FACT SHEET
Understanding the risks and prevention of refeeding syndrome in patients recovering from starvation.
What is refeeding syndrome?
Refeeding syndrome is a dangerous shift in fluids and electrolytes that can occur when a person is recovering from a period of starvation. If a starving person is fed too aggressively, it can result in this serious and sometimes fatal condition.
Refeeding syndrome is associated with low levels of phosphate, potassium, and magnesium in the bloodstream.
Who gets refeeding syndrome?
Refeeding syndrome is most commonly seen in patients who have anorexia nervosa, chronic alcoholism, cancer, chronic malnutrition, uncontrolled diabetes, or are post-op and/or have eaten extremely little for several days. Those who have severely restricted calories and/or who have had sudden weight loss are also at risk. It can occur in those who eat orally or those who depend on tube feeding for their nutrition.
Anorexia Nervosa
Patients with eating disorders
Chronic Alcoholism
Long-term alcohol abuse
Cancer Patients
Those with malignancies
Post-Operative
After surgery with limited intake
Why does refeeding syndrome occur?
Refeeding syndrome occurs because the body adapts to starvation. Under normal conditions, the body uses carbohydrates from the diet for energy. If very little food is available for 24 hours, the body uses energy that is stored in the liver and muscles. After about 3 days, it adapts again and uses other stored sources of energy. After a few days of starvation, the body becomes used to "being starved." When a person finally begins eating, the body suddenly shifts back to food as its source of energy. During this shift, there are changes in body processes that result in fluid and electrolyte imbalances and vitamin deficiencies.
Normal State
Body uses carbohydrates from diet for energy
24 Hours Without Food
Body uses stored energy in liver and muscles
After 3 Days
Body adapts and uses other stored energy sources
Refeeding Begins
Body shifts back to food, causing dangerous imbalances
What happens when a person has refeeding syndrome?
Those with refeeding syndrome are deficient in potassium, magnesium, and phosphorous, and are often deficient in fluid and a vitamin called thiamin. These nutrients are involved in many important body processes. As a result of nutrient imbalances, patients who are suddenly re-fed can have serious complications, including heart problems, breathing problems, impaired mental status, seizures, paralysis, insulin resistance, and bone problems. There have been deaths associated with refeeding syndrome.
Nutrient Deficiencies
- Potassium
- Magnesium
- Phosphorous
- Thiamin (Vitamin B1)
- Fluid
Serious Complications
- Heart problems
- Breathing problems
- Impaired mental status
- Seizures
- Paralysis
- Insulin resistance
- Bone problems
- Death
Can refeeding syndrome be prevented?
Yes, usually. The key is to identify if a patient is at risk for refeeding syndrome because of poor intake over a period of time. Once a person has been determined to be at risk, food and fluids should be provided slowly during the refeeding process. It is dangerous to provide too many calories and too much fluid to a person whose body has adapted to starvation or very low calories.
Identify At-Risk Patients
Determine if patient has had poor intake over time
Provide Food and Fluids Slowly
Gradual refeeding is essential for safety
Avoid Aggressive Feeding
Too many calories and fluids can be dangerous
Refeeding Syndrome
CONTINUED
What is the right way to nourish someone with refeeding syndrome?
Most importantly, those who have eaten very little food for several days should avoid eating or drinking large amounts of food or liquid. Several small meals and fluids in small quantities are key to re-nourishing a starving body. For acutely ill or post-surgical patients who are tube fed, feeding should be provided in small amounts and gradually increased. To prevent refeeding syndrome, a person should not be fully fed and hydrated for several days after a period of starvation. Careful monitoring of blood nutrients and tolerance of food and fluids is important. A registered dietitian can help determine how much food and fluid should be provided to prevent refeeding syndrome.
Small Meals
Several small meals instead of large amounts
Limited Fluids
Fluids in small quantities
Gradual Increase
Slowly increase feeding over several days
Careful Monitoring
Monitor blood nutrients and tolerance
Dietitian Support
Registered dietitian can guide safe refeeding
How do I know if I am at risk for refeeding syndrome?
If you have gone without much food and/or fluid for 3 or more days, you may be at risk for refeeding syndrome. In general, the more severe the malnutrition, the higher the risk for refeeding syndrome.
If you have gone without much food and/or fluid for 3 or more days, you may be at risk for refeeding syndrome.
In general, the more severe the malnutrition, the higher the risk for refeeding syndrome.
References
Academy of Nutrition and Dietetics. Nutrition Care Manual. Available to purchase at www.nutritioncaremanual.org.
Gaudiani JL. Sick Enough : A Guide to the Medical Complications of Eating Disorders. Routledge; 2019.
Kraft, MD, Btaiche IF, Sacks, GS. Review of the Refeeding Syndrome. Nutrition in Clinical Practice 20:625–633, 2005. Abstract available at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16306300&query_hl=22&itool=pubmed_docsum
McCray, S, Walker, S, and Parrish, CR. Much Ado About Refeeding. Nutrition Issues in Gastroenterology, Series # 23. Practical Gastroenterology, January 2005. Available at http://www.healthsystem.virginia.edu/internet/digestivehealth/nutritionarticles/McCrayArticle.pdf
Refeeding Syndrome