Applied nutritional investigationRefeeding procedures after 43 days of total fasting
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.
Section snippets
Patients and methods
The population consisted of eight adult prisoners (seven men and one woman) with a mean age of 43.3 ± 6.2 y (range: 33–52 y). For the first 11 d of the prisoners’ hunger strike, they were maintained within the correctional facility, but afterward seven of eight were transferred to Hospital das Clı́nicas (the eighth patient arrived 1 wk later). The hunger strike lasted for 46 d, but after 43 d of starvation (“absolute hunger”), replenishment of intravenous fluids and micronutrients was started.
Results
Nutritional rehabilitation started with intravenous fluids, electrolytes, and vitamins for approximately 48 h, supplying less than 5% of daily energy needs but between 100% and 200% of the allowances for vitamins and also intracellular electrolytes (potassium, magnesium, and phosphate). This regimen was followed by standard peripheral parenteral nutrition (glucose and amino acids) in combination with modest amounts of a commercial semielemental oral diet enriched with glutamine (mean total
Discussion
Chronic hunger is a fact of life in overpopulated, agriculturally challenged, and poor countries and can degenerate to true famine as a result of droughts, floods, and military conflicts. The most devastating and widespread occurrence of food deprivation in modern times was precipitated by World War II, which affected millions of persons in industrialized and developing countries alike. Much of the disaster affected civilian populations, either as part of the war effort or in connection with
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Cited by (32)
Serum Albumin and Prealbumin in Calorically Restricted, Nondiseased Individuals: A Systematic Review
2015, American Journal of MedicineCitation Excerpt :Three (3.35, 3.24, 2.95 g/dL) were recorded in groups of patients with anorexia nervosa and average BMI values of 9.8, 11.1, and 10.5 kg/m2 respectively.14,24,35 The fourth was 3.4 g/dL in a group of prisoners on hunger strike for an average 43 days with a mean BMI of 21.5 kg/m2.39 All other mean albumin values were above 3.5 g/dL, in groups with mean BMI as low as 11.3 kg/m2.
Old disease, new look? A first report of parkinsonism due to scurvy, and of refeeding-induced worsening of scurvy
2013, PsychosomaticsCitation Excerpt :Mr. P had been receiving IV thiamine as a sole nutritional supplement for several days, and this may have prevented a more robust and classic refeeding syndrome. Even occasional provision of micro-nutrients, and in particular thiamine, may be sufficient to prevent the sometimes fatal constellation of hypophosphatemia, electrolyte disturbances, and organ malfunction.22,24 But why Mr. P suffered an isolated worsening of scurvy remains a question.
A 40-day water-only fast by a pentecostal woman: Clinical and religious observations
2013, American Journal of the Medical SciencesCitation Excerpt :Among 33 political prisoners on hunger strikes for 6 to 24 days, mild hyponatremia developed in 10 people (range of serum sodium, 128–134 mmol/L).5 However, in another series of 8 hunger strikers, hyponatremia reportedly did not occur during 43-day water-only fasts.6 Metabolic studies have shown that a natriuresis occurs during the first several days of acaloric fasting.12,13
Nutrition Assessment and Management in Amyotrophic Lateral Sclerosis
2012, Physical Medicine and Rehabilitation Clinics of North AmericaCitation Excerpt :In a perfect setting, laboratory values would be followed over 8 days with adjustments made to provide necessary electrolytes and nutrients by intravenous administration. Some serum electrolyte values, in particular magnesium, are resistant to changes in the serum even as malnutrition progresses121–123 and it should be assumed that changes have occurred when greater than 10% of body weight has been lost.124 In the home setting, patients should complete their 10-day course of supplementation and then rely on a daily multivitamin with trace minerals in addition to the micronutrients provided by the formula.
Clinical and laboratory observations during refeeding after starvation in patients
2012, European Journal of Internal Medicine