Presentation is loading. Please wait.

Presentation is loading. Please wait.

HANNAH TOWER CONCORDIA COLLEGE MOORHEAD, MN Nutrition Implications of Starvation and Refeeding Syndrome.

Similar presentations


Presentation on theme: "HANNAH TOWER CONCORDIA COLLEGE MOORHEAD, MN Nutrition Implications of Starvation and Refeeding Syndrome."— Presentation transcript:

1 HANNAH TOWER CONCORDIA COLLEGE MOORHEAD, MN Nutrition Implications of Starvation and Refeeding Syndrome

2 Objectives Describe the pathophysiology of starvation and refeeding syndrome (RFS) Explain and identify signs and symptoms along with risk factors of starvation and RFS Be able to recognize a patient at risk of starvation and RFS Describe the medical nutrition therapy (MNT) for starvation and RFS Describe ways to prevent starvation and RFS

3 What is RFS? Term used to describe several metabolic alterations that occur during nutritional repletion of starved patients Electrolyte depletion Fluid shifts Glucose derangements Can occur when reinstating nutrition orally, enterally, or parenterally It was first reported among those released from concentration camps after WWII -Long, S., Nelms, M., & Suchner, K. (2007). -Marinella, M. A. (2003).

4 Pathophysiology: Early Fasting State Tissues cannot get their energy from ingested glucose and other macromolecules Glycogenolysis Gluconeogenesis assists in maintaining blood glucose levels Glucose from the liver to the muscles comes from the recycling of lactate and glycogenolysis Rate of glucose use is greater than production by gluconeogenesis and the stores diminish rapidly -Gropper, S. S., Smith, J. L., & Groff, J. L. (2009).

5 Pathophysiology: Fasting State -Gropper, S. S., Smith, J. L., & Groff, J. L. (2009). - Tresley, J., Sheean, P. M. (2008) hours of no food intake Amino acids from muscle protein breakdown provide the main substrate for gluconeogenesis The shift to gluconeogenesis is signaled by the secretion of glucagon Ketogenic amino acids released by muscle protein hydrolysis are converted into ketones Large daily loses of nitrogen in the urine

6 Pathophysiology: Starvation State Gropper, S. S., Smith, J. L., & Groff, J. L. (2009). Goal: spare body protein Fat stores main energy source The shift to fat breakdown releases large amounts of glycerol Assure a continued supply of glucose as fuel for the brain Eventually ketosis occurs Ketone bodies are delivered to skeletal muscle, heart, and brain Survival time 3 months When the fat reserves are depleted the body uses essential protein Loss of liver and muscle function and eventually death

7 Pathophysiology of RFS Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010) Reintroduction of carbohydrates (CHO) causes increase in insulin production Body fluid disturbances Fluid overload pulmonary edema Hyperglycemia Thiamin deficiency Electrolyte depletion Phosphate Potassium Magnesium

8 Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010)

9 Hyperglycemia Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010). Blood glucose level above normal Results from glucose introduction into a starved system adopted for fat metabolism Infections are more common Thiamin deficiency Wernickes encephalopathy

10 Thiamin Deficiency Tresley, J., Sheean, P. M. (2008). Thiamin is required as a cofactor in the oxidation of CHO Wernickes encephalopathy Symptoms generally do not appear until refeeding of CHO Confusion Ocular disturbances Ataxia Coma Common in alcoholics

11 Hypophosphatemia -Marinella, M. A. (2003). - Tresley, J., Sheean, P. M. (2008). Low serum phosphate Moderate: <2.5 mg/dL Severe: <1.0 mg/dL Caused by starvation-induced loss of lean tissue mass, minerals, and water Transcellular shift of phosphorus and a decline in the serum phosphorus Can lead to: Irregular heartbeat Respiratory failure Confusion

12 Hypokalemia -Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010) - Tresley, J., Sheean, P. M. (2008) Low serum potassium <2.5 mEq/L Results from the cellular uptake of potassium Can result in: Paralysis Compromised respiratory system Muscle necrosis Irregular heartbeat

13 Hypomagnesemia -Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010). -Tresley, J., Sheean, P. M. (2008). Low serum magnesium <1.0 mg/dL Results from cellular uptake of magnesium after feeding Can result in: Convulsions Seizures

14 Risk Factors -Marinella, M. A. (2003). -Tresley, J., Sheean, P. M. (2008). Anorexia nervosa Prolonged starvation

15 Risk Factors cont. -Marinella, M. A. (2003). Alcoholism Homelessness

16 Risk Factors cont. -Marinella, M. A. (2003). The refeeding syndrome and hypophosphatemia. Nutrition Reviews, 61 (9), Obesity with significant weight loss loss.html History of cancer

17 Risk Factors cont. -Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010) -http://directory.ac/dr-carson-liu.html Prolonged vomiting and diarrhea Recent major surgery Depression in the elderly Poorly controlled diabetes Prolonged NPO status Bariatric surgery

18 Signs and Symptoms -Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010) - Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008). CVS Sudden death Heart failure GI Anorexia Abdominal pain Constipation or diarrhea Vomiting Neurologic Tremors Coma Ataxia Metabolic Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory Respiratory failure Ventilator dependency Musculoskeletal Weakness Osteomalacia

19 Identifying Patients at a High Risk of RFS - National Institute for Health and Clinical Excellence (NICE) (2006). National Institute for Health and Clinical Excellence (NICE) Guidelines Patient has one or more of the following BMI < 16 kg/m 2 Unintentional weight loss > than 15% (3-6 months) Little or no nutritional intake >10 days Low levels of potassium, phosphate or magnesium prior to feeding OR …

20 Identifying Patients at a High Risk of RFS cont. - National Institute for Health and Clinical Excellence (NICE) (2006). Patient has two or more of the following BMI < 18.5 mg/m 2 Unintentional weight loss > than 10% (3-6 months) Little or no nutritional intake > 5 days History of: Alcohol abuse Insulin Chemotherapy Antacids Diuretics

21 Clinical Indicators Escott-Stump, S. (2012). Clinical/ History Height Weight Blood pressure BMI Desirable BMI % UBW History of weight changes Tricep skin fold Diet history I & O Temperature Edema Bone pain Dizziness Diarrhea/vomiting Lab values Serum phosphate Magnesium Potassium Glucose Sodium Cholesterol/TG Serum iron BUN

22 MNT for RFS Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008) Energy intake should be instituted carefully, and gradually increased over 4-10 days Supplementation of electrolytes and vitamins can be started before feeding Monitor fluid administration carefully

23 MNT for RFS Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008). Days 1-3 Energy: 10 kcal/kg/day (5 kcal/kg/day if BMI <14) CHO: 50-60% Protein: 15-20% Fat: 30-40% Electrolytes: measure daily during feeding and increase if necessary Phosphate:.5-.8 mmol/kg/day Potassium: 1-3 mmol/kg/day Magnesium:.3-.4 mmol/kg/day Fluid: restrict to maintain renal function About mL/kg/day Sodium Minerals: 100% DRI Vitamins: 200% DRI Thiamine: mg i.v. 30 minutes prior to feeding

24 MNT for RFS Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008). Days 4-6 Energy: kcal/kg/ day Days 7-10 Energy: kcal/kg/day Iron: supplement after day 7

25 Medications Escott-Stump, S. (2012). Replacement of phosphorus, potassium, and magnesium if depleted Insulin to correct hyperglycemia 100 mg thiamin bolus daily for three days Other B-complex and vitamins if needed

26 Current Research - Wagstaff, G. (2011). - American Dietetic Association (2009). No recent randomized, controlled trials exist Ethical issues EAL: Does serum prealbumin correlate with weight loss in starvation? One non-randomized trial found that serum prealbumin does not correlate with weight loss in starvation Evidence comes from case studies, case series, and cohort studies

27 Current Research cont. Wagstaff, G. (2011). Electronic, anonymous, internet survey sent out covering current practice, perceived prevalence of refeeding risk, and opinions on the NICE guidelines. Target population: RDs in London working with adults Response rate: 168 RDs, 30.8%

28 Current Research cont. Wagstaff, G. (2011). Results 89.8% have read the NICE guidelines History of nutritional intake and biochemistry are the most important factors when treating RFS 89.5% do not wait for biochemistry to normalize before commencing feeding 31.2% classified and fed pt. 1 according to NICE recommendations 22.7% for pt % for pt. 3 Conclusions Limited by small sample size Inconsistent dietary practices regarding refeeding syndrome

29 Keys Study -Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945). 36 young men between the ages of served as volunteer subjects Study began in 1944 and lasted a year Control data was obtained for three months 3,492 calories/day Semistarvation period for six months Stimulate the quantity and quality of the food available in western and central Europe 1,570 calories/day Controlled rehabilitation for three months

30 Keys Study: Physical Changes - Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945). 24% body weight loss Face and body showed great emaciation Clothes and shoes too large Muscle wasting Edema in knees, ankles, and faces Nails grew slower Hair loss Slower wound healing Muscle cramps and soreness Tolerance to heat was increased Cold body temperature Blackouts and fainting Inability to focus Nausea Decrease in pulse rate Fatigue and weakness Loss of ambition Depression Polyuria and nocturia

31 Keys Study: Physical Changes cont. -

32 Keys Study: Hunger and Appetite - Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945). In total starvation the sensation of hunger rapidly disappears, not true in semistarvation Subjects referred to sensations located in the abdomen Mild to intense pain Varied for each subject great-starvation-experiment/

33 Keys Study: Eating Habits Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945). Anticipation of eating heightened the craving for food Each subject defensively guarded his plate Food had to be very hot in order to be satisfying During meals they were silent, deliberate, and gave total attention to their food Played with their food Spend hours eating their meal Saved parts of their meal for later Taste appeal of the meals increased Food substitution Gum chewing Limited to two packs a day Large amounts of water Smoking Coffee and tea Limited to nine cups per day

34 Keys Study: Rehabilitation Phase Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945). Purpose: measure the relative efficiency of several levels of refeeding in order to secure the most efficient, practical, and economic regimen for dietary rehabilitation First six weeks: 2,448 calories Seventh to tenth weeks: 3,257 calories Eleventh and twelfth weeks: 3,518 calories

35 Keys Study: Rehabilitation Stage cont. - Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945). -http://www.psychologytoday.com/blog/hunger-artist/201011/starvation-study-shows-recovery-anorexia-is-possible-only-regaining-weight At the end of the 12 weeks the subjects in the highest caloric group regained <60% of the weight lost 120 calories more Lowest group Gained no weight during the first six weeks Regained 20% of weight lost after the 12 weeks Recovery from dizziness, apathy, and lethargy was the most rapid Little change and some increase in edema Appetites were insatiable Frustration with lack of strength and endurance

36 Prevention -Hearing, S. D. (2004). -Marinella, M. A. (2003). -Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010). Improve awareness General physicians, surgeons, RDs, nurses Recognition of patients at risk Knowing the warning signs and risk factors Prevent the development of severe symptoms Lessen the symptoms is RFS has already developed

37 Role of the RD Make recommendations for providing, withholding, or withdrawing nutrition in individual cases Promote the right of the individual patient Assist the healthcare team in recognizing RFS Signs and symptoms Risk factors

38 Case Study: Hunger Striker -http://www.huffingtonpost.com/greg-boose/the-sign-guy-goes-on-hung_b_ html -Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008). 27 y.o. male went on hunger strike for 4 months Refused any nourishment Except tea and coffee with sugar Lost further 2 kg in hospital and became weaker, more inactive, and apathetic Treated with enteral and parenteral nutrition 1600 kcal/day Gained 5 kg due to salt and water retention Hypokalemia, hypomagnesaemia, and hypophosphatemia 200 mg thiamine was administered as well as potassium phosphate for three days (40 mmol) and magnesium sulphate (20mmol) After three days electrolyte/ mineral concentrations were in the normal range, and three days later oral nutrition was started Discharged after 57 days

39 Case Study: Anorexia Nervosa - - Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008). 40 y.o. woman with long standing anorexia Upon admission Ankle edema Hypotension Phosphate, magnesium, and potassium were low Oral supplementation of vitamins and electrolytes Regardless she developed muscle weakness, drowsiness, and rapid heartbeat I.V. supplements of electrolytes and minerals Within 2 days muscle weakness and heart rate were resolved and serum electrolyte concentrations were normal

40 Ethical Issues - American Dietetic Association (2008). ADA position: individuals have the right to accept or refuse nutrition and hydration as MNT Experiments Cant ethically subject people to starvation like in Keys Study

41 Summary Starvation is severe reduction in energy, vitamin, and mineral intake RFS is a term used to describe several metabolic alterations that occur during nutritional repletion of starved patients RFS is caused by rapid refeeding after a period of undernutrition Characterized by hypophosphatemia Gradually introduce feeding


Download ppt "HANNAH TOWER CONCORDIA COLLEGE MOORHEAD, MN Nutrition Implications of Starvation and Refeeding Syndrome."

Similar presentations


Ads by Google