How to Avoid Refeeding Syndrome in Eating Disorder Recovery

Refeeding syndrome is a medical complication that occurs in well below 1% of patients during the refeeding process. Today, I’ll talk about what it is, underlying causes and risk factors, and how it can be avoided. I’ll also touch on weight-gain guidelines, and the recommended calorie increases prescribed by the APA, NICE, and Minnie Maud.

DISCLAIMER: this is not medical advice

Refeeding syndrome is a medical complication that occurs in well below 1% of patients during the refeeding process. It is characterized by potentially fatal shifts in electrolytes during refeeding and presents as abnormalities within bloodwork, usually 1-5 of these: 

• Drops in potassium
• Drops in phosphorus 
• Drops in magnesium
• Drops in calcium 
• Drops in sodium (1-5 of these)

Symptoms can usually be identified within the first few days:

• Lightheadedness
• Fatigue and feeling weak 
• Drop in blood pressure 
• Drop in heart rate 

In combination with low electrolyte balance, the person experiencing refeeding syndrome will notice edema in the arms and legs and disturbances to organ function. These symptoms would be very evident and not at all subtle. If at any time during the initial stages of refeeding you are dizzy, light-headed, feverish, nauseous, or if you experience severe swelling of the hands or feet or bouts of chills and sweats, you should seek emergency care. The syndrome can be reversed with medical attention, but commencing the process under medical care is a safer approach. 

You may wonder, or the ED may wonder, why even bother when there’s all this risk?

For 1: nothing is riskier than maintain the eating disorder, so making the choice to move towards recovery is definitely worth it!

For 2, whilst you may increase the risk of refeeding syndrome, consider what you’ve already got nagging at your health in this moment: Starvation syndrome! And if you don’t experience the symptoms yet, it’s only a matter of time before these physical and psychological changes – the result of starvation – set in. And they can set in for individuals of all shapes/sizes/diagnoses! You may find that some of these symtpoms get worse before they get better. But once this passes, once you get through this hurdle, I promise you that recovery will be worth it in the end. 

With this question out of the way, you may now wonder: what causes refeeding? What puts me at risk?

Refeeding happens when carbohydrates again become the preferred energy source (after a period of using muscle breakdown and fat as fuel, due to insufficient intakes), and this process increases insulin secretion, which in turn sets in motion a range of other processes. Long story short: minerals are required, a whole lot of them, and this causes drastic electrolyte shifts in the blood.

Although refeeding is rare, risk of it happening is higher among individuals who have endured prolonged restriction, more severe restriction, laxative use, and frequent purging. To start the refeeding process in a safe manner, the general advice, even today, stands as follows:

1. Involve a medical professional. Have your blood levels of phosphorus, magnesium, potassium, calcium, and thiamin monitored for the first week of refeeding, and every other day for several weeks after this. Electrocardiograms should also be performed. 
2. Take things slow. Start low. Let’s dive into this second point a little more deeply. 

What is classified as a ‘low’ start? And what caloric increases are considered sufficiently ‘slow’? There are different guidelines put forth by different associations, with APA, NICE and Minnie Maud guidelines all differing slightly (see specific calorie suggestions here). However, they have one thing in common:  they have relatively low starting calorie target, which is increased incrementally (slower if the risk of refeeding syndrome is deemed higher).

HOWEVER, recent research suggests that slower increases in food intake do not in fact lower the risk of refeeding syndrome, and that faster increases do not elevate the risk. Starting on 1,500 kcal may be preferred over starting on 1,000 kcal, and starting on 2,000 kcal may be preferred over starting on 1,500 kcal. A study in March 2022, summarized these outcomes perfectly, stating that “over 18 published studies to date have used a rapid refeeding approach […] in adults and adolescents with a total sample size of 1632. Of these studies, none have reported cases of refeeding syndrome or deaths due to refeeding.” In other words, the risk is much lower than we may have thought initially, and it can normally be managed under medical supervision and with appropriate electrolyte supplementation. 

Rather than pose additional risk, more rapid refeeding may in fact be the beneficial approach: with reduced inpatient stay durations and more rapid weight restoration, the approach appears both financially and otherwise superior. Combined with close medical monitoring, it in fact foregoes some of the problems associated with slower approaches, namely, issues related to initial ‘underfeeding’ and a prolonged period at a critically low weight and energy deficient diet. 

So, here’s my recommendations: add just one thing to what you are already eating, and add another in a few days’ time. Continue like this, even if at first you may not be hungry for more food. If you notice that your body is dealing with this okay, build up to an intake at which you gain weight and, once this intake no longer sustains this weight gain, increase again. You will notice that, eating the same calories you initially gain weight on, you soon stabilize, so build up more until you reach your target weight. At this point, you should be able to eat recovery amounts whilst maintaining. There should never be a reason to go back to restriction in order to maintain.

My second recommendation is to do this under medical supervision, preferably also with the help of a specialised dietician if this is available to you. Personally, I prefer this approach because it foregoes the obsessive number-counting mess you may be dragged into if you decide to rely on calorie-counting strategies. Also, there simply isn’t a one-size-fits-all calorie approach that works for everyone! Find your way... and keep moving!