Eating disorders are serious and complex health issues with a wide variety of formidable health impacts. For those with more intense cases of an eating disorder, or for those struggling with other health conditions that cause malnourishment, a procedure called refeeding may be necessary for recovery. Refeeding syndrome is a dangerous and underestimated problem associated with refeeding. This article will explore eating disorders, refeeding syndrome, and what can be done to prevent and treat refeeding syndrome. 

Eating Disorders: What to Know

Eating disorders are a serious mental health condition that are common and always treatable. An eating disorder is characterized by intense, persistent changes in eating behaviors and a person’s relationship with food, eating, and their body image. Eating disorders include specific conditions like anorexia nervosa, bulimia nervosa, binge-eating disorder, and more. Those who experience eating disorders may have obsessions with food and eating, negative associations with food, hyperfocus on body weight, body shape or, muscularity, distorted body image, and reduced self esteem. Often, these complicated symptoms occur alongside other mental health problems such as anxiety, depression, obsessive-compulsive disorder (OCD), substance abuse and addiction, and other conditions. When conditions such as these overlap, the result is a complex and serious health condition that requires professional help from trained eating disorder healthcare providers. 

Symptoms of eating disorders look different for every individual who experiences an eating disorder. Behaviors among those experiencing an eating disorder may include:

• Constant dieting
• Excessive exercise
• Binging and purging behaviors 
• Induced vomiting and laxative misuse
• Fixation on body weight and body shape
• Avoidance of particular food groups
• Obsession with calories and other macronutrient quantities
• Secretive or ritualized eating habits
• Drastic changes in weight loss or weight gain

These behavioral signs of an eating disorder can lead to a wide variety of health complications, from gastrointestinal issues and reduced immune system response to organ failure and even death. Many people with eating disorders also experience impacts to their mental health as well as physical wellbeing. These may include intense feelings of shame and guilt, self-harm, substance misuse, depression, and anxiety. When an eating disorder is identified, diagnosed, and professionally addressed with eating disorder treatment, the negative effects on the body and mind can be minimized. 

Eating disorders can develop for a variety of reasons based on personal history and environmental factors. One of the highest predictors of developing an eating disorder is if a family member also has had an eating disorder. Along with family medical history, social influences have a role in the development of eating disorders. Pressures regarding body size and body image, social media and advertising, and body-related cultural norms can all contribute to an eating disorder. Additionally, eating disorders commonly co-occur with mental health conditions as well as trauma. 

Anyone can have an eating disorder regardless of gender, age, race, or demographic background. Eating disorders symptoms can vary greatly in presentation and impacts on health, so it is important to know the common signs and symptoms. One commonality is that all eating disorders are treatable with proper diagnosis and medical support. If you or someone you know is struggling with an eating disorder, seek help. Recovery is alway possible. 

What is Refeeding Syndrome?

When an eating disorder is particularly advanced, sometimes patients need medical intervention in the form of refeeding. Refeeding, or nutritional rehabilitation, is required when a person has experienced a prolonged period of malnutrition or starvation. Medical professionals will provide nutrients to restore body weight and provide energy to a malnourished individual. Though these nutrients are required for the body to recover and the patient to continue to heal, sometimes refeeding can have dangerous and unexpected impacts on the body when there are present vitamin deficiencies. This is refeeding syndrome (RFS).

Refeeding syndrome occurs when the body undergoes drastic and harmful shifts during the process of refeeding. A body that has been in a prolonged state of starvation begins to adapt to the lack of incoming nutrients and electrolyte imbalances. It makes major changes to your metabolism in an effort to survive the period of starvation. The body shifts from getting energy from carbohydrates found in food and instead from the fat and muscle within your own body. The rate of metabolism slows significantly and vital body functions are reduced. This kind of metabolism uses a limited amount of energy and requires no influx of vitamins, minerals, or electrolytes. It is the final, heroic effort of the human body to survive. 

Upon refeeding, sudden changes in electrolytes and other nutrients can cause the body to go into a sort of shock. When carbohydrates are resupplied by an external food source, the human body immediately requires those vitamins, minerals, and electrolytes it was previously going without. If those micronutrients are not available immediately for metabolizing the food, harmful health effects can arise quickly. The risk of refeeding syndrome is highest in the first few days of refeeding intervention, when the body is at its most vulnerable, nutrient-deficient state.

If a person experiences refeeding syndrome, they are at risk of a wide variety of dangerous health problems. The shift in electrolytes that help the body metabolize food can cause drastic and even fatal complications. These symptoms may include:

• Weakness and exhaustion
• Disorientation and memory loss
• Troubled breathing or swallowing
• Cardiovascular complications
• Changes in vision
• Seizures
• Nausea and vomiting
• Organ dysfunction
• Low blood pressure (known as hypotension) 
• Death 

Refeeding syndrome is particularly dangerous and concerning because there is no way of knowing if a person will experience this severe reaction to necessary refeeding. There are risk factors that can help predict a patient’s predisposition to this alarming condition but the condition will only arise once nutrient rehabilitation has begun. It can be a very difficult position for patients, families, and doctors to be in, as the procedure is necessary and life-saving but with a high risk of refeeding syndrome complications. 

Nutrients Involved in Refeeding Syndrome

The body requires particular nutrients to resume its normal and healthy metabolism. These nutrients, though necessary to the patient’s recovery, can pose complexities in treating malnutrition and prompt refeeding syndrome to arise in various ways.

Phosphorus

Phosphorus deficiency, or hypophosphatemia, plays a leading role in refeeding syndrome. This nutrient has impacts on cellular function within the body and a phosphorus depletion can lead to muscle fatigue, cardiovascular complications, double vision, problems with swallowing, seizures, and even coma. 

Magnesium

Magnesium deficiency, medically known as hypomagnesemia, can have dire effects on organ health. When food and carbohydrates are reintroduced to the body, normal metabolism will require magnesium. A lack of magnesium at that point causes nausea, vomiting, lack of muscle control, seizures, cardiac arrhythmias, coma. 

Potassium

Potassium is required in small amounts for vital body functions. Hypokalemia, or potassium deficiency, can result in negative health effects such as cramping and muscle weakness, severe constipation and gastrointestinal abnormalities, and respiratory failure. These problems are compounded with other nutrient deficiencies in cases of refeeding syndrome. 

Thiamine (Vitamin B1)

The influx of carbohydrates during nutrient rehabilitation can instigate severe reactions to thiamine deficiency. Vitamin B1, or thiamine, deficiencies tend to have more neurological effects than other nutrient deficiencies. These complications include amnesia, delirium, hypothermia, and changes in balance and coordination (ataxia). Coupling neurological complications with the other physical symptoms of nutrient deficiency further intensifies refeeding syndrome and subsequent health interventions. 

Blood Glucose

Hyperglycemia, or high blood glucose, is a common effect of refeeding syndrome. Major changes in blood glucose levels can cause severe headaches, blurred vision, exhaustion, and increased frequency of urination.  For those who suffer from diabetes, changes in blood sugar can impact insulin secretion which can further complicate refeeding syndrome treatment. 

Body Fluid

As refeeding occurs, there can be metabolic shifts that impact the balance of sodium and water that the body usually maintains, leading to dehydration or fluid overload. These can cause hypotension (low blood pressure), heart failure, organ dysfunction, pulmonary edema, and seizures.

It is clear that there is a wide array of nutrients that play a critical role in normal body functions. The disruption that starvation and subsequent refeeding cause to these systems can have drastic and even life-threatening effects.

Risk Factors

Though refeeding syndrome can occur for anyone undergoing the rigorous process of nutrient rehabilitation, there are a number of distinct risk factors for refeeding syndrome. 

If a patient has one or more of the following health conditions, refeeding syndrome is considered a greater risk:

• A person has a body mass index (BMI) under 16.
• More than fifteen percent of a person’s body weight has been lost in the last three to six months.
• A person’s blood test confirms low levels of phosphate, potassium, and/or magnesium. 
• Little to no food has been consumed by the patient in ten or more days. 

An individual may also be at risk for refeeding syndrome if two or more of the following list apply:

• A person has a body mass index (BMI) under 18.5.
• More than ten percent of a person’s body weight has been lost in the past three to six months.
• Little to no food has been consumed in five or more days.
• A patient has a history of alcohol abuse or use/misuse of insulin, chemotherapy medications, diuretics, and antacids. 

Other risk factors include:

• Experiencing anorexia nervosa
• Experiencing alcohol use disorder
• Recent surgery or current cancer diagnosis
• Unregulated and untreated diabetes
• Malnourishment for other unnoted reasons. 

If you or a loved one is experiencing any of these symptoms, it is important to seek professional medical help immediately. Recovery is always possible, even when the situation seems challenging or beyond repair. 

Treatment and Prevention of Refeeding Syndrome

If a doctor has deemed that nutrient rehabilitation is necessary, there are many strategies to prevent refeeding syndrome from occurring, treating the condition if it does arise, and continuing the treatment of the original malnourishment condition. Because malnourishment is a stressful and precarious condition for the human body to handle, every step moving toward renourishment is complex, highly monitored, and constantly adapting to the ever-changing needs of the malnourished patient’s body. High-risk patients may require more intensive care at this critical point in a person’s health history. 

Before refeeding begins, a care team will take a battery of blood tests. These tests will measure electrolyte levels and nutrient levels in the body to understand what deficiencies are present and how to proceed for best nutrition support. Based on initial blood tests, doctors will formulate nutrient solutions that replace deficient nutrients. Once the deficient micronutrients are replaced, the body can better handle the introduction of carbohydrates. Because nutrient levels can change very quickly throughout the refeeding process, more blood tests may be taken throughout refeeding and nutrient introduction may be altered to better suit the needs of the patient’s body. 

Refeeding can take days, weeks, and even months. Refeeding syndrome arises in the first several days of refeeding treatment. If a patient begins to show symptoms of refeeding syndrome, doctors will slow the pace of feeding and potentially reformulate their nutrient rehabilitation plan to accommodate the shifting needs of a healing body. Sometimes clinicians will use parenteral nutrition, or supplying nutrients via an intravenous fluid bag (IV). Other times they can utilize enteral nutrition (EN), which involves placing a feeding tube into the digestive system. Using these strategies, refeeding syndrome can be identified and course-corrected very quickly in a professional medical setting, even if the refeeding and recovery process can take a while. 

Healthcare teams are committed to preventing refeeding syndrome in those patients who need nutrient rehabilitation but you can take your own precautions against this dangerous condition. If you experience an ongoing condition that leads to malnutrition, work closely with a doctor to help you maintain necessary nutrient levels by using vitamins and supplements as directed. Only engage in prolonged fasting under the guidance of a medical professional. Lastly, avoid overuse of alcohol, drugs, and prescription medications. It is often unavoidable to experience a condition that may require refeeding interventions, but there is much you can do to help your body succeed in the challenges it experiences.  

Seek Help

If you or a loved one is experiencing an eating disorder, you are not alone. Recovery is always possible and help is available with the National Alliance for Eating Disorders.