What is the recommended follow-up protocol for a patient with anorexia?

Recommended Follow-Up Protocol for Patients with Anorexia Nervosa

Regular follow-up visits every 2-4 weeks are essential for patients with anorexia nervosa to monitor weight, assess for medical complications, evaluate nutritional status, and provide ongoing psychological support. 1

Initial Assessment Components for Follow-Up Visits

Physical Assessment

• Weight measurement (unclothed or in consistent light clothing)
• Vital signs (heart rate, blood pressure, temperature)
• Physical examination focusing on:
  • Cardiovascular status (bradycardia, orthostatic hypotension)
  • Skin condition (lanugo, dry skin, poor wound healing)
  • Peripheral edema
  • Muscle wasting
  • Dental erosion (if purging behaviors present)

Laboratory Monitoring

• Complete blood count (every 3-6 months)
• Comprehensive metabolic panel including:
  • Electrolytes (sodium, potassium, chloride, bicarbonate)
  • Liver function tests
  • Kidney function (BUN, creatinine)
• Vitamin B12 and folate levels (every 3-6 months)
• Vitamin D levels
• Consider micronutrient testing in patients with:
  • Small bowel involvement
  • History of significant weight loss
  • Prolonged malnutrition

Nutritional Assessment

• Dietary intake evaluation
• Weight trends (gain, loss, or maintenance)
• Eating behaviors and patterns
• Use of compensatory behaviors (purging, excessive exercise)
• Assessment for secondary causes of anorexia

Follow-Up Frequency and Monitoring

Frequency Guidelines

• Severely malnourished patients (BMI ≤14): Weekly visits until medically stable 2
• Moderately malnourished patients (BMI 14-16): Every 2 weeks
• Mild malnutrition or weight-restored patients (BMI ≥16): Every 3-4 weeks
• Adjust frequency based on:
  • Clinical stability
  • Rate of weight restoration
  • Presence of medical complications
  • Level of insight 2

Specific Monitoring Parameters

1. Weight restoration goals:

   • Target weight gain of 0.5-1 kg/week for outpatients
   • Document weight trajectory at each visit
   • Assess for fluid retention that may mask true weight status

2. Vital sign monitoring:

   • Heart rate <50 bpm requires increased monitoring
   • Orthostatic hypotension (drop >20 mmHg systolic or >10 mmHg diastolic)
   • Temperature <36°C

3. Psychological assessment:

   • Eating disorder thoughts and behaviors
   • Anxiety and depression symptoms
   • Suicidal ideation
   • Body image disturbance
   • Insight into illness (strong predictor of recovery) 2

Multidisciplinary Approach

Team Coordination

• Regular communication between:
  • Primary care physician
  • Psychiatrist/psychologist
  • Registered dietitian
  • Other specialists as needed (cardiologist, endocrinologist)

Treatment Components to Monitor

1. Nutritional rehabilitation:

   • Progress with meal plan adherence
   • Need for nutritional supplements
   • Consider appetite stimulants in select cases 3

2. Psychological interventions:

   • Adherence to therapy appointments
   • Response to cognitive-behavioral therapy or other modalities
   • Family involvement in treatment (especially for adolescents)

3. Medication management:

   • Response to psychiatric medications
   • Side effects monitoring
   • Medication adherence

Criteria for Level of Care Adjustment

Hospitalization Indicators

• Heart rate <40 bpm
• Blood pressure <90/60 mmHg
• Temperature <35.5°C
• Weight <75% of expected body weight
• Rapid weight loss (>1 kg/week)
• Electrolyte abnormalities
• Suicidal ideation with plan or intent
• Failure of outpatient treatment

Transition to Less Intensive Care

• Medical stability for at least 2 weeks
• Consistent weight gain in outpatient setting
• Improved insight and motivation
• Reduced eating disorder behaviors
• Adequate social support

Long-Term Follow-Up Considerations

Duration of Monitoring

• Continue regular follow-up for at least 2-3 years after weight restoration 4
• Long-term monitoring is essential as recovery from anorexia nervosa can continue over many years 4
• Early recovery is strongly associated with long-term recovery (odds ratio = 10.5) 4

Relapse Prevention

• Identify early warning signs of relapse
• Develop relapse prevention plan
• Maintain connection with treatment team even during periods of stability
• Consider booster sessions during high-risk periods

Special Considerations

Adolescents

• More frequent monitoring (often weekly)
• Growth chart monitoring
• Pubertal development assessment
• Family involvement in treatment and monitoring

Pregnancy

• Increased monitoring frequency
• Coordination with obstetric care
• Nutritional supplementation
• Fetal growth monitoring

Comorbid Medical Conditions

• Diabetes: Monitor blood glucose and insulin requirements
• Gastrointestinal disorders: Assess for malabsorption
• Cardiac abnormalities: Regular ECG monitoring

Documentation Template for Follow-Up Visits

1. Vital signs and anthropometrics:

   • Weight, BMI, vital signs
   • Comparison to previous measurements

2. Nutritional status:

   • Current dietary intake
   • Eating behaviors
   • Supplement use

3. Medical assessment:

   • Physical examination findings
   • Laboratory results
   • Medical complications

4. Psychological status:

   • Eating disorder thoughts/behaviors
   • Mood, anxiety
   • Insight and motivation

5. Treatment plan:

   • Adjustments to meal plan
   • Medication changes
   • Psychological interventions
   • Next appointment timing

By implementing this structured follow-up protocol, clinicians can effectively monitor patients with anorexia nervosa, detect complications early, and support long-term recovery. The evidence shows that recovery can continue over many years, with approximately two-thirds of patients achieving recovery with appropriate long-term care 4.