How is refeeding syndrome prevented in the treatment of anorexia nervosa?

Updated: Jun 10, 2019
  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
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Rio et al (2013) and Mehler et al (2010) have proposed the following strategies to avoid the refeeding syndrome: [112, 110]

  • Identify patients at risk.

  • Measure serum electrolyte levels and correct abnormalities before refeeding, as low levels of potassium, magnesium, and phosphate may be a risk factor for refeeding syndrome

  • Obtain serum chemistry values every 3 days for the first 7 days and then weekly during the rest of the refeeding period

  • Attempt to increase daily caloric intake slowly from 1000 to 1900 kcal/day by 200-300 kcal every 3-5 days until a sustained weight gain of 1-2 pounds (0.45-0.9 kg) per week is achieved (rapid refeeding can lead to excessive bloating, edema, and, rarely, congestive heart failure)

  • Monitor the patient carefully for development of tachycardia [113] or edema

  • Monitor for pellagra and administer niacin supplementation if needed [114]

A small, but well-done, study by Garber et al of 35 hospitalized patients with anorexia nervosa found that increased fluid output and less-dilute specific gravity at the start of refeeding may be causally related to the common finding that initial weight loss occurs at the start of treatment and continues until day 8. Thus, it may be better to refeed anorexic patients with a higher caloric intake (average, 1966 kcal) than has been recommended by the American Psychiatric Association and the American Dietetic Association, which generally results in a low weight gain (1 kg/wk maximum on an initial 1200-kcal/day diet) following initial weight loss. [115]

In the Garber study, refeeding more aggressively did not result in refeeding syndrome, as phosphorus levels did not decrease to an unacceptable level. The result was a reduction in the duration of hospital stay by almost 1 day, without increased risk of medical complications. [115]

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