Refeeding procedures after 43 days of total fasting

Abstract

Refeeding syndrome encompasses fluid and electrolyte imbalances and metabolic, intestinal, and cardiorespiratory derangements associated with appreciable morbidity and mortality. Although refeeding syndrome has been well documented in concentration-camp subjects, and more recently during parenteral therapy of critically ill patients, little is known about the importance of refeeding syndrome during recovery from a hunger strike. Thus, we studied the response to a four-step dietary replenishment routine in eight hunger strikers who refused food for 43 d. In this retrospective, observational study, we assessed the safety and efficacy of the refeeding procedure and analyzed the clinical and nutritional course of the cohort during both starvation and refeeding, mainly on the basis of clinical as well as a few biochemical determinations. During starvation, average weight loss was about 18% and, with the exception of occasional oral vitamins and electrolytes, the subjects consumed only water. Available body-composition and biochemical profiles showed no clinically significant changes during starvation, but one-half of the group displayed spontaneous diarrhea at some time before refeeding. Stepwise nutritional replenishment lasted for 9 d, after which all patients tolerated a full, unrestricted diet. Only one episode of diarrhea occurred during this phase, and both clinical and biochemical indexes confirmed a favorable clinical course, without any manifestation of refeeding syndrome. In conclusion, we observed the following: 1) Hypophosphatemia and other micronutrient imbalances did not occur, nor was macronutrient intolerance detected. 2) Despite some episodes of diarrhea, nutritional replenishment was not associated with significant enteral dysfunction. 3) There was some fluid retention, but this was mild. 4) Acute-phase markers were abnormally elevated during the refeeding phase, without associated sepsis or inflammation.

Introduction

Although hunger strikes are rare, prolonged subtotal or total food deprivation has been used as a therapy for morbid obesity in many centers over the past four decades.1, 2, 3 Both situations have in common a discontinuation, for weeks up to 1 to 2 months, of the normal energy and protein intake of previously healthy persons. This time frame is commonly perceived as being insufficient for severe tissue damage,3 especially because metabolic adaptation mechanisms to negative energy balance are assumed to be fully operative.4

Subtle but possibly important differences exist between hunger strikes and food deprivation and the advanced, chronic starvation of concentration camp inmates5 as well as hospital malnutrition,6 in which, after many months or years of hunger and associated diseases, the anatomy and physiology of organ systems are often compromised and the complex metabolic aberrations create difficulties for therapeutic replenishment.6 Although acute total fasting is not exempt from dangerous and potentially fatal consequences,10, 11 refeeding syndrome although theoretically possible in any malnourished organism submitted to vigorous nutritional repletion is mostly associated with chronically depleted subjects.7, 8, 9

Given the theoretical risks of generous food reintroduction in nutritionally debilitated persons, various modifications and precautions for refeeding have been devised.12, 13 However, techniques specific for voluntary fasting or radical weight-losing regimens have not been recommended.1, 2, 3, 4 Such omission could be explained by the rarity of these situations. However, even in the classic studies of prolonged, spontaneous food deprivation conducted by Keys et al.,14 no special care to prevent intolerance during refeeding was taken, nor were any untoward effects reported. In the present study, we report the routines adopted for nutritional replenishment and the clinical result of these procedures in eight prisoners who refused food for 43 d.