Refeeding Syndrome

By Delia Aldridge

What is Refeeding Syndrome?

The most feared and potentially deadly complication of the refeeding process of malnourished patients is the refeeding syndrome.

Refeeding syndrome occurs when patients that have been nutritionally depleted begin to eat and metabolize calories. These patients have either lost 10% of their body weight the last three months or have had no nutritional intake for 10 days.

With this level of nutritional depletion, the body shifts from a catabolic state (a state of breaking down tissues for nutrients) to an anabolic state (a state of rebuilding tissues/growth). This change in metabolism leads to secretion of many hormones which contribute to shifts in salts and fluids in the body. The body is so hungry for nutrients that, in an effort to rebuild cells, it moves many salts from the blood to the growing cells.

Life-threatening complications

Low levels of electrolytes such as potassium, phosphorus and magnesium in the blood may lead to potentially life-threatening complications such as:

  • Heart failure
  • Arrhythmias (abnormal heart rhythms)
  • Respiratory failure
  • Seizure
  • Muscle breakdown
  • Death

Guidelines for refeeding process

There are clear guidelines regarding when malnourished patients should go through the refeeding process in specialized units or a hospital setting: 

  • Weight < 75% ideal body weight
  • Bradycardia (heart rate <50 bpm)
  • Arrhythmias (irregular heart rate)
  • Abnormal labs and unstable vital signs (Note: Baseline labs can be normal until patients start eating more and gaining weight)

Because these complications are so dangerous and can be fatal, the refeeding syndrome is typically treated in an inpatient eating disorder unit and overseen by physicians with experience in treating the medical complications of eating disorders. These experts leverage the most current research to develop protocols for monitoring and treating refeeding syndrome. 

At this severity of illness, treatment teams must also engage in concurrent psychoeducation for patients and families alike. Patients’ decision-making capabilities about treatment options can be impaired by the eating disorder itself, and they need to understand the dangers of the refeeding syndrome and why inpatient treatment is essential. Families benefit from information to understand the potential severity and complications of an eating disorder; with this knowledge, they can better support and assist their loved ones in making safe decisions when inpatient hospitalization is recommended following assessment.  

ERC has extensive expertise in identifying patients at increased risk for the refeeding syndrome and managing the weight restoration process compassionately and strategically. For more information about medically supported treatment at ERC, a master’s-level clinician is available at 877-711-1878. 

Summary of the Impacts of Refeeding Syndrome

Refeeding syndrome occurs when patients that have been nutritionally depleted begin to eat and metabolize calories leading to a change in metabolism and secretion of many hormones which contribute to shifts in salts and fluids in the body. Refeeding syndrome can be deadly.


[1] Treatment of patients with eating disorders, third edition. American Psychiatric Association. Am J Psychiatry 2006;163(7 Suppl):4e54.
[2] American Psychiatric Association. American Psychiatric Association Practice Guidelines for the treatment of psychiatric disorders: compendium 2006. American Psychiatric Pub, 2006.
[3] NICE. Eating disorders—core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. NICE Clinical Guideline no 9. London: NICE, 2004: (accessed Nov 9, 2004).
[4] Gaudiani, J. L., Sabel, A. L. and Mehler, P. S. (2014), Low prealbumin is a significant predictor of medical complications in severe anorexia nervosa. Int. J. Eat. Disord., 47: 148–156. doi:10.1002/eat.22233
[5] Golden NH, Katzman DK, Kreipe RE, et al. Eating disorders in adolescents: Position paper of the society for adolescent medicine. J Adolesc Health 2003;33:496e503.

Written by

Delia Aldridge, MD, FAPA, CEDS-S

Dr. Delia Aldridge is a Board Certified Psychiatrist with 20 years of experience in treating adults and adolescents with eating disorder, PTSD, personality disorders, substance abuse, self injury,…

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