Presentation on theme: "Nutrition Implications of Starvation and Refeeding Syndrome"— Presentation transcript:
1 Nutrition Implications of Starvation and Refeeding Syndrome Hannah TowerConcordia collegeMoorhead, MN
2 ObjectivesDescribe the pathophysiology of starvation and refeeding syndrome (RFS)Explain and identify signs and symptoms along with risk factors of starvation and RFSBe able to recognize a patient at risk of starvation and RFSDescribe the medical nutrition therapy (MNT) for starvation and RFSDescribe ways to prevent starvation and RFS
3 What is RFS?Term used to describe several metabolic alterations that occur during nutritional repletion of starved patientsElectrolyte depletionFluid shiftsGlucose derangementsCan occur when reinstating nutrition orally, enterally, or parenterallyIt was first reported among those released from concentration camps after WWIITalk about Keys studyLong, 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 macromoleculesGlycogenolysisGluconeogenesis assists in maintaining blood glucose levelsGlucose from the liver to the muscles comes from the recycling of lactate and glycogenolysisRate of glucose use is greater than production by gluconeogenesis and the stores diminish rapidlyFew hours after eatingHepatic glycogenolysis is the major provider of glucose to the bloodGropper, S. S., Smith, J. L., & Groff, J. L. (2009).
5 Pathophysiology: Fasting State 18-48 hours of no food intakeAmino acids from muscle protein breakdown provide the main substrate for gluconeogenesisThe shift to gluconeogenesis is signaled by the secretion of glucagonKetogenic amino acids released by muscle protein hydrolysis are converted into ketonesLarge daily loses of nitrogen in the urineGropper, S. S., Smith, J. L., & Groff, J. L. (2009).Tresley, J., Sheean, P. M. (2008).
6 Pathophysiology: Starvation State Goal: spare body proteinFat stores main energy sourceThe shift to fat breakdown releases large amounts of glycerolAssure a continued supply of glucose as fuel for the brainEventually ketosis occursKetone bodies are delivered to skeletal muscle, heart, and brainSurvival time3 monthsWhen the fat reserves are depleted the body uses essential proteinLoss 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 energyKetosis: 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 proteinSurvival time depends on the amount of fat stores, normal person about 3 monthsGropper, S. S., Smith, J. L., & Groff, J. L. (2009).
7 Pathophysiology of RFS Reintroduction of carbohydrates (CHO) causes increase in insulin productionBody fluid disturbancesFluid overload pulmonary edemaHyperglycemiaThiamin deficiencyElectrolyte depletionPhosphatePotassiumMagnesiumThe 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 edemaBoateng, 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 metabolismInfections are more commonThiamin deficiencyWernicke’s encephalopathyInfections are more common because hyperglycemia disrupts neutrophilic functionThe sudden introduction of glucose drives already depleted stores of thiamin even lowerBoateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010).
10 Thiamin DeficiencyThiamin is required as a cofactor in the oxidation of CHOWernicke’s encephalopathySymptoms generally do not appear until refeeding of CHOConfusionOcular disturbancesAtaxiaComaCommon in alcoholics- Thiamin requirements are related to CHO intakeWernicke’s encephalopathy is a neurological disorder resulting from thiamin deficiency which can result in long term neurological damage or deathAtaxia: loss of ability to coordinate muscle movementTresley, J., Sheean, P. M. (2008).
11 Hypophosphatemia Low serum phosphate Moderate: <2.5 mg/dLSevere: <1.0 mg/dLCaused by starvation-induced loss of lean tissue mass, minerals, and waterTranscellular shift of phosphorus and a decline in the serum phosphorusCan lead to:Irregular heartbeatRespiratory failureConfusion- 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 phosphorusMarinella, M. A. (2003).- Tresley, J., Sheean, P. M. (2008).
12 Hypokalemia Low serum potassium <2.5 mEq/LResults from the cellular uptake of potassiumCan result in:ParalysisCompromised respiratory systemMuscle necrosisIrregular heartbeatCellular uptake of potassium is enduced by insulin produced in response to the nutritional loadBoateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010)Tresley, J., Sheean, P. M. (2008)
13 Hypomagnesemia Low serum magnesium <1.0 mg/dLResults from cellular uptake of magnesium after feedingCan result in:ConvulsionsSeizuresBoateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010).Tresley, J., Sheean, P. M. (2008).
14 Risk Factors Anorexia nervosa Prolonged starvation Prolonged starvationMarinella, M. A. (2003).Tresley, J., Sheean, P. M. (2008).
15 Risk Factors cont. Alcoholism Homelessness HomelessnessMarinella, M. A. (2003).
16 Risk Factors cont. Obesity with significant weight loss loss.htmlHistory of cancerMarinella, M. A. (2003). The refeeding syndrome and hypophosphatemia. Nutrition Reviews, 61 (9),
17 Risk Factors cont. Prolonged vomiting and diarrhea Recent major surgeryDepression in the elderlyPoorly controlled diabetesProlonged NPO statusBariatric surgeryBoateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010)
18 Signs and Symptoms CVS GI Neurologic Metabolic Respiratory Sudden deathHeart failureGIAnorexiaAbdominal painConstipation or diarrheaVomitingNeurologicTremorsComaAtaxiaMetabolicMetabolic alkalosisMetabolic acidosisRespiratory alkalosisRespiratoryRespiratory failureVentilator dependencyMusculoskeletalWeaknessOsteomalaciaAtaxia: lack of muscle coordinationMetabolic alkalosis: pH of tissue is elevated beyond the normal range ( )Metabolic acidosis: When the body produces too much acid, blood pH is less than 7.35Respiratory alkalosis: low levels of carbon dioxide in the blood due to excessive breathingOsteomalacia: softening of bones due to lack of vitamin DBoateng, 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) GuidelinesPatient has one or more of the followingBMI < 16 kg/m2Unintentional weight loss > than 15% (3-6 months)Little or no nutritional intake >10 daysLow levels of potassium, phosphate or magnesium prior to feedingOR …- 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 followingBMI < 18.5 mg/m2Unintentional weight loss > than 10% (3-6 months)Little or no nutritional intake > 5 daysHistory of:Alcohol abuseInsulinChemotherapyAntacidsDiuretics- National Institute for Health and Clinical Excellence (NICE) (2006).
21 Clinical Indicators Clinical/ History Lab values Height Weight Blood pressureBMIDesirable BMI% UBWHistory of weight changesTricep skin foldDiet historyI & OTemperatureEdemaBone painDizzinessDiarrhea/vomitingLab valuesSerum phosphateMagnesiumPotassiumGlucoseSodiumCholesterol/TGSerum ironBUNEscott-Stump, S. (2012).
22 MNT for RFSEnergy intake should be instituted carefully, and gradually increased over 4-10 daysSupplementation of electrolytes and vitamins can be started before feedingMonitor fluid administration carefullyGeneral recomendationsStanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008)
23 MNT for RFSDays 1-3Energy: 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 necessaryPhosphate: mmol/kg/dayPotassium: 1-3 mmol/kg/dayMagnesium: mmol/kg/dayFluid: restrict to maintain renal functionAbout mL/kg/daySodiumMinerals: 100% DRIVitamins: 200% DRIThiamine: mg i.v. 30 minutes prior to feedingStanga, 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 7Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R.F., Shenkin, A., Allison, S.P., & Lobo, D.N. (2008).
25 MedicationsReplacement of phosphorus, potassium, and magnesium if depletedInsulin to correct hyperglycemia100 mg thiamin bolus daily for three daysOther B-complex and vitamins if needed- Make sure to monitor blood glocose levels during refeedingEscott-Stump, S. (2012).
26 Current Research No recent randomized, controlled trials exist Ethical issuesEAL: Does serum prealbumin correlate with weight loss in starvation?One non-randomized trial found that serum prealbumin does not correlate with weight loss in starvationEvidence 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 adultsResponse rate: 168 RD’s, 30.8%Wagstaff, G. (2011).
28 Current Research cont. Results Conclusions 89.8% have read the NICE guidelinesHistory of nutritional intake and biochemistry are the most important factors when treating RFS89.5% do not wait for biochemistry to normalize before commencing feeding31.2% classified and fed pt. 1 according to NICE recommendations22.7% for pt. 219.5% for pt. 3ConclusionsLimited by small sample sizeInconsistent dietary practices regarding refeeding syndromeWagstaff, G. (2011).
29 Keys’ Study36 young men between the ages of served as volunteer subjectsStudy began in 1944 and lasted a yearControl data was obtained for three months3,492 calories/daySemistarvation period for six monthsStimulate the quantity and quality of the food available in western and central Europe1,570 calories/dayControlled rehabilitation for three monthsFranklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).
30 Keys’ Study: Physical Changes 24% body weight lossFace and body showed great emaciationClothes and shoes too largeMuscle wastingEdema in knees, ankles, and facesNails grew slowerHair lossSlower wound healingMuscle cramps and sorenessTolerance to heat was increasedCold body temperatureBlackouts and faintingInability to focusNauseaDecrease in pulse rateFatigue and weaknessLoss of ambitionDepressionPolyuria and nocturia- Franklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).
32 Keys’ Study: Hunger and Appetite In total starvation the sensation of hunger rapidly disappears, not true in semistarvationSubjects referred to sensations located in the abdomenMild to intense painVaried 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 foodEach subject defensively guarded his plateFood had to be very hot in order to be satisfyingDuring meals they were silent, deliberate, and gave total attention to their foodPlayed with their foodSpend hours eating their mealSaved parts of their meal for laterTaste appeal of the meals increasedFood substitutionGum chewingLimited to two packs a dayLarge amounts of waterSmokingCoffee and teaLimited to nine cups per dayIt was as though they borrowed heat from their food as a means of conserving energyAs starvation progressed the number of men who toyed and played with their food increasedToward 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 minutesEven though they were only fed three different meals over the course of the study the taste appeal of the diet increased rather than decreasedFranklin, 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 rehabilitationFirst six weeks: 2,448 caloriesSeventh to tenth weeks: 3,257 caloriesEleventh and twelfth weeks: 3,518 caloriesFranklin, J. C., Schiele, B. C. Brozek, J., Keys, A. (1945).
35 Keys’ Study: Rehabilitation Stage cont. At the end of the 12 weeks the subjectsin the highest caloric group regained<60% of the weight lost120 calories moreLowest groupGained no weight during the first six weeksRegained 20% of weight lost after the 12 weeksRecovery from dizziness, apathy, andlethargy was the most rapidLittle change and some increase in edemaAppetites were insatiableFrustration with lack of strength and enduranceFollow-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, nursesRecognition of patients at riskKnowing the warning signs and risk factorsPrevent the development of severe symptomsLessen the symptoms is RFS has already developedHearing, S. D. (2004).Marinella, M. A. (2003).Boateng, A. A., Sriram, F., Meguid, M. M., & Crook, M. (2010).
37 Role of the RDMake recommendations for providing, withholding, or withdrawing nutrition in individual casesPromote the right of the individual patientAssist the healthcare team in recognizing RFSSigns and symptomsRisk factors
38 Case Study: Hunger Striker 27 y.o. male went on hunger strike for 4 monthsRefused any nourishmentExcept tea and coffee with sugarLost further 2 kg in hospital and became weaker, more inactive, and apatheticTreated with enteral and parenteral nutrition1600 kcal/dayGained 5 kg due to salt and water retentionHypokalemia, hypomagnesaemia, and hypophosphatemia200 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 startedDischarged after 57 daysStanga, 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 anorexiaUpon admissionAnkle edemaHypotensionPhosphate, magnesium, and potassium were lowOral supplementation of vitamins and electrolytesRegardless she developed muscle weakness, drowsiness, and rapid heartbeatI.V. supplements of electrolytes and mineralsWithin 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 IssuesADA position: individuals have the right to accept or refuse nutrition and hydration as MNTExperimentsCan’t ethically subject people to starvation like in Key’s Study- American Dietetic Association (2008).
41 SummaryStarvation is severe reduction in energy, vitamin, and mineral intakeRFS is a term used to describe several metabolic alterations that occur during nutritional repletion of starved patientsRFS is caused by rapid refeeding after a period of undernutritionCharacterized by hypophosphatemiaGradually introduce feeding