March 4, 2018

What is Re-Feeding Syndrome

What is Re-Feeding Syndrome

Refeeding syndrome is not something to be trifled with. It's a serious condition that has no standard treatment in the medical community. At the most basic level, refeeding syndrome occurs when the body is unable to maintain electrolyte balance. It most often occurs when an individual has undergone a prolonged fasting period. While fasting may have many health benefits, most of those benefits are limited to the initial few days. The risk of refeeding Syndrome is too great to take a chance with longer fasts.

The Cause of Refeeding Syndrome

During early starvation periods, the body will begin to use fat and protein as its main source of energy. The metabolic rate of the patient also tends to go down by as much as 20 to 25 percent. At this point, the body is only concerned with attempting to maintain muscle mass and preventing the breakdown of muscle and protein. As ketone bodies begin to increase as a result, the body will begin to use fatty acids for the main source of energy.

The Rise of Ketones

As ketone levels begin to rise in the blood since the body is using fat as a fuel source, the brain will switch from using the glucose derived from carbohydrates to ketone bodies as the main source of energy. As the bodies minerals become depleted in a prolonged fasting state, the liver attempts to preserve muscle protein by making its own glucose to fuel the brain instead of muscle protein.

Increased Insulin

When an individual begins to eat again after a prolonged fast, the body will dramatically increase insulin levels and glucagon secretion. The main purpose of glucagon is to raise the concentration of glucose within the bloodstream. When insulin rises, glycogen, fat and protein synthesis begins, which requires a rather large amount of phosphate, magnesium, thiamine and other minerals.

Insulin also increases the absorption of potassium, magnesium and phosphate electrolytes into the cells, which reduces the total amount available to the body for other processes. As the body is already depleted by the fasted state, the body enters an unstable state where the balance of essential electrolytes, increase in insulin and an increased metabolic state puts the individual at risk of experiencing confusion, coma, convulsions and cardiac failure.

Imbalances in the Body

In order to better understand refeeding syndrome and how it can be treated or prevented, it's important to understand the imbalances in the body that can occur as a result of the syndrome. The body is a complex system that tries to maintain balance. When it doesn't get the right nutrients, it has the ability to pull from its stores or create the nutrients it needs from existing tissues. However, this sort of starvation diet should be avoided since it can cause irreparable harm to your body.

Fluid-Balance Abnormalities

Metabolic disturbances are one of the greatest issues that refeeding syndrome presents. Since the cells of the body begin to draw in additional electrolytes during refeeding syndrome, other important body functions like the heart can be affected. An imbalance of fluids can result in dehydration, cardiac arrest and fluid overload. Fluid overload is essentially what happens when the body is circulating more fluid than it can handle because of depleted sodium levels. It usually ends in heart failure. If you try to refeed using primarily carbohydrates, the body will often gain weight and reduce the overall levels of water and sodium removal. A high-protein diet will result in removal of sodium from the body, reduction in weight and dehydration.

fluid balance

Abnormal Glucose Metabolism

Glucose can wreak all sorts of havoc on the body during refeeding syndrome. When you start eating again, the body suppresses a process known as gluconeogenesis which allows the body to make glucose from non-carbohydrate substances. This can result in a range of issues, including ketotic coma, ketoacidosis and metabolic acidosis. It may also result in dehydration. If left untreated, these conditions may lead to an increase in carbon dioxide production, which can lead to respiratory failure.

Hypophosphatemia, Hypomagnesemia and Hypokalemia

Hypophosphatemia can result in death and it can affect the normal clotting processes in the body. It is essentially an electrolyte imbalance where there isn't enough phosphate in the blood. Hypomagnesemia is a condition where magnesium can't be adequately absorbed into the body. It's not clear how hypomagnesemia occurs as a result of refeeding syndrome, but it is associated with the syndrome. This condition results in cardiac arrhythmias and neuromuscular conditions. Hypokalemia is a lack of potassium in the body, and it can result in cardiac arrhythmia, hypotension and cardiac arrest. In short, refeeding syndrome is partially caused by low levels of phosphate, magnesium and potassium. Simply supplementing is not enough to restore these levels, since at least in the case of magnesium, close to 70 percent of the magnesium is not absorbed by the body.

Thiamine and Other Vitamin Deficiencies

A thiamine deficiency and other vitamin deficiencies can also result as a part of refeeding syndrome. One way to counteract this is to take B-vitamins, including thiamine, and a multi-vitamin product before starting to eat again. This will help reduce the possibility of thiamine deficiency and improve the probability of recovery. Deficiency could result in Wernicke's encephalopathy, which can cause problems with eyesight, confusion, hypothermia and coma.

In summary, the main conditions, electrolytes, minerals and vitamins to be concerned with are phosphorus, potassium, magnesium, glucose, sodium and water imbalances. Lacking any of the nutrients may result in congestive heart failure, pulmonary edema and cardiac arrhythmia. 

Preventing Refeeding Syndrome and Symptoms

The simple answer is to avoid going more than 3 days without food. Refeeding syndrome can begin to crop up in as little as 5 days. Other conditions that may contribute to refeeding syndrome include depression and alcoholism. Essentially, any condition that may result in a decreased absorption of nutrients can bring on refeeding syndrome. While less common, people who have dysphagia, which is an inability to swallow, may also be at risk.

It should be noted that any person who is at risk for refeeding syndrome should not attempt to treat themselves. Even with an understanding of how refeeding syndrome works, doctors still struggle to find the best way to treat each patient. The goal in prevention should involve sound nutritional guidelines that help the patient to maintain a healthy body weight. Low body weight, cancer, eating disorders and debilitating diseases can all put someone at risk of getting refeeding syndrome.

Diets that don't offer a full range of nutrients may also put an individual at risk. This is why it is so important to fully research and learn about any diet you plan to engage in before starting a new program. Your doctor can also help you get a better view of your personal profile, so you know if there are any imbalances before you begin a new diet. For the average person who doesn't have any medical conditions, the best protection against refeeding syndrome is knowledge. Knowing about the dangers of limited or no nutritional intake and how this may affect the body can help prevent the issue from occurring in the first place.

Many of the early signs of refeeding syndrome may go undetected since they seem somewhat general in nature. An individual who is suffering from refeeding syndrome may experience seizures, general weakness, muscle fiber breakdown, white blood cell issues, low blood pressure and more serious conditions like heart failure. Rather than relying on symptoms, it's a good idea to get tested if you're at risk for any eating disorder. If you suffer from a condition that prevents you from taking in the proper amount of food that is required, you should be tested regularly for any irregularities. 

refeeding syndrome

Treatment Options for Refeeding Syndrome

When a patient comes in with the symptoms of refeeding syndrome, doctors tend to follow a process to attempt to stabilize the patient. The first thing a doctor will do is check the potassium, calcium, phosphate and magnesium levels. Before the patient is allowed to begin eating, the doctor will give 200-300mg of thiamine per day. Patients are also given 1-2 tablets of vitamin B three times per day, and a multivitamin or mineral supplement once per day. Preventing refeeding requires the patient to take in very small amounts of food at first, which usually adds up to about 10-60 calories per kilogram of body weight per day. Depending on the condition of the patient, it may be possible to give up to 100 calories per kilogram of body weight per day.

Anything other than a mild deficit of potassium requires a trip to the emergency room for an intravenous replacement. For extremely mild cases, a potassium supplement may help the body recover more quickly. 1500-2000mg of elemental calcium divided into smaller doses in between meals can help to restore calcium levels, but it can reduce the absorption of other medicines. Magnesium should be given by mouth in doses of 20 to 24mg per day in doses that are divided over the course of five days. Phosphate should be provided in 1000mg increments per day until the condition has rectified itself. Of course, it should be noted that all of these doses are only appropriate for someone who has a very mild case of refeeding syndrome. More extreme cases can only be treated with intravenous fluids and injections.

Doctors are often torn between the risks of refeeding syndrome and starvation. Some doctors believe that it is less harmful to the patient to risk refeeding syndrome taking hold. Since refeeding syndrome can be monitored and mostly controlled, doctors who advocate immediate nutrition replenishment believe that brain damage and death caused by low glucose level poses the greater risk. There are many ways to prevent the possibility of refeeding syndrome. A low-carb diet with supplementation of phosphate may also help patients who are at risk recover more easily. Milk offers one of the best sources of phosphate for a patient who is lacking.

The Case for Aggressive Refeeding

There is some research that suggests that aggressive refeeding approaches may help reduce the length of stay necessary in a hospital. In a 2012 study, there was a group of 56 patients who had an average body weight that was 79 percent of the total ideal body weight. The group averaged 16.2 years of age. The study was completed with adolescents who suffered from anorexia. Patients received anywhere from 1100 to 1800 calories depending on their body weight and current condition. Patients who were in the higher calorie level had faster overall weight gain and increased their level of calories by a more drastic amount. There were also no cases of refeeding syndrome, which suggests that high calorie refeeding can be accomplished in a controlled setting. Of course, the subjects were all young and presumably more capable of handling a more aggressive refeeding approach.

It's important to note that while treatment therapies are starting to embrace the idea of aggressive refeeding, every individual must be treated on an individual basis. Treating adults is more complicated, and there is no one treatment method that is guaranteed to work. Most research suggests that by starting patients at about 1400 to 1800 calories each day and increasing the calories by 300 every three days offers a safe option.

No person should attempt to recover from refeeding syndrome on their own without close heart and electrolyte monitoring. An aggressive approach may have varying effects depending on the severity of starvation. Patients who are at less than 70 percent of their ideal body weight may need to start slower since they could be at higher risk. Setting a goal of increasing body weight by 1kg per week offers a safe and sensible approach, provided proper testing is conducted.


While refeeding syndrome is a serious condition that can be difficult to treat, recognizing the signs of the syndrome can help you get help before it's too late. The most common reason for refeeding syndrome is fasting, so it's important that you make sensible decisions on your diet to avoid putting yourself at risk. Refeeding syndrome can begin to affect you within as little as five days of a water fast. If you're coming off a fast now and experience refeeding syndrome, it's important to get medical help as soon as possible.