Refeeding Syndrome

When someone, of any age, who has been severely undernourished starts to eat more adequately during recovery from a restrictive eating disorder, refeeding syndrome can be a risk.

Refeeding syndrome is a medical condition that occurs after a period of starvation.

Refeeding can happen to anyone with any eating disorder or condition that leaves someone severely undernourished. This occurs not just in anorexia nervosa, but also ARFID, anorexia nervosa binge/purge type, substance abuse disorder, homelessness, cancer cachexia and more.

As long as an expert doctor and dietitian are on board, refeeding syndrome can be managed.

Nutritional Rehabilitation & Renourishment

Before describing refeeding syndrome, it is important to summarize the process of nutritional rehabilitation and renourishment and why it is so important.

Renourishment is when someone is given nutrition to rehabilitate their body and mind so they are medically stable and more able to continue treatment, especially psychological treatment.

Renourishment is essential as one of the first interventions for those with restrictive EDs. 

It is necessary because:

• Food is fuel! It provides the body with nutritional stability - what it needs to build muscle, fat, neurotransmitters, brain mass, heart muscle, normalize hormones and more.

• Nutrition is needed for medical stability. For instance, not feeling dizzy or cold all the time and having normal heart rate and blood pressure.

• Food is needed for psychological stability. For instance, mood stability, better awareness of and less intrusive ED thoughts, improved emotional stability and ability to do therapy.

If you are someone who has gone through nutritional rehabilitation, is going through it or is considering it, you know it can be a challenge. It often requires weight restoration, which is very scary for anyone with an eating disorder.

Since adults recover from eating disorders after an average of 5-6 years, this process may be done multiple times during the length of illness.

Challenges to renourishment include: 

• mental hunger and feast eating

• addressing fear foods or fear food situations

• going to the doctor regularly to monitor medical status

• finding a meal plan that works

• feeling really full and thus, distress

• gaining weight

• and, more.

It is hard, it is possible and it is necessary!!

The Nuts & Blots of Refeeding Syndrome

As you can probably imagine, if the body has not been eating much and suddenly, there is food being consumed, the body can go into shock.

What to do with all these nutrients?!

Our bodies want carbohydrates because they are the quickest and most efficient energy source.

When we start eating again after a period of starvation, our bodies want to get the carbs into our cells for energy ASAP!! To do this, the body needs micronutrients to convert nutrients into energy. 

Thus, if one is not eating enough, and starts to eat again, refeeding syndrome can occur because they do not have enough reserves of these important micronutrients.

Here is the potential result of eating more - without any management:

1. The individual increases their intake.

2. Insulin is released into the blood stream from the pancreas, particularly in response to carbohydrate intake. 

3. Insulin binds to blood sugar from the digested carbs and brings it into cells, feeding the glucose to hungry cells.

4. Micronutrients are needed in the cell to turn the glucose to ATP.

5. Micronutrients, especially phosphorus, potassium and magnesium, find their way into newly synthesized cells and tissues.

6. As a result, reserves of these micronutrients drop and blood levels can get dangerously low.

7. An increase in insulin can also cause the kidneys to retain salt and water. This can lead to fluid retention and higher blood volume, which burdens the heart and lungs.

8. Thiamine, a B vitamin, can also drop too low when eating more, causing neurological symptoms. 

9. Due to a reduction in micronutrient levels and the increased fluid, organ failure can occur.

Refeeding Signs & Symptoms

After just 3-4 days of eating more, one can experience a drop in micronutrient levels that causes symptoms. In fact, refeeding syndrome usually happens in the first 5 days of renourishment.

Symptoms of refeeding syndrome include:

• Fatigue

• Weakness

• Confusion

• Difficulty breathing

• Edema

• Low blood levels of phosphorus, potassium

• Muscle breakdown (rhabdomyolysis)

• Breakdown of red blood cells

• Seizure

• Heart failure and death

Who is at risk of Refeeding Syndrome?

According to the ASPEN Guidelines, someone is at moderate or severe risk or refeeding based on the chart below. 

Research shows that risk factors for refeeding syndrome in eating disorders are:

• Severe, rapid weight loss

• Having low electrolyte levels before eating more again

• Prolonged periods of undernourishment leading up to renourishment

Remember, people can be at risk for refeeding for many different reasons- not just eating disorders. 

Malnutrition can occur from lack of access to food, cancer treatment, severe gastrointestinal issues, severe burn injury, homelessness and more. 

(Please note that BMI is a blunt instrument, not a fine tool of precision.)

Prevalence of Refeeding Syndrome

There are not many studies looking at refeeding risk in people with anorexia nervosa. 

Prevalence rates of low to severe hypophosphatemia (low phosphorus) range between 5.8% to 40% in those with anorexia nervosa. 

Managing Refeeding Syndrome

Being proactive is important to successfully managing refeeding syndrome.

Ten years ago or so, refeeding risk was managed by feeding ‘low and slow’. However, the data shows that it is not necessary to feed people very low calorie diets and increase from there. This is true for oral intake as well as being fed with tube feeding. 

Higher calorie intake at the onset of nutrition rehabilitation is not associated with an increased risk of refeeding syndrome.

It is possible to feed people with calories that allow for initiation of the most nutrition possible, as long as refeeding risk is managed.

Management includes:

• Having comprehensive labs done within a week prior to increasing intake

• Monitoring labs weekly or more frequently, as the doctor recommends

• Getting repletion of phosphorus, magnesium, potassium and more from a doctor

• Considering other supplementation, like with thiamine (B1), with a doctor

• Working with a dietitian who can support you in: 

  • Individualizing dietary intake/calorie and macronutrient recommendations 

  • Increasing intake until there is weight gain or return to adequate intake

  • Adjusting fiber content, texture and more for any gastrointestinal issues 

  • Plating appropriate portions/calories 

  • Adjusting amount of carbohydrates if edema occurs

  • Incorporating ‘fear foods’ in a supportive way

  • Supporting you in symptom management of increased intake like bloating

There are special considerations for feeding tubes, which need to be monitored closely by the doctor, dietitian and nursing staff either inpatient or at home.

Given that refeeding syndrome occurs within 5 days of increased intake, the monitoring will be especially important the first week then slowly reduce, depending on how things are going.

Closing Thoughts

Refeeding syndrome can be scary, however it is manageable and can be avoided. 

One can eat more, and increase intake quite quickly, to meet goals for weight restoration as well as medical, nutritional and psychological stability as long as there is medical oversight.

In the future, we may find that nutritional rehabilitation can be individualized based on microbiome, genetics, and more. Until then, we forge ahead to support those with eating disorders eat adequately, avoid refeeding syndrome and do the work of recovery.

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