Everything You Should Know About Refeeding Syndrome

The reintroduction of glucose or sugar in your body can lead to the occurrence of Refeeding syndrome when someone who is malnourished begins to eat again. Thus, here in this article, we will study about the reasons behind the current shift in the fluids and what leads to refeeding syndrome electrolytes as well. As, well as their complications and treatment.

What is a refeeding syndrome?

After the malnourishment or starvation stage when you start taking up glucose, or sugar in your food diet there is a sudden shift in the electrolytes as well as some fluids which in all results in complications of refeeding syndrome.

Thus, Refeeding syndrome takes into account metabolic abnormalities when a starving person begins feeding himself, after a period of starvation or limited intake. 

It should be identified in an early stage is easier to treat, although it is difficult to determine, as it does not involve any set parameters concerning it. Though, t still can be found in some cases as:

  • malnourishment
  • fasting
  • extreme dieting
  • famine
  • starvation

Apart from these typical fasting conditions, some signs of refeeding syndrome include diseases as:

  • refeeding syndrome anorexia
  • alcohol use disorder
  • cancer
  • difficulty swallowing (also known as dysphagia)

Refeeding syndrome definition:

The definition of refeeding syndrome involves Metabolic and physiological problems relating to feeding malnourished patients.

Causes of refeeding syndrome:

Most of the symptoms of refeeding syndrome are usually noticed in persons who are starving for a lot of time and their body has adapted to that particular lifestyle and they had become malnourished.

After reaching this stage, the body has compromised its ability to process food. And refeeding syndrome pathophysiology involves a malnourished body that produces less insulin (which helps to breaks down glucose (sugar) from carbohydrates), and as the body has fewer carbohydrates due to malnourishment and starvation, the body uses fats reserves and stored proteins for energy, which in all affects the electrolyte stores to decrease.

When food is reintroduced in the body then the body no longer relies on fat and protein to produce energy. This results in an abrupt shift in metabolism., which results in an increase in glucose as well as secretion of more insulin in the body, which is an overall result of lack of electrolytes. Thus, the major problem associated with the refeeding syndrome is known as hypophosphatemia (which is a result of low phosphate as phosphate is an electrolyte in the human body). And some other issues involved are:

  • Abnormal sodium and fluid levels in the body
  • Changes in fat, glucose, or protein metabolism
  • Thiamine deficit
  • Hypomagnesemia (known as low magnesium)
  • Hypokalemia (known as low potassium)

And which in all can result in problem associated with the following organs in the human body:

  • Heart
  • Lungs
  • Kidneys
  • Blood
  • Muscles
  • Digestion
  • Nervous system

What are the symptoms of refeeding syndrome?

Some of the syndrome symptoms which can cause sudden and fatal complications indicated below are as:

  • fatigue
  • weakness
  • inability to breathe        
  • high blood pressure
  • seizures
  • heart failure
  • coma
  • heart arrhythmias
  • death
  • confusion

Hypophosphatemia: Apart from this, the major refeeding syndrome complication is hypophosphatemia, which is a result of a lack of phosphorus and causing symptoms such as:

  • confusion or hesitancy
  • seizures
  • muscle breakdown
  • neuromuscular problems
  • acute failure of the heart

Hypomagnesemia: Hypomagnesemia resulting from a lack of magnesium is also a Refeeding syndrome symptom including the following Hypomagnesemia symptoms as:

  • low calcium levels, or better known as hypocalcemia
  • low potassium levels, or better known as hypokalemia
  • weakness
  • fatigue
  • nausea and vomiting
  • abnormal heart rhythms

Common refeeding syndrome symptoms: Other common  syndrome symptoms can be as follows:

  • Hyperglycemia, or high blood sugar
  • mental problems, such as confusion
  • abnormal serum sodium levels
  • fluid retention
  • muscle weakness

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Refeeding Syndrome risk factors:

Here, in this Syndrome risk factors we will examine the persons or individuals who are at higher risk of causing refeeding syndrome depending upon the medical situations and terms. As starvation is the highest factor that can cause the this syndrome, etc.

Thus, an individual may be at risk if any one of the following condition applies:

  • You have an extremely low body mass index, usually under 16
  • You are losing weight too fast or say lost more than 15 percent of your body weight in the last 3 to 6 months.
  • You have consumed or intake fewer calories that are needed to sustain normal processes in the body, in the last 10 or more consecutive days.
  • your serum phosphate, potassium, or magnesium levels are lower than the normal level of the human body.

Apart from the above statements, you may also be at risk if any two of the following condition applies:

  • You have an extremely low body mass index, usually under 18.5
  • You are losing weight too fast or say lost more than 10 percent of your body weight in the last 3 to 6 months.
  • You have consumed or intake fewer calories that are needed to sustain normal processes in the body, in the last 5 or more consecutive days.
  • There exists some medical history of yours relating to chemotherapy drugs, diuretics, or antacids or the use of alcohol.

Note: Immediate medical care is prescribed in case any of the refeeding syndrome signs and symptoms are noticed. 

The table below tells us the refeeding syndrome risk factors in summarized form.

Theme Risk factor(s) Theme Risk factor(s)
Malnutrition Weight loss:

  • 5% in 1 month
  • 10% in 6 months 
  • >15%
Low BMI 

  • mean 12.3kg/m2 
  • mean 16.7kg/m2 
  • mean 16.2kg/m2
High nutrition risk score ≥3
Starvation Prolonged fast:

  • For 10 days 
  • For 7 days
Nutritional support
  • EN containing 34kcal/kg
  • PN containing 20kcal/kg
  • <12 mmol in phosphate in first day
  • EN with a mean of 23kcal/kg
  • EN more than PN
Biochemistry Hypomagnesaemia: <0.5 mmol/L

<0.7 mmol/L

Hypokalaemia: <3.2 mmol/L

Disease/clinical condition
  • Anorexia nervosa
  • Crohn’s disease
  • small bowel obstruction
  • poorly controlled diabetes
  • pneumonia
  • dysphagia
  • complications post bariatric surgery
  • alcoholism and 
  • cancer

Persons or individuals associated with refeeding risk:

Here, we will discuss some of the medical conditions as well as the reason of refeeding syndrome.

Some medical conditions that may cause refeeding syndrome are:

  • anorexia
  • cancer
  • alcoholism
  • problems swallowing, or dysphagia
  • inflammatory bowel disease
  • celiac disease
  • depression
  • painful conditions affecting the mouth
  • uncontrolled diabetes

And, apart from this reason of refeeding syndrome includes:

  • starvation
  • malnourishment
  • extreme diets
  • fasting
  • famine

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How to treat refeeding syndrome?

Immediate intervention is required in refeeding syndrome with medical supervision and even specialized facility. Gastroenterology and dietetics may be helpful person in treating the refeeding syndrome. refeeding syndrome treatment just involves normal levels of electrolytes in the human body.

Here, you can also replace vitamins to treat certain symptoms. As a continued vitamin and electrolyte replacement is needed until the refeeding syndrome condition stabilizes. Or you can also slow down the refeeding process or say 20 calories per kilogram of body weight is needed to recover.

The Electrolyte levels should be monitored in the body carefully by the doctors. As typically, Intravenous (IV) infusions are used by the doctors to replace electrolytes based on the bodyweight of an individual. But this method, Intravenous (IV) infusions of increasing electrolytes in the body is not recommended for the individuals suffering from the following:

  • Person compromised of kidney function
  • A person faced with hypocalcemia (a disease associated with low calcium)
  • A person faced with hypercalcemia (a disease associated with high calcium)
  • Further, in heart patients, the intake of salt should be monitored carefully.

Refeeding syndrome prevention:

As you know “prevention is better than cure.: So, does it applies here too? Prevention is the most real way to overcome or fight the battle from refeeding syndrome. Thus, you can prevent refeeding syndrome by:

  • Identifying individuals or people at risk.
  • acclimatizing the refeeding programs
  • once treatment has begun you need to monitor the patients continuously
  • People associated with the following diseases should be monitored carefully:
    • depression
    • dysphagia
    • alcoholism and drug use
    • anorexia nervosa
    • uncontrolled diabetes

Nice guidelines refeeding syndrome:

Some of the common nice (National Institute for Health and Clinical Excellence (UK)) guidelines refeeding syndrome includes NICE clinical guideline 32 (2006) which tells us that you can identify a person with refeeding syndrome by:

  • An individual may be at risk and able to recognize refeeding syndrome if any one of the following condition applies:
    • You have an extremely low body mass index, usually under 16
    • You are losing weight too fast or say lost more than 15 percent of your body weight in the last 3 to 6 months.
    • You have consumed or intake fewer calories that are needed to sustain normal processes in the body, in the last 10 or more consecutive days.
    • your serum phosphate, potassium, or magnesium levels are lower than the normal level of the human body.
  • Apart from the above statements, you may also be at risk and able to recognize refeeding syndrome if any two of the following condition applies:
    • You have an extremely low body mass index, usually under 18.5
    • You are losing weight too fast or say lost more than 10 percent of your body weight in the last 3 to 6 months.
    • You have consumed or intake fewer calories that are needed to sustain normal processes in the body, in the last 5 or more consecutive days.
    • There exists some medical history of yours relating to chemotherapy drugs, diuretics, or antacids or the use of alcohol.

The further refeeding syndrome nice guidelines also tells us about how you should feed the individuals by stating that in the case of:

  • High risk: In case of high risk, the following should be taken care of:
    • The starting nutrition providing to individuals should be a maximum of 10 kcal/kg, where you further need to increase the consumption in 4 to 7 days.
    • You need to restore circulatory volume and also monitor fluid balance and overall clinical status deeply.
  • Extreme high risk: In case of extremely high risk, the following should be taken care of:
    • The starting nutrition providing to individuals should be a maximum of 5 kcal/kg.
    • In the very first 10 days of feeding you need to provide the following:
    • Oral thiamine 200-300 mg/day
    • Vitamin B co strong 1or 2 tablets TDS OR
    • Full dose intravenous vitamin B preparation if necessary
    • A balanced multivitamin/trace element supplement
  • Oral, enteral, or intravenous supplements should be provided as follows:
    • Potassium = 2 – 4mmol/kg/day
    • Phosphate = 0.3 – 0.6mmol/kg/day
    • Magnesium = IV 0.2 or oral 0.4mmol/kg/day (unless pre-feeding plasma levels are high)
    • Pre feeding correction of low plasma levels unnecessary

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Conclusion:

When food is reintroduced in your body after a period of starvation or malnourishment then refeeding syndrome fasting occurs, which can lead to electrolyte imbalance and other complications as well. Thus, the individuals associated with the refeeding syndrome should be treated properly.

Frequently Asked Questions

How to prevent refeeding syndrome?

You can prevent this syndrome by:

  • Identifying individuals or people at risk.
  • acclimatizing the refeeding programs
  • once treatment has begun you need to monitor the patients continuously
  • People associated with the following diseases should be monitored carefully:
    • depression
    • dysphagia
    • alcoholism and drug use
    • anorexia nervosa
    • uncontrolled diabetes

How to avoid refeeding syndrome?

You can avoid this syndrome by slowly increasing the nutritional intake of an individual and monitor the patient continues to treat him better. 

What are the symptoms of refeeding syndrome?

Some of the refeeding syndrome symptoms which can cause sudden and fatal complications indicated below are as:

  • fatigue
  • weakness
  • inability to breathe        
  • high blood pressure
  • seizures
  • heart failure
  • coma
  • heart arrhythmias
  • death
  • confusion

What happens in refeeding syndrome?

Some metabolic abnormalities are involved in refeeding starving that includes a breakdown of fat and muscle in order to lose fluids and electrolytes. 

How long does it take to develop refeeding syndrome?

Just a period of four days long takes up to develop the refeeding syndrome

How do anorexics lose weight in starvation mode?

Anorexics lose weight in starvation mode by losing on fluids and electrolytes.

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