Outpatient Follow-up of Patients with Eating Disorders

Frequency of visits determined by rapidity of weight loss, dehydration, bradycardia, hypotension. If these are present, patient is unable/unwilling to terminate purging behaviors, follow up 1-2x/ week may be indicated.

Non-judgmental review of previously asked questions, assume the worst (e.g. "how many times a day do you vomit," not "do you vomit" "what time of day do you tend to feel dizzy?" not "do you ever feel dizzy?") asking questions in this way is less threatening and makes it easier for the patient to give accurate, honest answers.

Review of systems for any complaints that may not be associated with the eating disorder. Most patients assume all physical and mental ailments are a direct consequence of the eating disorder. Because of this, they may be hesitant to bring up new concerns.

Review care plan patient has established with mental health professionals/nutritionist/other.

Weigh in gown, facing backwards, encourage patient not to look at weight or self-weigh when staff leaves the room. If necessary, remove scale from room after patient is weighed.

Check supine, sitting and standing blood pressure and pulse at each visit as long as weight loss continues or previous exam showed hypotension, bradycardia or dehydration.

If no additional examination is necessary, allow patient to dress before provider sees them.

Prioritize care at each visit. e.g. is it more important to stop exercising, increase fluids, or eat breakfast right now. Do depressive, anxiety, compulsive symptoms need to be better controlled before purging behavior can change? Give feedback about exam, labs, in general terms only. (e.g. "your blood count shows that you are not making blood cells as well as you could be. I would like you to include these iron containing foods and begin a once a day vitamin with iron." Next visit review these recommendations to see if patient was able to comply. If behavior is not changing based on recommendations and current level of care, what will be indications for day treatment program or hospitalization?

Extend frequency of visits as weight improves and behaviors change positively. Reinstate frequent visits if relapse occurs. Patients in recovery from bulimia are at high risk for sudden death if restrictive eating and purging behavior recurs. These patients need intensive monitoring of vital signs and electrolytes.

Patients with Compulsive Overeating Disorder benefit from frequent visits and follow up of weight loss efforts, continued guidance about compulsive behavior, exercise, successes and failures about adhering to calorie plan, monitoring for complications which result from obesity directly, and medication monitoring if anorectic or SSRI agents are used.