What are the recommendations for refeeding a 23-year-old male after an 18-day water fast (Water Only Fasting), presenting with fatigue?

From the Guidelines

For a 23-year-old male ending an 18-day water fast while experiencing fatigue, I strongly recommend a careful, gradual refeeding process over 5-7 days to prevent refeeding syndrome, as supported by the most recent guidelines from the ESPEN guideline on hospital nutrition 1.

Key Considerations

• The refeeding syndrome can be a life-threatening metabolic condition if not recognized early and treated adequately, with possible predictors including low energy intake for over 10 days or weight loss over 15% 1.
• The ESPEN guideline recommends starting nutritional therapy with low caloric input and increasing step by step over five to ten days, according to the individual’s risk of the refeeding syndrome and clinical features 1.
• Monitoring of electrolytes, including potassium, phosphate, and magnesium, is crucial during the refeeding process, as hypophosphatemia, hypokalaemia, and hypomagnesemia can occur 1.

Refeeding Process

• Start with small portions of easily digestible foods every 2-3 hours, beginning with clear broths, diluted fruit juices, and small amounts of watermelon on day 1.
• Introduce soft fruits, steamed vegetables, and small amounts of yogurt on days 2-3.
• Gradually add more substantial foods like whole grains, legumes, and lean proteins in small portions by days 4-5.

Additional Recommendations

• Stay well-hydrated with water and electrolyte-containing fluids throughout the refeeding process.
• Monitor for warning signs, including rapid heart rate, confusion, swelling, or severe weakness, which could indicate refeeding syndrome requiring immediate medical attention.
• Consider supplementing with vitamin B1 (200-300 mg daily) and a balanced micronutrient mixture, as recommended by the ESPEN practical guideline on clinical nutrition in cancer 1.
• Be aware of the potential complications of refeeding, including aspiration, overfeeding, and electrolyte imbalances, and take measures to minimize these risks, as outlined in the guidelines for enteral feeding in adult hospital patients 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: ... Patients with marginal thiamine status to whom dextrose is being administered should receive 100 mg thiamine hydrochloride in each of the first few liters of IV fluid to avoid precipitating heart failure. The patient is stopping an 18-day water fast and is tired, which may indicate a risk of refeeding syndrome. Refeeding syndrome can lead to severe complications, including heart failure.

• The patient may be at risk of thiamine deficiency due to poor dietary habits during the water fast.
• Administering dextrose without thiamine may precipitate heart failure in patients with marginal thiamine status. Considering the patient's condition, it is essential to ensure adequate thiamine supplementation during the refeeding process to prevent complications. 2

From the Research

Refeeding Process After 18-Day Water Fast

The refeeding process after a prolonged water fast can be challenging and requires careful management to prevent complications.

• The main clinical problems associated with refeeding include hypophosphataemia, hypomagnesaemia, and hypokalaemia, which can lead to sudden death 3, 4, 5, 6.
• Thiamine deficiency is also a concern, as it can cause Wernike's encephalopathy/Korsakoff psychosis 3, 4.
• Sodium and water retention are additional complications that can arise during the refeeding process 3, 4.

Managing the Refeeding Process

To manage the refeeding process, it is essential to:

• Monitor the patient closely and provide generous vitamin and electrolyte supplementation 3.
• Increase calorie intake reasonably rapidly, starting from 10 to 20 kcal/kg/24 hours 3.
• Be cautious of refeeding problems, especially in patients who have had no or very little nutrition for over 5 days 3.
• Slow down or stop the feed if problems occur, and correct fluid and electrolyte issues before resuming 3.

Prevention and Treatment

Prevention and treatment of refeeding syndrome involve:

• Identifying patients at risk and taking proactive measures to prevent complications 4, 5, 6.
• Providing specific interventions to address deficiencies and low plasma levels of potassium, phosphate, magnesium, and thiamine 4.
• Implementing a protocol to anticipate, prevent, and treat refeeding syndrome in adults 4.

Note: The study 7 is not relevant to the topic of refeeding syndrome and water fasting.