What patient education should be provided to a patient with a history of eating disorders?

Patient Education for History of Eating Disorders

Patients with a history of eating disorders require structured education focused on recognizing relapse warning signs, understanding the medical consequences of disordered eating behaviors, maintaining nutritional rehabilitation, and knowing when to seek help—delivered through a coordinated approach involving medical providers, dietitians, and mental health professionals. 1

Core Educational Components

Understanding the Disorder and Its Medical Consequences

• Educate patients that eating disorders carry serious medical risks, including cardiac complications (bradycardia, QTc prolongation leading to sudden cardiac death), electrolyte abnormalities (hypokalemia, hyponatremia), bone density loss, and reproductive hormone disturbances 2, 1
• Explain that approximately 25% of deaths in anorexia nervosa result from suicide, making psychiatric monitoring essential at every visit 3, 4
• Teach patients that purging behaviors cause specific physical signs including dental erosion, parotid gland enlargement (swollen cheeks), gastroesophageal reflux, and dangerous electrolyte imbalances that can trigger fatal arrhythmias 3, 5
• Emphasize that most cardiac and metabolic complications are completely reversible with appropriate nutritional rehabilitation and cessation of purging behaviors 4, 6

Recognizing Relapse Warning Signs

• Instruct patients to monitor for return of restrictive eating patterns, preoccupation with food and weight, resumption of purging behaviors (vomiting, laxative abuse, excessive exercise), or rapid weight changes 1, 3
• Teach patients to identify gastrointestinal symptoms that may signal relapse, including postprandial fullness, abdominal distention, early satiety, and constipation 5, 7
• Educate about the risk of developing diet-related anxiety, manifesting as unnecessary dietary restrictions, strongly held beliefs around "forbidden" foods, and fear of eating in uncontrolled settings 1
• Explain that depression, anxiety, and obsessive-compulsive symptoms commonly co-occur with eating disorders and may worsen before behavioral relapse 1, 2

Nutritional Rehabilitation and Dietary Guidance

• Provide evidence-based dietary advice that debunks myths and focuses on gradual normalization of eating patterns rather than rigid restriction 1, 4
• Educate patients that dietary restriction is not a solution for managing gastrointestinal symptoms; instead, work with a dietitian to identify truly problematic foods while maintaining dietary diversity 1
• Teach patients to focus on what they can eat rather than what they cannot, setting realistic expectations that no single dietary approach will eliminate all symptoms 1
• For patients with co-occurring irritable bowel syndrome, explain that a low FODMAP diet requires three phases (restriction, reintroduction, personalization) and should only be undertaken with dietitian supervision to prevent unnecessary long-term restriction 1

Medication Education (When Applicable)

• For bulimia nervosa, explain that fluoxetine 60 mg daily (higher than typical antidepressant dosing) combined with cognitive-behavioral therapy is the recommended treatment, and response should be assessed at 6 weeks 1, 4
• For binge-eating disorder, educate that cognitive-behavioral therapy or interpersonal therapy is first-line, with antidepressants or lisdexamfetamine added if psychotherapy alone is insufficient 1, 4
• Warn patients explicitly that bupropion is contraindicated in bulimia nervosa and binge-eating disorder due to markedly increased seizure risk 4
• Emphasize that no medication is effective for anorexia nervosa; treatment relies on psychotherapy and nutritional rehabilitation 4, 2

When to Seek Immediate Help

• Instruct patients to seek emergency care for severe bradycardia (heart rate below 40-50 bpm), orthostatic vital sign changes (dizziness upon standing), chest pain, syncope, or severe weakness 1, 3
• Teach patients that suicidal thoughts require immediate psychiatric evaluation, as eating disorders have among the highest suicide rates of any mental illness 3, 4
• Educate about refeeding syndrome risk: patients who have been severely restricting and then begin eating normally may develop dangerous electrolyte shifts requiring medical monitoring 4, 8
• Explain that persistent vomiting, inability to keep fluids down, or severe abdominal pain warrants urgent medical assessment 5

Family and Caregiver Education

For Adolescents and Emerging Adults

• Educate families that family-based treatment is the first-line approach for adolescents with anorexia nervosa, achieving 48.6% remission at 6-12 months compared to 34.3% with individual treatment alone 8, 2
• Teach caregivers that parental supervision of eating is crucial for therapeutic success in younger patients, with families taking an active role in meal planning and monitoring 8
• Explain that denial or disagreement about treatment approach by parents can worsen outcomes, making family alignment with the treatment team essential 3, 8

For Adult Patients

• Educate that adults with anorexia nervosa require eating disorder-focused psychotherapy addressing fear of weight gain, body image disturbance, and normalization of eating behaviors 1, 4
• Explain that treatment requires a coordinated multidisciplinary team including medical providers, psychiatrists, psychotherapists, and dietitians 1, 4

Addressing Comorbid Conditions

• Screen for and educate about common psychiatric comorbidities: depression (76.3% lifetime prevalence in bulimia nervosa, 65.5% in binge-eating disorder, 49.5% in anorexia nervosa) 2
• Assess for history of trauma (physical, sexual, or emotional abuse), as adverse experiences affect symptom perception, treatment response, and the patient-provider relationship 1, 3
• Evaluate for food insecurity, which is more common among individuals with depression and can complicate nutritional rehabilitation 1

Common Pitfalls to Avoid

• Never prescribe appetite suppressants, weight-loss agents (phentermine, orlistat, GLP-1 agonists), or bupropion to patients with eating disorder history, as these worsen restriction and carry serious risks 4
• Do not rely on normal laboratory values to exclude serious illness; approximately 60% of anorexia nervosa patients show normal routine testing despite severe malnutrition 4
• Avoid delaying psychiatric or multidisciplinary referral, as early coordinated intervention improves outcomes 4, 9
• Do not attempt rapid nutritional rehabilitation in severely malnourished patients without medical supervision, as this increases fatal refeeding syndrome risk 4, 8

Ongoing Monitoring Requirements

• Educate patients that regular monitoring of vital signs (including orthostatic measurements), weight, and BMI is necessary to detect early relapse 1, 3
• Explain that patients with history of restrictive eating or severe purging require serial electrocardiograms to monitor QTc intervals and cardiac risk 1, 4
• Teach that routine laboratory monitoring (complete blood count, comprehensive metabolic panel including electrolytes) helps identify medical complications before they become life-threatening 1, 3