Disordered eating often evolves over time, and risk may increase even when presentations appear stable.

In general practice, disordered eating is rarely resolved in a single consultation. Patients may present early, share some information but not all, or move between engagement and minimisation. Medical risk and safeguarding concerns often emerge over time, rather than being obvious from the first appointment

Follow-up matters because:

• risk can accumulate quietly, even when symptoms appear unchanged

• patterns only become visible with multiple consultations, not from a single snapshot

• apparent stability can mask ongoing restriction, compensatory behaviours or deterioration

• early reassurance may delay necessary escalation

In contrast to acute care, general practice is uniquely placed to notice:

• repeated low-grade attendance

• gradual shifts in behaviour, weight, function or physical symptoms

• increasing clinician concern despite “similar” presentations

Follow-up is therefore not a passive process. It is an active clinical intervention, allowing the clinician to:

• reassess risk as behaviours evolve

• notice when engagement is not translating into change

• recognise when concern is increasing, even if objective markers lag behind

A key challenge in disordered eating is that lack of deterioration is often mistaken for safety. In reality, unchanged symptoms may reflect:

• entrenched behaviours

• ongoing physiological stress

• delayed consequences

Planned, purposeful follow-up allows clinicians to move beyond single-consultation decision-making and respond to the trajectory, not just the moment.

This section explores how to work safely when concern is present but there is no immediate crisis.

A common challenge in disordered eating is managing situations where risk is real, but urgency is unclear. The patient may not be acutely unwell, investigations may be reassuring, and there may be no single trigger for emergency admission — yet something does not feel right.

This uncertainty is a normal part of general practice. It often arises when:

• behaviours are concerning but not extreme

• symptoms fluctuate rather than progress clearly

• the patient is engaging but not changing

• risk feels cumulative rather than acute

The danger in these situations is drifting into passive waiting, where uncertainty leads to repeated reassurance without a clear plan. Over time, this can allow risk to increase unnoticed.

Managing uncertainty safely involves:

• acknowledging that not being an emergency does not mean low risk

• being explicit (to yourself and the patient) about what you are monitoring

• setting a clear timeframe for review, rather than open-ended follow-up

• noticing whether your level of concern is increasing, even if the presentation looks similar

It can be helpful to name uncertainty internally:

“I don’t think this needs emergency admission today, but I’m not comfortable leaving this without close follow-up.”

This framing supports proportionate action without overreacting.

Uncertainty should prompt structured monitoring, not inaction. Over time, patterns usually declare themselves — either through improvement, ongoing stagnation, or escalation of risk.

The key skill here is tolerating uncertainty without normalising risk. This allows clinicians to respond early when the situation changes, rather than waiting for a crisis to force action.

This section distinguishes active monitoring from delay that becomes unsafe over time.

In disordered eating, follow-up can look deceptively similar whether it is being used well or poorly. Both may involve review appointments, repeat conversations and ongoing reassurance. The difference lies in intent, structure and pace.

Planned follow-up is an active process. It involves:

• a clear reason for reviewing again

• an agreed timeframe, based on clinical concern rather than convenience

• an understanding of what would prompt a change in plan

• explicit attention to risk, not just symptoms

In contrast, unsafe delay often develops gradually. It may be characterised by:

• repeated reviews with the same conversation, the same plan and the same outcome.

• reassurance being repeated despite no or little improvement

• concern being acknowledged but not acted on

• a growing sense of “let’s see how things go”

Unsafe delay is rarely deliberate. It often reflects:

• discomfort with escalation

• hope that engagement alone will lead to change

• uncertainty about thresholds

• pressure to avoid over-medicalising

• an unconscious drift towards maintaining rapport at the expense of changing the plan

A useful question to ask yourself is:

“Have I actively chosen this plan — or has it simply continued?”

Planned follow-up should feel purposeful. Even when change is slow, there should be clarity about:

• what you are monitoring

• why this pace currently feels safe

• what would prompt you to reassess urgency

If follow-up no longer feels like it is moving the situation forward — or if your concern is increasing despite repeated reviews — this is a signal to change pace, not extend the same plan.

The status quo should not be reassuring. If things are not improving or progressing, a change in approach or escalation is required.

In disordered eating, lack of change does not mean lack of risk.

Risk in disordered eating is dynamic and cumulative. A presentation that looks unchanged from one review to the next may still represent a worsening clinical situation, even if behaviours appear stable and there has been no obvious deterioration.

This is because the risks associated with disordered eating accumulate over time. Ongoing restriction, purging or compensatory behaviours continue to place physiological and psychological strain on the body, even when the level of behaviour does not escalate.

In this context, lack of improvement is itself clinically significant.

At follow-up, it is important to look beyond whether symptoms are “the same” and consider:

• whether behaviours are continuing without improvement

• whether rigidity, control or preoccupation is persisting

• whether physical symptoms are subtle but ongoing

• whether function is being maintained at increasing personal cost

Risk may therefore increase despite:

• stable weight or blood results

• repeated attendance and engagement

• the absence of new symptoms

A helpful way to think about this is to focus on trajectory rather than snapshot. Ask yourself:

• Is this improving, or simply persisting?

• Is the cumulative risk increasing because this is ongoing?

Re-assessing risk also includes noticing your own response as a clinician. If the plan has remained unchanged despite no improvement, or if reassurance is being repeated in the face of persistence, this is a prompt to pause and reconsider the approach.

In disordered eating, ongoing exposure to risk matters. When there is no meaningful improvement over time, a change in approach or escalation should be considered — even if the presentation has not become an emergency.

Partial engagement is common in disordered eating and does not reliably indicate safety.

Many patients with disordered eating engage with care in part. They may attend appointments, agree to monitoring, or acknowledge some concern, while still struggling to change behaviours. This pattern is expected and should not be interpreted as resistance or failure.

Ambivalence often shows up as:

• agreeing with concerns but not acting on them

• small, short-lived changes that are hard to sustain

• selective disclosure of behaviours

• reassurance-seeking alongside ongoing risk

It is important to recognise that engagement does not equal improvement, and that maintaining contact alone does not reduce risk.

A common challenge for clinicians is balancing:

• the wish to preserve rapport and trust

• the need to respond to ongoing or cumulative risk

When engagement is partial, there can be a subtle pull to slow the pace, soften concern, or continue the same plan in the hope that motivation will increase. Over time, this can unintentionally allow risk to persist without change.

Helpful questions to ask yourself include:

• Is engagement translating into meaningful change?

• Am I prioritising keeping the relationship comfortable over addressing risk?

• Has my plan changed in response to ongoing behaviour, or just continued?

Managing ambivalence safely involves:

• acknowledging the difficulty of change without minimising risk

• being clear that concern remains even when engagement is good

• revisiting goals and expectations explicitly

• adjusting pace when partial engagement becomes prolonged

It can be helpful to name this dynamic calmly and transparently:

“I can see you’re trying to engage, and I’m still concerned about the impact this is having on your health.”

This keeps the focus on safety rather than motivation.

Partial engagement is a starting point, not an endpoint. When it persists without improvement, it should prompt a review of the plan and consideration of whether a different approach — or escalation — is needed.

Escalation is part of good care when risk increases or fails to reduce over time.

In disordered eating, escalation is often delayed not because risk is absent, but because the situation feels familiar, contained, or relationally complex. Changing gear can feel uncomfortable, particularly when a patient is engaging or the relationship feels fragile.

Escalation should be considered when:

• medical risk is increasing or no longer feels manageable in primary care

• behaviours are persisting without improvement despite follow-up

• cumulative risk is rising over time

• safeguarding concerns are emerging or intensifying

• capacity to make or act on safe decisions is in doubt

Escalation is not a sign that earlier care has failed. It reflects a change in clinical need, not a breakdown in rapport.

A helpful reframing is:

“This has reached a point where it needs a different level of support.”

When escalation is needed, clarity helps:

• be explicit with yourself about why the plan needs to change

• explain the rationale to the patient in terms of safety

• acknowledge the impact on the therapeutic relationship

• document concerns and decision-making clearly

It is common for patients to feel disappointed, anxious, or resistant when escalation is discussed. These reactions do not invalidate the decision. Maintaining transparency and calm reassurance helps preserve trust even when agreement is limited.

Changing gear is often most effective when it is:

• timely rather than reactive

• proportionate rather than abrupt

• framed as support, not punishment

Escalation is a clinical decision made in response to risk. Acting earlier can prevent crises and supports safer care for both patients and clinicians.

Clear documentation and safety-netting support safe care over time, particularly when risk is evolving.

In disordered eating, care is often shared across time, clinicians and settings. Good documentation and safety-netting are therefore essential to maintain continuity and reduce the risk of drift, repetition or missed escalation.

Documentation should make clear:

• the concerns you have identified

• the patterns you are noticing over time

• your assessment of risk and uncertainty

• the rationale for the current plan

• what would prompt a change in approach

This helps ensure that concern is carried forward, rather than reset at each consultation.

Safety-netting should be explicit and proportionate. This includes:

• clear advice about when to seek urgent review

• planned review dates rather than open-ended follow-up

• clarity about who the patient should contact if things worsen

• shared understanding of what “getting worse” might look like

Continuity matters, but it cannot always be guaranteed. Helpful practices include:

• documenting concerns clearly enough that another clinician can pick up the thread

• avoiding reliance on unspoken assumptions or familiarity

• recognising when repeated reassurance across clinicians may unintentionally dilute concern

It is also important to document changes in clinician concern, even when the presentation appears similar. An increasing sense of unease, frustration, or uncertainty is clinically relevant and should prompt reflection on whether the plan remains appropriate.

Good documentation and safety-netting do not replace clinical judgement — they support it. Together, they help ensure that evolving risk is recognised and acted on, even when care is shared or stretched over time.

This section offers prompts to help clinicians step back and reassess when care feels static or uncertain.

In ongoing care for disordered eating, it is easy to become focused on individual consultations rather than the wider picture. This final section is designed to support periodic re-evaluation, particularly when progress is slow or concern is persistent.

Helpful prompts include:

• Is this genuinely improving, or simply continuing?

• Has the level of risk changed because this has been ongoing?

• Have I adjusted my plan in response to what I’m seeing?

• Would I be comfortable if this approach continued for another few months?

It can also be useful to reflect on your own responses:

• Do I feel increasingly uneasy, frustrated, or stuck?

• Am I repeating reassurance because the situation feels familiar?

• Am I holding risk because escalation feels difficult?

These reflections are not a sign of poor care. They are often an early signal that the current approach needs to be reviewed.

Re-evaluation does not always mean escalation. It may involve:

• tightening follow-up

• being more explicit about concern

• revisiting expectations and goals

• seeking senior or colleague input

What matters is avoiding default continuation of the same plan when it no longer feels right.

Regularly pausing to re-evaluate helps ensure that care remains responsive to cumulative risk, rather than anchored to the appearance of stability.

Escalation based on concern and trajectory , even without diagnostic certainty, is appropriate and expected in both independent practice and the SCA.