However, refeeding involves an abrupt shift in metabolism. This occurs with an increase in glucose, and the body responds by secreting more insulin. This can result in a lack of electrolytes, such as phosphorous. Refeeding syndrome can cause hypophosphatemia, a condition characterized by a phosphorus deficiency. It can also lead to low levels of other important electrolytes. The harmful effects of refeeding syndrome are widespread, and they can include problems with the:. Refeeding syndrome affects people who do not receive enough nutrition.
Electrolytes play an essential role in the body. When the balance is skewed, the most common complication is hypophosphatemia, which is a lack of phosphorus. Refeeding syndrome can also lead to a lack of magnesium. Hypomagnesemia is the name for dangerously low levels of magnesium.
In some cases, a potassium deficiency can lead to a coma or death. Doctors can identify people at risk for refeeding syndrome, but it is impossible to know whether a person will develop it. Attempting to prevent the syndrome from developing is vital. People who have experienced recent starvation have the highest risk of developing refeeding syndrome. People who have recently lost weight quickly, or who have had minimal or no food before starting the refeeding process are also at significant risk.
People with refeeding syndrome need to regain normal levels of electrolytes. Doctors can achieve this by replacing electrolytes, usually intravenously. Replacing vitamins, such as thiamine, can also help to treat certain symptoms. Elevated aldosterone levels in turn lead to increased sodium reabsorption in the kidney to maintain blood pressure. The end result is hypokalemia, metabolic alkalosis, and edema formation due to the new salt-retaining state.
Similar metabolic and electrolyte disturbances have been observed in eating disorder patients in a state of chronic hypovolemia dehydration due to all purging behaviors Brown and Mehler, The elevated serum aldosterone levels take approximately 1 to 3 weeks to return to normal once chronic dehydration from purging has been removed.
Thus, when patients enter treatment and stop their purging behaviors, their persistently abnormally elevated aldosterone levels lead to rapid edema formation, fluid retention, and excessive weight gain, which can reach 10 to 20 lb of edema weight gain over just a few days. This can understandably be quite distressing to patients with eating disorders. If no pharmacologic intervention is undertaken, edema and weight gain have been observed to peak between 4 to 10 days after purging ends, and can last up to 2 to 4 weeks.
It is important to keep in mind the need to minimize edema formation in patients with eating disorders as much as possible, as it causes significant mental distress and discomfort. When left untreated, the tendency for edema to develop upon abrupt cessation of chronic excessive purging can interfere with successful treatment Brown, As mentioned earlier, patients with AN-R who have edema do not typically have high aldosterone levels.
As a result, the aldosterone antagonist spironolactone is generally not indicated for this population. During this process sodium and water continue to be avidly reabsorbed without the previously present egress of fluids due to the purging behaviors.
A component of this is treating the volume depletion and low blood pressure, which drive the compensatory elevation in serum aldosterone levels. In an inpatient medical setting this can be accomplished with slow intravenous administration of saline, to turn off the stimulus for serum aldosterone. Unfortunately, this leads to an undesired further state of increased retention of salt and water.
Thus, the treatment of these disturbances involves aggressively addressing the electrolyte and acid-base disturbances as well as preventing and treating the resultant edema. When left untreated, the tendency for edema to develop upon abrupt cessation of chronic excessive purging can interfere with successful eating disorder treatment Brown and Mehler, In addition to discontinuing the purging behaviors, treatment of edema in AN-BP patients who purge or use laxatives involves addressing the core hyperaldosterone response and correcting electrolyte disturbances.
One specific form of edema is known as re-feeding edema, and it occurs when a malnourished body begins to attempt to eat normally again. Re-feeding syndrome, and re-feeding edema, were first described during the World War II era, when severely malnourished Americans were released from Japanese prisoners of war camps.
Issues arise due to the potentially fatal shifts in fluids and electrolytes that may occur when malnourished people start feeding again.
Often, they begin eating too much too quickly, and becomes detrimental to the body. During early refeeding, phosphorus levels can become dangerously low leading to muscle damage, weakness, cardiac arrhythmias, and death. Another critical electrolyte in the refeeding process is potassium. A decreased potassium level in the blood may lead to seizures, cardiac arrhythmias, and death. Fatal complications from these electrolyte abnormalities can be avoided with daily lab checks and aggressive replacement of electrolytes.
Another common physiologic change that occurs during the refeeding process is refeeding edema or swelling not to be confused with the edema caused by Pseudo-Bartters syndrome which can occur upon the cessation of purging. During the refeeding process, one of the many hormones at play is insulin. When insulin secretion increases it makes the kidneys hold on to salt and water.
This water retention is seen as swelling, typically in the lower extremities. The accumulation of fluid and the visible changes it causes in the lower extremities is very distressing, especially for patients suffering from severe eating disorders and associated body dysmorphia. There is no treatment for refeeding edema and in most cases it will resolve with continued nutritional rehabilitation. It is important to set expectations and provide reassurance that refeeding edema will resolve with nutrition and time.
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