Refeeding Syndrome: Pathophysiology, Clinical Management, and Implications for Disaster Preparedness

Apichat Kaewdech, Chaitong Churuangsuk

Abstract

Refeeding syndrome (RFS) is a potentially fatal, multisystem disorder triggered by the reintroduction of nutrition (whether oral, enteral, or parenteral) after prolonged starvation or significant undernutrition. Its hallmark is hypophosphatemia, accompanied by hypokalemia, hypomagnesemia, thiamine deficiency, and disordered fluid balance, which together may precipitate cardiac arrhythmia, heart failure, respiratory failure, encephalopathy, rhabdomyolysis, and sudden death. Despite growing recognition, RFS remains underdiagnosed owing to inconsistent definitions and subtle early manifestations. The 2020 American Society for Parenteral and Enteral Nutrition (ASPEN) consensus introduced standardized diagnostic criteria, while the National Institute for Health and Care Excellence (NICE) criteria continue to guide risk stratification. Those at the greatest risk include patients with anorexia nervosa, advanced malignancy, chronic alcohol use disorder, prolonged fasting, prior bariatric surgery, or extended intensive care unit (ICU) admission. Prevention centres on the early identification of at-risk individuals, prophylactic thiamine, correction of electrolyte deficits, and gradual caloric advancement under close biochemical monitoring. Because this review forms part of a special collection on the November 2025 Hat Yai flooding, where prolonged involuntary fasting, disrupted chronic disease care, and abrupt refeeding with carbohydrate-dominant relief food converged across a population of over 3.5 million, a dedicated section addresses RFS recognition, prevention, and management in flood- and disaster-affected populations. Together, these topics reflect the full clinical and public-health spectrum of a preventable but potentially fatal condition.

 Keywords

disaster; flood; hypophosphatemia; malnutrition; refeeding syndrome; thiamine

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DOI: http://dx.doi.org/10.31584/jhsmr.20261437

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