Perhaps you or a loved one has committed to recovering from an eating disorder. This is great news! However, with the onset of more normal eating patterns may come physiological complications if not carefully monitored. Of particular concern to those recovering from an eating disorder is refeeding syndrome.
Refeeding syndrome may occur when one goes from a state of starvation, as in the case with some eating disorders, to eating regularly. This is due to physiological processes that shift with the reintroduction of more normal eating habits. Refeeding syndrome is most likely to occur within the first week of normal eating1.
According to the National Institute for Health Care Excellence, those who are most at risk for developing refeeding syndrome either have one or more of the following:
- Weight loss of >15% within the past three to six months
- Little to no nutritional intake for >10 days
- Low potassium, phosphate or magnesium levels prior to feeding
Or two or more of the following:
- Weight loss of >10% within the past three to six months
- Little to no nutritional intake for >5 days
- History of alcohol abuse or drug use (including insulin, antacids, laxatives or diuretics)2
If you or someone you know has any of the above risk factors, be sure to seek medical attention during the refeeding process to avoid any potential complications. Returning to eating normally after a prolonged period of restriction is not something you should do on your own!
When the body is in a state of starvation, such as with eating disorders, it goes from breaking down body tissues for energy, a catabolic state, to rebuilding tissues, an anabolic state3. This shift in metabolic pathways causes various hormones to be released which leads to shifts in fluid and electrolyte levels3. This causes fluids and electrolytes to move from the outside of the cell to the inside to support cell growth4. When fluids and electrolytes move inside the cell, low blood levels of electrolytes such as potassium, phosphorus and magnesium result5. The potential negative effects of refeeding syndrome caused by low blood electrolyte levels include irregular heartbeat, cardiac failure, the breakdown of red blood cells (hemolytic anemia), respiratory failure, seizures, coma and even death1.
So why is refeeding syndrome such a concern to those recovering from an eating disorder? When in a state of starvation, the brain is being starved of nutrients and is not able to process as clearly as usual. Because of this, patients may not be able to undergo psychotherapy right away3. This is why weight regain, and therefore nutrient repletion, is an essential component of recovery and why normal eating is encouraged. While this is a necessary step in recovery, it may cause complications if not gone about carefully. What is the best approach to regain weight during recovery then?
If an individual meets any of the criteria listed above, it is important they receive medical care, including working with a Registered Dietitian, to oversee the refeeding process. A widely known feeding approach for eating disorder recovery is “start low and go slow” which suggests aiming for a lower daily energy intake and slowly increasing it over time. This is especially important in the outpatient setting. Emerging research suggests that starting at a higher energy intake baseline and increasing it more steadily may be more effective in promoting weight gain, shortening hospital stay and quickening the repletion of nutrients, but this is only the case for inpatient admissions5. Careful attention to the patient’s individual needs is most important during the refeeding process.
Refeeding syndrome can be a potentially fatal complication seen in some eating disorder recoveries. A small portion of those recovering from an eating disorder will develop refeeding syndrome but it is important to be aware of its existence and severity. Seeking medical attention and proper monitoring are the best measures to prevent complications that may arise during recovery.
- Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome.J Adolesc Health,53, 573-578. doi:10.1016/j.jadohealth.2013.05.014
- Nutrition support for adults: Oral nutrition support, enteral tube feeding and parenteral nutrition. (2016, February). Retrieved from https://www.nice.org.uk/guidance/cg32
- Refeeding Patients with Anorexia Nervosa: What Does Research Show? (n.d.). Retrieved from https://www.eatingdisorderhope.com/information/anorexia/refeeding-patients-with-anorexia-nervosa-what-does-research-show
- Katzman, D. K. (2005). Medical Complications in Adolescents with Anorexia Nervosa: A Review of the Literature.Int J Eat Disorders,37, 52-59.
- Katzman, D. K. (2012). Refeeding Hospitalized Adolescents With Anorexia Nervosa: Is “Start Low, Advance Slow” Urban Legend or Evidence Based?Journal of Adolescent Health,50(1), 1-2. doi:10.1016/j.jadohealth.2011.10.003