How Refeeding Syndrome Jeopardizes Anorexia Treatment

 “Anorexia, you starve yourself. Bulimia, you binge and purge. You eat huge amounts of food until you’re sick and then you throw up. And anorexia, you just deny yourself. It’s about control.”

-Tracey Gold

Stripping the body of all flesh and leaving the bones behind is what is now the ‘acceptable’ standard of beauty in the modern world. But is it worth it?

Judy Frost does not remember how her anorexia started.

“I don’t remember how I became ill. My parents and my friends all loved me. I was an exceptional student and I had male and female friends,” she recalls.

“I was never abused; nobody in my family has ever been on a diet. My parents taught me how to eat well and I would automatically reach out for fruits and vegetables instead of chips and crisps,” Judy said.

“Things got a little difficult when I went to secondary school. There were girls there who mocked my appearance. I think that was the trigger. I think I started losing self-esteem and that made me deprive myself of food to feel in control,” she said.

Judy had reached the point where she was nearly about to die. It was a good doctor’s observation of her behavior that made her recover.

“A skin specialist was the one who referred me to the hospital’s inpatient ward. And I am grateful to him. I think my brain has blanked out all those years of illness because I really can’t recall what happened,” she adds.

Anorexia nervosa is one of the most fatal types of eating disorders. Anorexia victims are plagued by fears of gaining weight. The resultant weight loss acts as a precursor to many nutritional complications.

Anorexia may not just a mental problem but can also be a biological breakdown. It may sound crazy but many people may or may not survive anorexia even after recognizing and getting treatment.

It is believed that 85% of anorexics are unable to maintain a normal body weight in accordance with their ages and heights. The abnormal body image views shared by most anorexics can be further classified into two types:

  • Curbing their food intake through dieting, fasting or even excessive exercise.
  • Binge eaters or those who purge regularly to compensate in the form of self-induced vomiting or the use of laxatives and so on.

Refeeding Syndrome: A Consequence Of Anorexia

The road to recovery is not easy for people with anorexia and many lose the battle for their lives during treatment. Refeeding syndrome is one of the grave consequences of anorexia and is defined by clinical problems which arise during nutritional treatment or rehabilitation of anorexic individuals. The name ‘refeeding syndrome’ was given to a particular set of medical drawbacks which arise as a result of refeeding an anorexic person.

The term ‘refeeding syndrome’ was coined during World War II, after prisoners released from Japanese concentration camps showed symptoms of the previously unknown malady. At the time, health providers were flabbergasted to learn that severely starved prisoners of war died from cardiac failure when they were fed again. After being starved for weeks, months and in some cases even years, the prisoners belonging to Far East areas like Australia, lost their lives within four days of being fed again.

Patients with anorexia nervosa who are at risk of developing the refeeding syndrome have:

  • A Body Mass Index (BMI) less than 16
  • No nutrition intake for the last 10 days
  • Very low biochemical levels of potassium, phosphate, or magnesium
  • Significant weight loss in the last few months

Refeeding syndrome occurs when the fluid and electrolyte levels of an anorexic shift during treatment. Anorexics with a body weight less than 70% are at increased risk of contracting the syndrome. One study reported that 6% of anorexic adolescents develop refeeding syndrome during their hospital stay. The risk of refeeding syndrome looms over an anorexic person in the first two weeks of the nutritional treatment for weight gain, but it slowly dissipates as the weeks pass away.

The refeeding syndrome was discovered more than 70 years ago but there is a glaring lack of data on it. The syndrome lacks a standard definition and recommendations. There are many heterogeneous definitions of the re-feeding syndrome. Some definitions are based on blood electrolyte disturbances, while others characterize the syndrome with clinical symptoms. More research is needed to properly study the mechanism of the condition.

Not every anorexic patient undergoing nutrition therapy experiences the effects of the refeeding syndrome but the incidence varies from person to person. Usually if a person suffers from the effects of the syndrome it is in between 72 hours after the start of the nutrition therapy.

Refeeding Syndrome Fatalities:

The refeeding syndrome is characterized by critical or fatal medical difficulties such as:

  • Hypophosphatemia (a phosphate level of less than 2.5 mg/dL).
  • Hypokalemia (a serum potassium level of less than 3.5 mq/L).
  • Hypomagnesemia (very low serum magnesium and calcium levels).
  • Essential vitamin and mineral deficiencies.
  • Volume overload (one chamber of the heart is too large to function properly).
  • Edema (excess of fluid collecting in cavities or tissues/swelling).

We can characterize hypophosphatemia as a hallmark condition of refeeding syndrome, since it occurs in 28% of anorexic adolescents hospitalized for treatment. When the body’s phosphate stores are exhausted through regular starvation or other anorexia-related activities, hypophosphatemia manifests itself.

During treatment when an anorexic is fed carbs, the reintroduction of glucose into his or her blood releases insulin, which triggers the uptake of phosphates from cells since molecules like ATP and 2,3-DPG (2,3-diphosphoglycerate) require nutrients for carrying out metabolism.

Insulin also triggers the uptake of a number of other nutrients like potassium and magnesium. However when such nutrients are deficient, the tissues develop hypoxia which could lead to fatal myocardial dysfunction or even respiratory failure. Regularly starving one’s self also causes vitamin and mineral deficiencies.

Hypokalemia: Similarly, when insulin re-enters the blood stream of a patient in the early stages of refeeding, it increases the requirement of sodium in the renal or urinary system for processes such as water reabsorption and retention. However, the absence of sodium disturbs the homeostasis of the body and leads to swelling in one chamber of the heart.

Multiple Organ Failure: is the biggest threat posed by refeeding syndrome, followed by cardiac failure for the malnourished patients. The only way to avert the problem is by managing the symptoms of all nutritional obstacles in the road to recovery.

Cardiac Troubles: are the cause behind a majority of deaths which occur due to refeeding syndrome. Problems such as heart failure, stroke, and arrhythmias i.e. irregular heartbeat, occur as a result of constant starvation. During treatment, regular cardiac consultation is the only way to reduce risk of heart complications. If the patient has a heart rate of over 70 beats per minute, then there is a risk of heart failure i.e. Bradycardia. Refeeding syndrome also poses risks of adverse hypertension and hypotension, which may lead to death by cardiac shock.

Although breathing complications are rarely seen in patients with refeeding syndromes, the risk remains. Sometimes, the respiratory function is impaired and it can even completely fail, in which case mechanical ventilation is the only option. It is possible that gradual heart failure may be behind respiratory failure.

Other Complications: in the refeeding syndrome include impaired muscular functions, weakness, tetany, abnormal creatinine phosphokinase (CPK) levels, gastrointestinal problems and irregular liver function.

Malnutrition, hepatic apoptosis (self-death of liver cells) or the abruptly excessive calories and fat accumulation during treatment enhance the function of the liver in the first few weeks of refeeding. Liver function tests such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, and bilirubin show elevated results. Non-fatal symptoms of refeeding syndrome include diarrhea, abdominal pain, constipation and nausea which can be avoided or managed by reducing the rate of or stopping refeeding for a short time.

Not only does refeeding syndrome disturb the metabolism but it also affects the neurological status of a patient. Complications such as delirium, tremors, seizures and paresthesia ( abnormal sensations) can arise due to severe electrolyte imbalance. Electrolyte imbalance in refeeding syndrome can be avoided by giving the patient 100 mg of Thiamine 30 minutes before the nutritional refilling therapy is started.

Rehabilitation Of A Refeeding Syndrome Patient

Refeeding syndrome can be prevented or managed by making sure that normal body weight is restored without rapidly increasing the daily caloric intake. The amount of calories should be kept only slightly above the resting energy expenditure. If any complications still arise, then the speed of the nutritional therapy should be slowed down and all biochemical levels should be constantly monitored during the refeeding process.

New guidelines suggest that the nutrient stores should be restocked only after the electrolyte imbalances have been corrected, which takes 12-24 hours only.

In-patients i.e., patients who are hospitalized and who are suffering from anorexia can be treated by:

  • Determining their daily caloric intake.
  • Developing a protocol for feeding them.
  • Standardizing the intake levels of nutrients e.g. sodium, potassium, magnesium and so on.
  • Monitoring all vital signs constantly.
  • Daily physical examinations for heart or breathing problems.

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