HANNAH TOWERCONCORDIA COLLEGE

MOORHEAD, MN

Nutrition Implications of Starvation and Refeeding

Syndrome

Objectives

Describe the pathophysiology of starvation and refeeding syndrome (RFS)

Explain and identify signs and symptoms along with risk factors of starvation and RFS

Be able to recognize a patient at risk of starvation and RFS

Describe the medical nutrition therapy (MNT) for starvation and RFS

Describe ways to prevent starvation and RFS

What is RFS?

Term used to describe several metabolic alterations that occur during nutritional repletion of starved patients Electrolyte depletion Fluid shifts Glucose derangements

Can occur when reinstating nutrition orally, enterally, or parenterally

It was first reported among those released from concentration camps after WWII

- Long, S., Nelms, M., & Suchner, K. (2007). - Marinella, M. A. (2003).

Pathophysiology: Early Fasting State

Tissues cannot get their energy from ingested glucose and other macromolecules Glycogenolysis

Gluconeogenesis assists in maintaining blood glucose levels

Glucose from the liver to the muscles comes from the recycling of lactate and glycogenolysis

Rate of glucose use is greater than production by gluconeogenesis and the stores diminish rapidly

- Gropper, S. S., Smith, J. L., & Groff, J. L. (2009).

Pathophysiology: Fasting State

- Gropper, S. S., Smith, J. L., & Groff, J. L. (2009).- Tresley, J., Sheean, P. M. (2008).

18-48 hours of no food intakeAmino acids from muscle protein breakdown

provide the main substrate for gluconeogenesis

The shift to gluconeogenesis is signaled by the secretion of glucagon

Ketogenic amino acids released by muscle protein hydrolysis are converted into ketones

Large daily loses of nitrogen in the urine

Gropper, S. S., Smith, J. L., & Groff, J. L. (2009).

Pathophysiology: Starvation State

Goal: spare body proteinFat stores main energy source The shift to fat breakdown releases large amounts of

glycerol Assure a continued supply of glucose as fuel for the brain

Eventually ketosis occurs Ketone bodies are delivered to skeletal muscle, heart, and brain

Survival time 3 months

When the fat reserves are depleted the body uses essential protein Loss of liver and muscle function and eventually death

Pathophysiology of RFS

Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010)

Reintroduction of carbohydrates (CHO) causes increase in insulin production

Body fluid disturbances Fluid overload pulmonary edema

HyperglycemiaThiamin deficiencyElectrolyte depletion

Phosphate Potassium Magnesium

Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010)

Hyperglycemia

Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010).

Blood glucose level above normalResults from glucose introduction into a

starved system adopted for fat metabolismInfections are more commonThiamin deficiency

Wernicke’s encephalopathy

Thiamin Deficiency

Tresley, J., Sheean, P. M. (2008).

Thiamin is required as a cofactor in the oxidation of CHO

Wernicke’s encephalopathy Symptoms generally do not appear until refeeding of

CHO Confusion Ocular disturbances Ataxia Coma

Common in alcoholics

Hypophosphatemia

- Marinella, M. A. (2003). - Tresley, J., Sheean, P. M. (2008).

Low serum phosphate Moderate: <2.5 mg/dL Severe: <1.0 mg/dL

Caused by starvation-induced loss of lean tissue mass, minerals, and water

Transcellular shift of phosphorus and a decline in the serum phosphorus

Can lead to: Irregular heartbeat Respiratory failure Confusion

Hypokalemia

- Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010)- Tresley, J., Sheean, P. M. (2008)

Low serum potassium <2.5 mEq/L

Results from the cellular uptake of potassiumCan result in:

Paralysis Compromised respiratory system Muscle necrosis Irregular heartbeat

Hypomagnesemia

- Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010). - Tresley, J., Sheean, P. M. (2008).

Low serum magnesium <1.0 mg/dL

Results from cellular uptake of magnesium after feeding

Can result in: Convulsions Seizures

Risk Factors

- Marinella, M. A. (2003). - Tresley, J., Sheean, P. M. (2008).

Anorexia nervosa

http://www.doctortipster.com/tag/anorexia-fear

Prolonged starvation

http://poorfund.blogspot.com/2010/06/third-worldstarvation.html

Risk Factors cont.

- Marinella, M. A. (2003).

Alcoholism

http://www.drug-rehabilitation.com/alcoholism.htm

Homelessness

http://homelesschicago.wordpress.com/

Risk Factors cont.

- Marinella, M. A. (2003). The refeeding syndrome and hypophosphatemia. Nutrition Reviews, 61 (9), 320-323.

Obesity with significant weight loss

http://www.fitnessthroughfasting.com/water-fasting-for-weight loss.html

History of cancer

http://www.topnews.in/health/diseases/cancer

Risk Factors cont.

- Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010)- http://directory.ac/dr-carson-liu.html

Prolonged vomiting and diarrheaRecent major surgeryDepression in the elderlyPoorly controlled diabetesProlonged NPO statusBariatric surgery

Signs and Symptoms

- Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010)- Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008).

CVS Sudden death Heart failure

GI Anorexia Abdominal pain Constipation or diarrhea Vomiting

Neurologic Tremors Coma Ataxia

Metabolic Metabolic alkalosis Metabolic acidosis Respiratory alkalosis

Respiratory Respiratory failure Ventilator dependency

Musculoskeletal Weakness Osteomalacia

Identifying Patients at a High Risk of RFS

- National Institute for Health and Clinical Excellence (NICE) (2006).

National Institute for Health and Clinical Excellence (NICE) Guidelines

Patient has one or more of the following BMI < 16 kg/m2

Unintentional weight loss > than 15% (3-6 months) Little or no nutritional intake >10 days Low levels of potassium, phosphate or magnesium

prior to feedingOR …

Identifying Patients at a High Risk of RFS cont.

- National Institute for Health and Clinical Excellence (NICE) (2006).

Patient has two or more of the following BMI < 18.5 mg/m2

Unintentional weight loss > than 10% (3-6 months) Little or no nutritional intake > 5 days History of:

Alcohol abuse Insulin Chemotherapy Antacids Diuretics

Clinical Indicators

Escott-Stump, S. (2012).

Clinical/ History Height Weight Blood pressure BMI Desirable BMI % UBW History of weight changes Tricep skin fold Diet history I & O Temperature Edema Bone pain Dizziness Diarrhea/vomiting

Lab values Serum phosphate Magnesium Potassium Glucose Sodium Cholesterol/TG Serum iron BUN

MNT for RFS

Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008)

Energy intake should be instituted carefully, and gradually increased over 4-10 days

Supplementation of electrolytes and vitamins can be started before feeding

Monitor fluid administration carefully

MNT for RFS

Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008).

Days 1-3 Energy: 10 kcal/kg/day (5 kcal/kg/day if BMI <14)

CHO: 50-60% Protein: 15-20% Fat: 30-40%

Electrolytes: measure daily during feeding and increase if necessary Phosphate: .5-.8 mmol/kg/day Potassium: 1-3 mmol/kg/day Magnesium: .3-.4 mmol/kg/day

Fluid: restrict to maintain renal function About 20-30 mL/kg/day

Sodium Minerals: 100% DRI Vitamins: 200% DRI

Thiamine: 200-300 mg i.v. 30 minutes prior to feeding

MNT for RFS

Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008).

Days 4-6 Energy: 15-20 kcal/kg/ day

Days 7-10 Energy: 20-30 kcal/kg/day Iron: supplement after day 7

Medications

Escott-Stump, S. (2012).

Replacement of phosphorus, potassium, and magnesium if depleted

Insulin to correct hyperglycemia100 mg thiamin bolus daily for three days

Other B-complex and vitamins if needed

Current Research

- Wagstaff, G. (2011).- American Dietetic Association (2009).

No recent randomized, controlled trials exist

Ethical issuesEAL: Does serum prealbumin correlate with

weight loss in starvation? One non-randomized trial found that serum

prealbumin does not correlate with weight loss in starvation

Evidence comes from case studies, case series, and cohort studies

Current Research cont.

Wagstaff, G. (2011).

Electronic, anonymous, internet survey sent out covering current practice, perceived prevalence of refeeding risk, and opinions on the NICE guidelines. Target population: RD’s in London working with

adults Response rate: 168 RD’s, 30.8%

Current Research cont.

Wagstaff, G. (2011).

Results 89.8% have read the NICE guidelines History of nutritional intake and biochemistry are the

most important factors when treating RFS 89.5% do not wait for biochemistry to normalize before

commencing feeding 31.2% classified and fed pt. 1 according to NICE

recommendations 22.7% for pt. 2 19.5% for pt. 3

Conclusions Limited by small sample size Inconsistent dietary practices regarding refeeding

syndrome

Keys’ Study

- Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).

36 young men between the ages of 20-33 served as volunteer subjects

Study began in 1944 and lasted a yearControl data was obtained for three months

3,492 calories/daySemistarvation period for six months

Stimulate the quantity and quality of the food available in western and central Europe

1,570 calories/dayControlled rehabilitation for three months

Keys’ Study: Physical Changes

- Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).

24% body weight lossFace and body showed

great emaciationClothes and shoes too

largeMuscle wastingEdema in knees, ankles,

and facesNails grew slowerHair lossSlower wound healingMuscle cramps and

soreness

Tolerance to heat was increased

Cold body temperatureBlackouts and faintingInability to focusNauseaDecrease in pulse rateFatigue and weaknessLoss of ambitionDepressionPolyuria and nocturia

Keys’ Study: Physical Changes cont.

- http://leanmeanvirilemachine.com/2010/10/25/why-eat-less-exercise-more-doesnt-work/

Keys’ Study: Hunger and Appetite

- Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).

In total starvation the sensation of hunger rapidly disappears, not true in semistarvation

Subjects referred to sensations located in the abdomen Mild to intense pain Varied for each subject

http://www.sophisticateddorkiness.com/2010/02/review-the-great-starvation-experiment/

Keys’ Study: Eating Habits

Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).

Anticipation of eating heightened the craving for food

Each subject defensively guarded his plate

Food had to be very hot in order to be satisfying

During meals they were silent, deliberate, and gave total attention to their food

Played with their foodSpend hours eating their

meal

Saved parts of their meal for later

Taste appeal of the meals increased

Food substitution Gum chewing

Limited to two packs a day

Large amounts of water Smoking Coffee and tea

Limited to nine cups per day

Keys’ Study: Rehabilitation Phase

Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).

Purpose: measure the relative efficiency of several levels of refeeding in order to secure the most efficient, practical, and economic regimen for dietary rehabilitation

First six weeks: 2,448 caloriesSeventh to tenth weeks: 3,257 caloriesEleventh and twelfth weeks: 3,518 calories

Keys’ Study: Rehabilitation Stage cont.

- Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945). -http://www.psychologytoday.com/blog/hunger-artist/201011/starvation-study-shows-recovery-anorexia-is-possible-only-regaining-weight

At the end of the 12 weeks the subjects in the highest caloric group regained <60% of the weight lost

120 calories moreLowest group

Gained no weight during the first six weeks Regained 20% of weight lost after the 12 weeks

Recovery from dizziness, apathy, and lethargy was the most rapidLittle change and some increase in edemaAppetites were insatiableFrustration with lack of strength and endurance

Prevention

- Hearing, S. D. (2004). - Marinella, M. A. (2003). - Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010).

Improve awareness General physicians, surgeons, RD’s, nurses

Recognition of patients at risk Knowing the warning signs and risk factors

Prevent the development of severe symptomsLessen the symptoms is RFS has already

developed

Role of the RD

Make recommendations for providing, withholding, or withdrawing nutrition in individual cases

Promote the right of the individual patientAssist the healthcare team in recognizing

RFS Signs and symptoms Risk factors

Case Study: Hunger Striker

- http://www.huffingtonpost.com/greg-boose/the-sign-guy-goes-on-hung_b_187190.html- Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008).

27 y.o. male went on hunger strike for 4 months Refused any nourishment

Except tea and coffee with sugar Lost further 2 kg in hospital and became weaker, more inactive,

and apathetic Treated with enteral and parenteral nutrition

1600 kcal/day Gained 5 kg due to salt and water retention Hypokalemia, hypomagnesaemia, and hypophosphatemia

200 mg thiamine was administered as well as potassium phosphate for three days (40 mmol) and magnesium sulphate (20mmol)

After three days electrolyte/ mineral concentrations were in the normal range, and three days later oral nutrition was started

Discharged after 57 days

Case Study: Anorexia Nervosa

- http://www.101healthsolution.com/anorexia-nervosa/- Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008).

40 y.o. woman with long standing anorexiaUpon admission

Ankle edema Hypotension Phosphate, magnesium, and potassium were low

Oral supplementation of vitamins and electrolytes Regardless she developed muscle weakness, drowsiness,

and rapid heartbeatI.V. supplements of electrolytes and minerals

Within 2 days muscle weakness and heart rate were resolved and serum electrolyte concentrations were normal

Ethical Issues

- American Dietetic Association (2008).

ADA position: individuals have the right to accept or refuse nutrition and hydration as MNT

Experiments Can’t ethically subject

people to starvation like in Key’s Study

http://www.massbar.org/for-attorneys/ethical-inquiries

Summary

Starvation is severe reduction in energy, vitamin, and mineral intake

RFS is a term used to describe several metabolic alterations that occur during nutritional repletion of starved patients

RFS is caused by rapid refeeding after a period of undernutrition

Characterized by hypophosphatemiaGradually introduce feeding