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Literature review current through: Jul 2017. | This topic last updated: Apr 29,
2017.
In addition, patients other than those with anorexia nervosa are at risk for the
refeeding syndrome [3]. These include oncology patients undergoing
chemotherapy, malnourished elderly patients, certain postoperative patients, and
homeless or alcoholic patients who have not eaten for many days.
The refeeding syndrome in anorexia nervosa and its management are reviewed
here. Nutritional rehabilitation for anorexia nervosa; the evaluation for medical
complications and criteria for hospitalizing patients with anorexia nervosa;
medical complications of anorexia nervosa and their management; the
epidemiology, pathogenesis, clinical features, treatment, and outcome of anorexia
nervosa; and the medical complications of bulimia nervosa and binge eating
disorder are discussed separately.
DEFINITIONS
Anorexia nervosa The core features of anorexia nervosa (table 1) are [4]:
Disturbance in how one experiences body weight and shape, undue influence
of weight or shape on self-worth, or denial of the seriousness of ones low
body weight.
Hypophosphatemia
Hypokalemia
Vitamin (eg, thiamine) deficiencies
Congestive heart failure
Peripheral edema
Rhabdomyolysis
Seizures
Hemolysis
Vitamin and trace mineral deficiencies are due to starvation [10]. These
deficiencies are exacerbated by the onset of anabolic processes that accompany
refeeding the patient.
Volume overload begins with an increase in insulin secretion during the early
stage of refeeding the patient [9]. This eventually increases renal sodium
reabsorption and retention, and then fluid retention.
Risk factors The risk of developing the refeeding syndrome is directly related to
the amount of weight loss during the current episode and the rapidity of the weight
restoration process [7-9,16]. Patients who weigh less than 70 percent of ideal body
weight (calculator 1) or lose weight rapidly are at greatest risk for the syndrome.
Thus, patients who weigh less than 70 percent of their ideal body weight, or have a
body mass index (calculator 2) <15 to 16 kg/m2, generally require hospitalization
for the initial stage of nutritional replenishment. Other risk factors for the refeeding
syndrome include low baseline levels of phosphate, potassium, or magnesium
prior to refeeding the patient; and little or no nutritional intake for the previous 5 to
10 days. Criteria for hospitalization of patients with anorexia nervosa are
discussed separately. (See "Anorexia nervosa in adults: Evaluation for medical
complications and criteria for hospitalization to manage these complications",
section on 'Hospitalization'.)
Patients are at the highest risk for the refeeding syndrome in the first two weeks of
nutritional replenishment and weight gain [9]. Generally, the risk progressively
dissipates over the next few weeks.
Bradycardia is expected with anorexia nervosa [1,17,18]. A normal heart rate may
in fact be a harbinger of cardiac compromise in these patients. During the early
stages of refeeding, a resting heart rate >70 beats per minute may suggest heart
failure and the refeeding syndrome. Bradycardia in patients with anorexia nervosa
is discussed separately. (See "Anorexia nervosa in adults and adolescents:
Medical complications and their management", section on 'Bradycardia'.)
Hypertension, hypotension, and peripheral edema may also occur during the
refeeding syndrome [7,10]. An overview of hypertension, hypotension in the
context of shock, and diagnosis and treatment of edema are discussed separately.
(See "Definition, classification, etiology, and pathophysiology of shock in adults"
and "General principles of the treatment of edema in adults".)
Muscular Impaired contractility, weakness, myalgia, and tetany may occur [7].
Hypophosphatemia may also cause rhabdomyolysis, which is suggested by an
abnormally high creatine kinase (CK) [9]. (See "Clinical manifestations and
diagnosis of rhabdomyolysis".)
Diarrhea may occur during the early stages of refeeding, due to atrophy of the
intestinal mucosa and pancreatic impairment [9]. The diarrhea generally resolves
within the first few weeks of refeeding as the villous surface is reconstituted. In
the interim, working with a dietician to reduce the amount of complex
carbohydrates and to provide calories via a more elemental diet may help as well.
Electrolyte deficiencies that are present in patients with anorexia nervosa should
be corrected prior to initiating the refeeding process [7]. Although one clinical
guideline states that clinicians may correct electrolyte imbalances during the
feeding process rather than beforehand [5,11,16], we suggest that nutritional
replenishment not commence until electrolyte levels are normal, based upon
multiple reviews [3,7,8,10]. Treating electrolyte abnormalities usually requires no
more than 12 to 24 hours [3]. No randomized trials have studied this issue. In
addition, administering prophylactic phosphorous supplements to prevent
refeeding hypophosphatemia is a widening practice, but remains controversial
[22,23].
SUMMARY