Presentation is loading. Please wait.

Presentation is loading. Please wait.

Nutrition Implications of Starvation and Refeeding Syndrome

Similar presentations


Presentation on theme: "Nutrition Implications of Starvation and Refeeding Syndrome"— Presentation transcript:

1 Nutrition Implications of Starvation and Refeeding Syndrome
Hannah Tower Concordia college Moorhead, MN

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 Talk about Keys study 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 Few hours after eating Hepatic glycogenolysis is the major provider of glucose to the blood Gropper, S. S., Smith, J. L., & Groff, J. L. (2009).

5 Pathophysiology: Fasting State
18-48 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 Gropper, S. S., Smith, J. L., & Groff, J. L. (2009). Tresley, J., Sheean, P. M. (2008).

6 Pathophysiology: Starvation State
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 - Antibodies: fight infections, enzymes: catalyze life-sustaining reactions, hemoglobin: transport oxygen to tissues - FA fuel the heart, liver, and skeletal muscle tissues. Brain cant use fatty acids for energy b/c they cannot cross the blood-brain barrier, shift to fat breakdown releases large amounts of glycerol which replace AA as the major gluconeogenic precursor, assuring a continued supply of glucose as fuel for the brain, brain and skeletal muscle also adapt to use ketone bodies for energy Ketosis: ketone body concentraiton in the blood rises and they are delivered through the bloodstream to skeletal muscle, heart, and brain which oxidize them instead of glucose. As long as ketone bodies are maintained at a high concentration the need for glucose and gluconeogenesis is reduced, which spares valuable protein Survival time depends on the amount of fat stores, normal person about 3 months Gropper, S. S., Smith, J. L., & Groff, J. L. (2009).

7 Pathophysiology of RFS
Reintroduction of carbohydrates (CHO) causes increase in insulin production Body fluid disturbances Fluid overload  pulmonary edema Hyperglycemia Thiamin deficiency Electrolyte depletion Phosphate Potassium Magnesium The sudden swing from fat and protein catabolism to CHO metabolism stimulates a great increase in insulin production which results in intracellular shift of glucose with cellular uptakes of phosphate, magnesium, and potassium - Fluid overload occurs from the sodium retention effects of hyperglycemia and hyperinsulinemia. The introduction of CHO reduces sodium and water excretion, resulting in the expansion of the extracellular fluid compartment and pulmonary edema Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010)

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

9 Hyperglycemia Blood glucose level above normal
Results from glucose introduction into a starved system adopted for fat metabolism Infections are more common Thiamin deficiency Wernicke’s encephalopathy Infections are more common because hyperglycemia disrupts neutrophilic function The sudden introduction of glucose drives already depleted stores of thiamin even lower Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010).

10 Thiamin Deficiency Thiamin is required as a cofactor in the oxidation of CHO Wernicke’s encephalopathy Symptoms generally do not appear until refeeding of CHO Confusion Ocular disturbances Ataxia Coma Common in alcoholics - Thiamin requirements are related to CHO intake Wernicke’s encephalopathy is a neurological disorder resulting from thiamin deficiency which can result in long term neurological damage or death Ataxia: loss of ability to coordinate muscle movement Tresley, J., Sheean, P. M. (2008).

11 Hypophosphatemia 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 - PREDOMINANT FEATURE OF RFS - Reintroduction of CHO causes increase in insulin release which induces a transcellular shift of phosphorus and a decline in the serum phosphorus Marinella, M. A. (2003). - Tresley, J., Sheean, P. M. (2008).

12 Hypokalemia 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 Cellular uptake of potassium is enduced by insulin produced in response to the nutritional load Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010) Tresley, J., Sheean, P. M. (2008)

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

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

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

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

17 Risk Factors cont. Prolonged vomiting and diarrhea
Recent major surgery Depression in the elderly Poorly controlled diabetes Prolonged NPO status Bariatric surgery Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010)

18 Signs and Symptoms CVS GI Neurologic Metabolic Respiratory
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 Ataxia: lack of muscle coordination Metabolic alkalosis: pH of tissue is elevated beyond the normal range ( ) Metabolic acidosis: When the body produces too much acid, blood pH is less than 7.35 Respiratory alkalosis: low levels of carbon dioxide in the blood due to excessive breathing Osteomalacia: softening of bones due to lack of vitamin D 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).

19 Identifying Patients at a High Risk of RFS
National Institute for Health and Clinical Excellence (NICE) Guidelines Patient has one or more of the following BMI < 16 kg/m2 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 … - National Institute for Health and Clinical Excellence (NICE) (2006).

20 Identifying Patients at a High Risk of RFS cont.
Patient has two or more of the following BMI < 18.5 mg/m2 Unintentional weight loss > than 10% (3-6 months) Little or no nutritional intake > 5 days History of: Alcohol abuse Insulin Chemotherapy Antacids Diuretics - National Institute for Health and Clinical Excellence (NICE) (2006).

21 Clinical Indicators Clinical/ History Lab values 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 Escott-Stump, S. (2012).

22 MNT for RFS 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 General recomendations Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008)

23 MNT for RFS 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: mmol/kg/day Potassium: 1-3 mmol/kg/day Magnesium: 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 Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008).

24 MNT for RFS Days 4-6 Days 7-10 Energy: 15-20 kcal/kg/ day
Iron: supplement after day 7 Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008).

25 Medications 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 - Make sure to monitor blood glocose levels during refeeding Escott-Stump, S. (2012).

26 Current Research 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 - Wagstaff, G. (2011). - American Dietetic Association (2009).

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

28 Current Research cont. Results Conclusions
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. 2 19.5% for pt. 3 Conclusions Limited by small sample size Inconsistent dietary practices regarding refeeding syndrome Wagstaff, G. (2011).

29 Keys’ Study 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 Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).

30 Keys’ Study: Physical Changes
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 - Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).

31 Keys’ Study: Physical Changes cont.
-

32 Keys’ Study: Hunger and Appetite
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 - Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).

33 Keys’ Study: Eating Habits
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 It was as though they borrowed heat from their food as a means of conserving energy As starvation progressed the number of men who toyed and played with their food increased Toward the end of the starvation some of the men would dawdle and spend almost two hours over a meal that would have previoulsy taken them minutes Even though they were only fed three different meals over the course of the study the taste appeal of the diet increased rather than decreased Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).

34 Keys’ Study: Rehabilitation Phase
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 Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).

35 Keys’ Study: Rehabilitation Stage cont.
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 Follow-up studies made at 33 and 55 weeks after the end of semistarvation showed that the men had returned to their previous weight and that a number of men exceeded their pre-starvation weight. - 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

36 Prevention Improve awareness Recognition of patients at risk
General physicians, surgeons, RD’s, 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 Hearing, S. D. (2004). Marinella, M. A. (2003). Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010).

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
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 Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008).

39 Case Study: Anorexia Nervosa
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 - - Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008).

40 Ethical Issues ADA position: individuals have the right to accept or refuse nutrition and hydration as MNT Experiments Can’t ethically subject people to starvation like in Key’s Study - American Dietetic Association (2008).

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 "Nutrition Implications of Starvation and Refeeding Syndrome"

Similar presentations


Ads by Google