Refeeding Syndrome

One of the most serious, and possibly fatal, complications in the treatment of eating disorders is a condition called refeeding syndrome. Refeeding syndrome is a term used to describe the metabolic shifts in electrolytes and fluid that may occur during refeeding of a previously malnourished individual. Refeeding is essential to save lives, but it can also result severe consequences that can be detrimental to ones quality of life. Although refeeding syndrome is rare, it is important to be aware of the symptoms in order to prevent it.

Who is at Risk?

All of the conditions listed below put an individual at increased risk for developing refeeding syndrome.

  • Malnutrition
  • Long-term inadequate oral intake (e.g. eating disorder)
  • Minimal oral intake for several days (e.g. NPO diet order or poor appetite)
  • Significant weight loss in short period of time (e.g. post bariatric surgery)
  • Any disease state that compromises nutrition status (e.g. cancer)

The first two weeks of refeeding is when an individual is at the greatest risk of developing refeeding syndrome.

Mechanism for Refeeding Syndrome

During starvation, the body uses stored body fat and protein for energy. During refeeding (whether oral, enteral, or parenteral), carbohydrates are reintroduced into the diet, so the body stops breaking down its own tissues for energy and starts using glucose (sugar) for energy. As glucose levels increase in the blood, insulin (a hormone made in pancreas) secretion increases, which ignites a chain reaction where phosphorus, potassium, and magnesium move from the fluid between cells (extracellular fluid) to the fluid inside of the cells (intracellular fluid). This shift results in low blood levels of phosphorus (hypophosphatemia), potassium (hypokalemia), and magnesium (hypomagnesemia).

A sudden drop in phosphorus causes abnormalities in the cardiorespiratory system such as: inability to breathe, seizures and convulsions, and possibly cardiac arrest. If left untreated, low phosphorus levels can be fatal. Low magnesium may result in cardiac arrhythmias, tremors, muscle twitching, and even paralysis. Low potassium is associated with cardiac abnormalities. Electrolytes values MUST be monitored in order to prevent refeeding syndrome. Another way to prevent refeeding is by feeding patients a low amount of calories to start and slowly increasing until reaching calorie intake goals.

Article Written By: Ashley Groskind, dietetic intern Louis Strokes Cleveland VA Medical Center


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