Refeeding Syndrome

Weight restoration is the first and one of the most essential parts of the treatment process for patients with anorexia nervosa. Without nutritional rehabilitation, patients face severe and potentially life-threatening consequences of starvation, such as organ failure, stroke, or cardiac arrest. However, the process of nutritional rehabilitation—also called refeeding—can itself be risky. These patients are at risk for a medical complication known as refeeding syndrome, which can cause permanent disability and even death.

Why is Refeeding Important?

Most experts agree that anorexia cannot be effectively treated without first restoring body weight. When it comes to anorexia, weight restoration is the first and one of the most essential parts of the treatment process. There are several reasons for this. First, being underweight takes a toll on the body, including menstrual disturbances in females, muscle atrophy, and even organ failure. It is critical for the safety and wellbeing of patients to be restored to healthy weights at which their bodies can function optimally.

Second, starvation itself can exacerbate eating disorder thoughts that perpetuate a patient’s desire to lose weight. Starvation can negatively impact cognition, making patients unable to come to a rational understanding of the dangers of their eating disorder and preventing them from getting on board with the treatment process.

Third—which is related to the second point—patients who are underweight and may be suffering from the physical effects of starvation and malnutrition cannot do the psychological heavy lifting needed for long-term recovery. Because their energy and brainpower is being devoted solely to staying alive, they cannot spare any energy for abstract or long-term thinking.

What is Refeeding Syndrome?

Refeeding syndrome, in general, is a potentially fatal condition that affects patients who are starved or severely malnourished and are undergoing nutritional rehabilitation, or refeeding. People at risk for this syndrome include cancer patients undergoing chemotherapy, malnourished elderly people, homeless or alcoholic patients who haven’t eaten in several days, some postoperative patients, and patients with anorexia nervosa.

Refeeding syndrome is defined as severe electrolyte and fluid shifts that occur in the early stages of nutritional replenishment when a patient’s caloric intake is suddenly increased. During starvation mode, the body’s metabolism switches from an anabolic state—in which the body builds up or repairs tissue—to a catabolic state—which means the body is breaking down tissue, including fat and muscle, in attempt to garner the energy needed to sustain bodily functions.

Once refeeding begins, metabolism switches back to an anabolic state, increasing the uptake of electrolytes such as potassium, phosphate, and magnesium. A sudden change in the concentrations of these electrolytes causes the heart to work harder and can lead to serious complications, such as cardiac arrhythmias.

Refeeding syndrome can wreak havoc on nearly every body system and have a variety of physical consequences, including respiratory, cardiac, neurologic, gastrointestinal, and skeletal problems. See a full list of possible consequences here.

Who is at Risk for Refeeding Syndrome?

According to The National Institute for Health and Clinical Excellence (1), patients at the highest risk for refeeding syndrome are:

Patients who have one of the following indicators:

  • Body mass index of <16
  • Weight loss of >15% in the past three to six months
  • Little or no nutritional intake for >10 days
  • Low levels of potassium, phosphate, or magnesium before refeeding

Patients who have two or more of the following indicators:

  • Body mass index of <18.5
  • Weight loss of >10% in the past three to six months
  • Little or no nutritional intake for >5 days
  • History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics

How is Refeeding Syndrome Prevented?

Refeeding syndrome can be prevented by very gradually increasing a patient’s nutritional intake. Some outlets recommend that refeeding begin at no more than 50% of the patient’s typical energy requirements and then increase gradually over the next four to seven days. Others recommend specifically starting at roughly 1000 calories per day and increasing from there. It should be noted that for patients who are not deemed to be at risk of refeeding syndrome, faster refeeding rates are recommended. See this article on Anorexia Refeeding Guidelines.

All patients are different and will need to be monitored closely to determine the best approach to refeeding. In the early stages of refeeding, it is particularly important for a physician to monitor vital functions, fluid balance, electrolytes (especially magnesium, phosphate, sodium, and potassium), and cardiac rhythms.

Not all patients who undergo nutritional rehabilitation develop refeeding syndrome. However, because of the seriousness of the condition, it is important to anticipate it regardless.

What do Loved Ones of Eating Disorder Patients Need to Know About Refeeding Syndrome?

Patients who are at risk need close medical monitoring. It is important for families to educate themselves, but they cannot be expected to know the complexities of refeeding their loved one.

Despite the relative rareness of refeeding syndrome, treatment teams need to be aware of the possibility. It is important to find an eating disorder specialist who understands the risks of refeeding syndrome and how to prevent it. If you don’t have access to a specialist, be sure to ask your loved one’s doctor about the dangers associated with refeeding and perhaps bring information and materials with you.


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Written by Joanna Kay – 2015

Additional Reading:

Working Through the Weight Restoration Phase of Anorexia Nervosa

Anorexia Nervosa: Definitions, Signs and Symptoms, Complications

Your Doctor’s Role in Eating Disorders Treatment

Journal of Nutrition and Metabolism: Practical Guidelines for Refeeding the Anorectic Patient

(1) The National Institute for Health and Clinical Excellence