Eating Disorders and Refeeding Syndrome

What is Refeeding Syndrome?

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While there is no universally accepted definition of refeeding syndrome, it is generally described as the medical complications that can occur as a result of increasing caloric intake after a period of being malnourished.¹ One of the populations who are at increased risk of developing refeeding syndrome are individuals with eating disorders, particularly restrictive types of eating disorders like anorexia nervosa and atypical anorexia nervosa.²

The medical complications of refeeding syndrome are usually characterized by changes in electrolyte levels and metabolic functioning and can be fatal in severe cases.¹ Studies have found that compared to patients without refeeding syndrome, patients with the syndrome have an increased mortality rate and are more likely to be admitted to the intensive care unit.³ It is important, therefore, to be aware of the signs, symptoms, and risk factors of this serious condition and to seek specialized medical care as soon as possible.¹ It is also important to recognize that like eating disorders, refeeding syndrome can affect people of all ages, body sizes and races.¹

What are the Risk Factors for Refeeding Syndrome?

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There are many factors that can increase the risk of developing refeeding syndrome. Given the serious and at times fatal health consequences of this syndrome, it is essential for those who have experienced periods of undernourishment, their loved ones, and the professionals in their lives to be aware of these risk factors so that they can receive the appropriate treatment from a qualified medical professional as early as possible. 

Risk factors for the development of refeeding syndrome can include:

• Being undernourished or not consuming any calories for a long period of time (i.e. little or no caloric intake for more than 10 days).¹
• Having an eating disorder like anorexia nervosa, OSFED or atypical anorexia nervosa.⁴
• People with very low body weight.¹
• Rapid weight loss at any weight (i.e. losing 10-15% of body mass in 3-6 months).¹
• Vomiting for a long period of time.⁶
• History of diuretic or laxative misuse.¹
• Poorly managed diabetes or insulin misuse. ^1,5
• Post-bariatric surgery patients, particularly those who have experienced rapid weight loss.^1,6
• Individuals who consume large quantities of alcohol or who have a history of chronic substance use disorder(s).^1,6
• Food insecurity and homelessness.⁶
• Malabsorption conditions (i.e. inflammatory bowel disease, Crohn’s disease, cystic fibrosis etc.).^6,7
• Having cancer.⁶
• Experiencing physical abuse, sexual abuse and/or neglect, particularly in childhood.⁶
• Having a history of refeeding syndrome.¹
• Abnormal electrolyte levels before beginning the refeeding process.¹

What are the Health Consequences of Refeeding Syndrome?

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The following are some of the medical complications that people with refeeding syndrome can experience:

• Electrolyte changes including low levels of phosphorus (hypophosphatemia), potassium (hypokalemia), and/or magnesium (hypomagnesemia).¹
• Changes in metabolic functioning like hypoglycemia.^1,6
• Edema.³
• Anemia.⁸
• Gastrointestinal problems.¹
• Extreme muscle weakness.^1,3
• Cognitive impairment.^1,3
• Cardiac arrhythmias or cardiac failure.^1,8
• Difficulty breathing or respiratory failure.¹
• Death.¹

How is Refeeding Syndrome Treated?

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As stated earlier it is important to learn as much as possible about the risk factors of refeeding syndrome so it can be identified as early as possible.¹ Since refeeding syndrome can lead to serious health consequences and be fatal if the condition is not carefully monitored it is strongly recommended that if someone is at risk they seek treatment from a medical professional and/or an inpatient medical facility that specializes in eating disorders and are knowledgeable about the treatment of refeeding syndrome as soon as possible.¹ Since it can be difficult to find medical professionals specialized in eating disorders a first step could be seeking help from primary care physicians who can provide an initial medical evaluation and may be able to provide referrals to specialists in the area.

What to expect from your medical care team during refeeding:¹

• Your doctor might recommend taking a multivitamin prior to beginning nutritional rehabilitation.
• Medical standards of care call for regular blood tests to monitor electrolytes during the nutritional rehabilitation process.
• Medical personnel will also monitor your fluid intake and urine output to ensure that you are appropriately hydrated and to avoid fluid overload.
• Your medical provider will also monitor your vital signs, liver function, cardiac health and mental health during the refeeding process.
• Based on your blood test results, your provider might recommend supplements to correct any electrolyte deficiencies that you might have.

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