Everything You Should Know About Refeeding Syndrome

Medically reviewed by Natalie Butler, RD, LD on October 10, 2017Written by Carly Vandergriendt on October 10, 2017

What is refeeding syndrome?

Refeeding is the process of re-introducing food after malnourishment or starvation. Refeeding syndrome is a serious and potentially fatal condition that can occur during refeeding. It’s caused by sudden shifts in the electrolytes that help your body metabolize food.

Refeeding syndrome can affect anyone. However, it typically follows a period of:

Certain conditions may increase your risk for this condition, including:

Certain surgeries may also increase your risk.

Why does it occur?

Food deprivation changes the way your body metabolizes nutrients. For example, insulin is a hormone that breaks down glucose (sugar) from carbohydrates. When carbohydrate consumption is significantly reduced, insulin secretion slows.

In the absence of carbohydrates, the body turns to stored fats and proteins as sources of energy. Over time, this change can deplete electrolyte stores. Phosphate, an electrolyte that helps your cells convert glucose into energy, is often affected.

When food is re-introduced, there’s an abrupt shift from fat metabolism back to carbohydrate metabolism. This causes insulin secretion to increase. Cells need electrolytes like phosphate to convert glucose to energy, but phosphate is in short supply. This leads to another condition, called hypophosphatemia (low phosphate).

Hypophosphatemia is a common feature of refeeding syndrome. Other metabolic changes can also occur. These include:

  • abnormal sodium and fluid levels
  • changes in fat, glucose, or protein metabolism
  • thiamine deficiency
  • hypomagnesemia (low magnesium)
  • hypokalemia (low potassium)

Symptoms

Refeeding syndrome can cause sudden and fatal complications. Symptoms of refeeding syndrome may include:

These symptoms typically appear within four days of the start of the refeeding process. Though some at-risk people don’t develop symptoms, there’s no way to know who will develop symptoms before beginning treatment. As a result, prevention is critical.

Risk factors

There are clear risk factors for refeeding syndrome. You may be at risk if one or more of the following statements apply to you:

  • You have a body mass index (BMI) under 16.
  • You’ve lost more than 15 percent of your body weight in the past 3 to 6 months.
  • You’ve taken in little to no food for the past 10 or more consecutive days.
  • A blood test has revealed your serum phosphate, potassium, or magnesium levels are low.

You may also be at risk if two or more of the following statements apply to you:

  • You have a BMI under 18.5.
  • You’ve lost more than 10 percent of your body weight in the past 3 to 6 months.
  • You’ve taken in little to no food for the past 5 or more consecutive days.
  • You have a history of alcoholism or use of certain drugs, such as insulin, chemotherapy drugs, diuretics, or antacids.

If you fit these criteria, you should seek emergency medical care immediately.

Other factors can also put you at an increased risk of developing refeeding syndrome. You might be at risk if you:

  • have anorexia nervosa
  • have chronic alcoholism
  • have cancer
  • have uncontrolled diabetes
  • are malnourished
  • recently had surgery
  • have a history of using antacids or diuretics

Treatment

Refeeding syndrome is a serious condition. Complications that require immediate intervention can appear suddenly. As a result, people at risk require medical supervision at a hospital or specialized facility. A team with experience in gastroenterology and dietetics should oversee treatment.

Research is still needed to determine the best way to treat refeeding syndrome. Treatment usually involves replacing essential electrolytes and slowing down the refeeding process.

Electrolyte levels are monitored with frequent blood tests. Intravenous (IV) infusions based on body weight are often used to replace electrolytes. But this treatment may not be suitable for people with:

In addition, fluids are re-introduced at a slower rate. Sodium (salt) replacement may also be carefully monitored. People who are at risk of heart-related complications may require heart monitoring.

Recovery

Recovering from refeeding syndrome depends on the severity of malnourishment before food was re-introduced. Refeeding may take up to 10 days, with monitoring afterwards.

In addition, refeeding often occurs alongside other, serious conditions which typically require simultaneous treatment.

Prevention

Prevention is critical in avoiding the life-threatening complications of refeeding syndrome.

The underlying health conditions that increase the risk of refeeding syndrome aren’t always preventable. Healthcare professionals can prevent complications of refeeding syndrome by:

  • identifying at-risk individuals
  • adapting refeeding programs accordingly
  • monitoring treatment

Outlook

Refeeding syndrome appears when food is introduced too quickly after a period of malnourishment. Shifts in electrolyte levels can cause serious complications, including seizures, heart failure, and comas. In some cases, refeeding syndrome can be fatal.

People who are malnourished are at risk. Certain conditions, such as anorexia nervosa or chronic alcoholism, can increase risk.

Complications of refeeding syndrome can be prevented by electrolyte infusions and a slower refeeding regimen. When at-risk individuals are identified early, treatments are likely to succeed.

Increasing awareness and using screening programs to identify those at risk of developing refeeding syndrome are the next steps in improving the outlook.

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