnormality” and your gonna reassure your patient that there’s nothing wrong with them.

Kathy: Mmmhmm.

Dr. Schack: While they sit there complaining of their abdominal pain.

Kathy: I think that’s the question in reality. What’s happening? What’s hurting? How is it going for the patient?

Dr. Schack: What happens is, if a patient is not eating enough, what you get is something called slow transit constipation. So, as many people may be aware, in starvation, many body systems slow down. So, the heart rate slows down, metabolism slows down and intestinal motility slows down as well. And maybe that is to try to maximize the time that the nutrients go through the digestive tract because the job of the small intestine is actually to absorb nutrients so you could postulate that if everything slows down you’re going to have more time to absorb nutrients.

Kathy: Mmmhmm.

Dr. Schack: And the job of the colon is to reabsorb the water. And then you end up with stool at the end whatever is left over.

Kathy: Mmmhmm.

Dr. Schack: So, in slow transit constipation, what happens is, even if the patient is not eating a thing, you turn over the lining of your GI tract every three days so you’ll slough that whole lining completely in three days. And that creates a lot of fecal material even if you’re not eating food.

Kathy: Mmmhmm.

Dr. Schack: And most people are eating some food. And then everything is so slow that it’s just collecting at the bottom and it will expand the colon, expand the rectum like a balloon.

Kathy: Mmmhmm.

Dr. Schack: And the longer that goes on, the harder it then becomes for the patient to pass the fecal material out.

Kathy: Mmmhmm.

Dr. Schack: And that can really create some big problems. Patients are extremely uncomfortable, they feel full, you can feel that stool on physical exam.

Kathy: Mmmhmm.

Dr. Schack: The patients just don’t feel like eating because they got a belly full of poop.

Kathy: Yeah.

Dr. Schack: And I think often in programs they are labeled, you know, like unmotivated to recover or they’re, you know, they’ll say “they’re not hungry.” An people would just say “well, that’s in your head. You’re not motivated.”

Kathy: So in terms of this particular piece of information, what would you want physicians who are addressing the concerns of eating disordered patients to keep in mind?

Dr. Schack: Well I think you will always have to keep in mind that somebody with a restricting eating disorder can almost — I would say, if they’re sick enough to be referred to you as an eating disorder specialist or sick enough to be in treatment even in your general medicine doctor — that you should be thinking to look at an X-ray.

Kathy: Mmmhmm.

Dr. Schack: Cause often patients, especially the anorexic patients don’t even complain about it. Anorexic patients, in my experience, tends to play down a lot of their physical symptoms.

Kathy: Mmmhmm.

Dr. Schack: Whereas bulimics I think are much more expressive in talking about what’s going on with their body.

Kathy: Mmmhmm.

Dr. Schack: “This hurts, that hurts.”

Kathy: Mmmhmm.

Dr. Schack: Whereas an anorexic will downplay everything and they’ll say “everything’s fine.”

Kathy: Mmmhmm.

Dr. Schack: So you have to really look for it even if they don’t talk about it. Really in my practice is anyone who comes in who’s lost significant amount of weight or their BMI is low, everybody gets an X-ray and most of the time there is pretty significant constipation.

Kathy: Mmhmm. You raised the topic of patients with bulimia and there’s lots of different compensatory behaviors that bulimics engage in. What are some of the GI dilemmas that come from that in terms of their digestion?

Dr. Schack: Well, bulimics can be constipated as well though it tends to be not as severe as the anorexics by far but they also can have reflux. So what happens is that the little sphincter, which is sort of the muscle between the esophagus and the stomach which keeps your esophagus or the swallowing tube separate from your stomach, just becomes very lax doesn’t stops doing its job and so you get a slushing up of those stomach contents back up into the esophagus so patients complain of heartburn, or lot of burping or discomfort. And with time that can actually cause esophagitis or inflammation of the esophagus. And even in severe cases it could erode the esophagus.

Kathy: Mmmhmm.

Dr. Schack: So it’s a pretty significant and bad actor with —

Kathy: Yeah.

Dr. Schack: With purging through vomiting.

Kathy: And laxative abuse.

Dr. Schack: So the laxative abusers if you’re using stimulant laxatives such as Dulcolax and Ex Lax and those kinds of things, you can become dependent on them requiring more and more of those. You know you’ll hear people tossing around the fact that chronic laxative abuse is really dangerous and you can get Megacolon, which is a very widened colon and that can never go back and it can be paralytic, but I think that’s extremely rare. I’ve actually never seen a case of it.

Kathy: Mmmhmm.

Dr. Schack: But what you see much more frequently is kidney damage and kidney stones. I had a patient who is using four hundred laxatives a day —

Kathy: Mmmhmm.

Dr. Schack: For several years.

Kathy: Mmmhmm.

Dr. Schack: And as far as I could tell her colon was pretty much intact. But although she was dependent and she developed tolerance so she needed more and more.

Kathy: Right.

Dr. Schack: But her kidney, she had kidney stones.

Kathy: Kidney stones?

Dr. Schack: Which is pretty common and her kidneys, she also had renal insufficiency as well. So she had to be on Chronic Diuretics and which is extremely — also when you give diuretics that’s an unhealthy for the kidneys either so you’re between a rock and a hard place and ideally would have to give the diuretics and then wean them down.

Kathy: You know I’ve been doing this a long time and you’re the first doctor to explain that part of the impact of laxative abuse on the kidneys to me so I really appreciate that and I hope members of the audience who may not have been informed just learned something, that was really really helpful. And you know, very serious as well.

Dr. Schack: Yeah. You get the stones because you have dehydration, because they — you know, patients who are using laxatives think that they’re just losing calories but really all they are losing is water.

Kathy: Mmmhmm.

Dr. Schack: The body is losing water and the kidneys then don’t have enough water to profuse them properly and they need that water to be going through. And then they also have to work really hard to then retain water.

Kathy: Mmmhmm.

Dr. Schack: And they’re working hard and they’re not getting enough water, and so it really toxics the kidneys, that’s the really the danger of laxative abuse.

Kathy: Got it. Other aspects about digestion and recovery that you’d like the audience to learn?

Dr. Schack: I think that one of the things early in my career that patients come in and mostly parents of teenagers especially will come in like really concerned about their daughter’s anorexia, for example, they’re worried about reproduction, you know, “Is she going to be able to have children again?” Because the menstrual period stopped.

Kathy: Mmmhmm.

Dr. Schack: Or what is the impact on the heart? You know, I would just try to reassure them that for most of these things, they are reversible. And they never considered the impact of Chronic Constipation. And now that I’ve been in practice for over twenty years and I’ve been following patients for a long time, I can tell you that I have some patients that have Chronic Constipation. I have one in particular who is now about twenty-four years old and she has been recovered for several years, she’s completely weight-restored but she has Chronic Constipation and she has Chronic Anal Fissures.

Kathy: Mmmhmm.

Dr. Schack: And in order to fix that, she has to be on Miralax, which is an osmotic diuretic it’s not like Ex Lax which is a stimulant.

Kathy: Right.

Dr. Schack: Transmodic laxative, means that you draw the laxative is a large molecule and it draws water into the colon so it helps loosen everything up. And she really needs to be on Miralax like three or four times a day for a year. She has to — the gastroenterologist that she’s working with told her that in order to get that colon to then shrink back down to a normal size, she really has to keep her stools at a mushy caliber.

Kathy: Mmmhmm.

Dr. Schack: Which is really socially difficult to accomplish.

Kathy: Mmmhmm.

Dr. Schack: It’s very difficult to treat and she’s, up to this time, really not been able to do that.

Kathy: Mmmhmm.

Dr. Schack: You know and she’s told me that this is really the worst thing in her life and she wouldn’t wish it on anyone.

Kathy: Wow. Yeah.

Dr. Schack: So I think now, I’m going three hundred and sixty degrees where I feel like constipation’s almost the thing you really have to work to prevent and treat —

Kathy: Mmmhmm.

Dr. Schack: Aggressively to prevent Chronic Constipation.

Kathy: Yeah.

Dr. Schack: So it’s really impact somebody’s life.

Kathy: Yeah. I appreciate you sharing that vital information. Just so that people don’t take all of this information and assume you dwell only on the GI, we know that you are pretty much on top of every organ of the body when you’re dealing with an eating disordered patients. You know, please tell us what you have to monitor, because you work in a hospital setting.

Dr. Schack: I work in a hospital setting, I also work in private practice as well.

Kathy: Mmmhmm.

Dr. Schack: But so for eating disordered patients obviously, like you said, every organ system is involved or affected by an eating disorder, so we’re carefully monitoring fluid intake and output and want to make sure the patients don’t get fluid overloaded. If you have low protein in the body that can, which is common in anorexic patients, that can cause edema or swelling of the lower extremities or the legs, looking at the heart function. Really, everything is affected and we take care of the whole patient reproduction. Obviously we want their periods to come back, their bone density is affected, so we’re really making sure that weight restoration is really important because that’s going to fix almost everything wrong with the body. And it is true that almost everything you can name is reversible. Well, bone density looks like the evidence now is that they may not get up to their previous, their genetic potential, but certainly they recover some of their bone density.

Kathy: Mmmhmm. So there’s fascinating controversy about BMIs and percentages and that sort of thing? Can you weigh in on that?

Dr. Schack: Yeah. I’d love that. I would love to weigh in. I think BMI is an important measurement. I don’t think we should throw it away completely. I think it’s helpful. I think any measurement of weight has its place and its important role. So, for example, there is a measurement people, listeners may be familiar with this estimated weight, where it’s a hundred pounds if you’re a woman and five foot zero and then you add five pounds for every inch over five foot zero. And so for somebody who’s five foot three, they should weigh about one fifteen.

Kathy: Mmmhmm.

Dr. Schack: And it’s obviously a very loose, you know, measurement —

Kathy: Guideline

Dr. Schack: Guideline.

Kathy: Yeah.

Dr. Schack: And people love to just trash that thing. But I think it has its usefulness, for example, the way I use it as a physician is I get a phone call from somebody and I’m asking them or their parent you know, for example, so how tall is she and how much does she weigh? And using that in my head never having seen the patient just gives me a rough picture of what I’m going to be dealing with when that person walks in the door. So if I know that they’re five foot eight and they’re a hundred pounds, immediately, I’m thinking this patient might be sick enough to go to the hospital.

Kathy: Mmmhmm.

Dr. Schack: So, I think that’s the usefulness of that. Using BMIs, of course, also has its usefulness and it also has its limitations. The limitations which many people have pointed out is that, if you have  a BMI at the eighty-fifth percentile, that could be obese for somebody but for somebody else it could be normal, for example, a shotputter probably has a really high BMI. It just tells you how large you are on your frame, it doesn’t tell you anything about percentage of body fat.

Kathy: Mmmhmm.

Dr. Schack: So I think you have to look at a lot of different factors when you’re trying to figure out if somebody’s overweight, underweight and by how much. So I think all of those things are useful.

Kathy: Mmmhmm.

Dr. Schack: I don’t like the idea of throwing them out.

Kathy: Mmmhmm.

Dr. Schack: I just think you need to know what the limitations are.

Kathy: Limitations and use the wisdom.

Dr. Schack: And the usefulness. Yeah.

Kathy: Yeah.

Dr. Schack: And use the proper method for what you’re trying to accomplish.

Kathy: So in closing I want to thank you so so much. But I’m actually going to share a little tidbit that I just learned about Dr. Schack and apparently, she’s a singer on the side. And I’m hoping, who knows, one point in time maybe we’ll get her back here and she can share some of that talent with us. But Linda, thank you so much for joining us. I appreciate your time and your wisdom and hope to have you back again.

Dr. Schack: Thank you so much for having me.

Kathy: You’re welcome.

 

RELATED ARTICLES

Most Popular

Recent Comments

Linda Cerveny on Thank you
Carol steinberg on Thank you
Julia on My Peace Treaty
Susi on My Peace Treaty
Rosemary Mueller, MPH, RDN, LDN on Can You Try Too Hard to Eat Healthy?
Deborah Brenner-Liss, Ph.D., CEDS, iaedp approved supervisor on To Tell or Not to Tell, Therapists With a Personal History of Eating Disorders Part 2
Chris Beregi on Overworked Overeaters
Bonnie Adelson on Overworked Overeaters
Patricia R Gerrero on Overworked Overeaters
Linda Westen on Overworked Overeaters
Zonya R on Jay’s Journey
Dennise Beal on Jay’s Journey
Tamia M Carey on Jay’s Journey
Lissette Piloto on Jay’s Journey
Kim-NutritionPro Consulting on Feeding Our Families in Our Diet-Centered Culture
Nancy on Thank you
Darby Bolich on Lasagna for Lunch Interview