Refeeding Syndrome Risk Hard To Predict With Eating Disorders


MONTREAL — Refeeding syndrome is a potential problem for all eating-disordered patients who are reintroducing fluids and food, but it is difficult to predict which patients are at greatest risk, Ovidio Bermudez, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

“There is something about the reintroduction of nutrients to someone who has suffered a significant nutritional insult that can cause severe metabolic imbalances, resulting in cardiovascular, pulmonary, neurological, hepatic, and even bone marrow dysfunction,” he said in an interview.

Once the body has adjusted to a state of malnourishment, refeeding will immediately signal the body to switch off compensatory mechanisms, thus unmasking nutritional deficiencies, said Dr. Bermudez, medical director of the eating disorders program at Laureate Psychiatric Clinic and Hospital in Tulsa, Okla.

The result is electrolyte and fluid imbalances, glucose intolerance, liver dysfunction, and thiamine deficiency.

“All patients who are refed will develop some degree of refeeding syndrome, but there is great variability in terms of the severity of the readjustment. Most patients fare well without any apparent clinical challenges, some patients have a moderate challenge,” and a few have severe or even fatal consequences, he said.

Although there are few predictive factors to identify patients most at risk, they tend to be those who are the most underweight and have low prealbumin levels. But these predictors should not be relied on too heavily, Dr. Bermudez said.

“The idea that a person who has had only a moderate metabolic insult is not going to develop some of these problems would be a false reassurance. The best approach we should have as physicians is to know the literature and know the group of patients at highest risk,” but to be alert for any trouble, he said.

By screening for problems prior to refeeding and then monitoring patients carefully during the refeeding, Dr. Bermudez noted, most serious consequences can be avoided.

He recommended that a comprehensive metabolic panel (including liver and renal function tests), calcium, phosphorous and magnesium levels, CBC, and a prealbumin test should be performed prior to refeeding. Any vitamin and trace mineral deficiencies, as well as electrolyte and glucose imbalances, should also be corrected at that time.

During refeeding, fluids and caloric intake should be increased gradually by 200–250 kcal every 2–3 days, and weight gain should not exceed 2–3 pounds per week, Dr. Bermudez said.

Initially, patients should have their vital signs, weight, and fluid intake and output monitored daily, with weekly assessments of CBC, electrolytes and glucose, calcium, phosphorous, magnesium, and liver and renal function. “How long to do this is not quite clear. In our setting, it is usually 2–3 weeks, but in others it can be up to 6 weeks,” he said.

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