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What Lies Beneath

What Lies Beneath

A Hershey's Bar, Refeeding Syndrome, and World War II

Johnston, Michelle MBBS

Emergency Medicine News: May 2020 - Volume 42 - Issue 5 - p 21
doi: 10.1097/01.EEM.0000666332.66546.71
    refeeding syndrome

    Apocryphal stories are not in short supply in medical history. One worth examining is the tragedy of the deaths that occurred following the liberation of Nazi concentration camps at the end of World War II.

    One of these, Bergen-Belsen, which, unlike Auschwitz, did not employ gas chambers or conduct mass executions, had 60,000 survivors within its grim walls when the Allied troops arrived in 1945. Typhus and starvation had already taken unthinkable numbers of people by then (including Anne Frank, an extraordinary loss for literature and humanity). But when the Allied troops arrived and immediately gave food to the brutally emaciated inmates, the horror was compounded by a significant percentage of them dropping dead, some reportedly within minutes. For a time, it was believed that the stomachs and intestines of the prisoners had shrunk so much they were unable to digest anything. The word was that the soldiers were killing the prisoners with kindness.

    Of course, as we understood more over time, it became clear that what occurred was classic refeeding syndrome, an underdiagnosed problem we may fail to recognize in the theatre of critical care today.

    This condition can occur in any malnourished patient who has had prolonged decreased nutritional intake, such as in anorexia or alcoholism, or of decreased absorption in the classic malabsorptive patterns of short bowel syndrome, inflammatory bowel disease, or severe chronic pancreatitis. Giving a glucose load suddenly to those at risk can lead to potentially fatal shifts in fluid and electrolytes. The main culprit is phosphate, but it is a complex syndrome, with effects on sodium and fluid balance, disruption to glucose, fat, and protein metabolism, thiamine deficiency, hypokalemia, and hypomagnesemia.

    During prolonged fasting and periods of malnutrition, massive regulatory hormonal and metabolic changes attempt to prevent protein (and therefore muscle) breakdown. Fatty acids are relied upon, and intracellular minerals become severely depleted, even if serum levels remain pleasantly normal. At the moment of refeeding, insulin levels shoot up with the glucose load, and glycogen, protein, and fat synthesis skyrocket. This also causes massive intracellular shifts of the already depleted electrolytes. Cue the protean features of the clinical syndrome: congestive heart failure, GI disturbances, Wernicke encephalopathy, and, most importantly, the sequelae of sudden, profound hypophosphatemia.

    Life-threatening Effects

    Now we in emergency medicine can, quite rightly, be accused of being a little phosphatist. We tend to poo-poo the importance of this molecule, leaving it to the attention of intensivists, who are far fonder of it than we are. That is mostly a fair tactic, except in refeeding syndrome, where the phosphate, which has been steadily depleted over time and is then made to fall precipitously with the shifts of a glucose load, can drop so low it has profound and life-threatening effects: respiratory failure, ataxia, diffuse muscle weakness, bulbar dysfunction with aspiration, and seizures. Thus, the EP must be alert to phosphate levels in these situations.

    The key features for managing refeeding syndrome are to recognize patients at risk, replace fluids judiciously, prepare to test and replace (and retest) critical electrolytes (phosphate, of course, but also potassium, magnesium, and calcium) under generous thiamine cover, and then give consideration to the micronutrients (the rare birds of emergency medicine, e.g., selenium and zinc) plus the smorgasbord of other necessary vitamins. They should all be admitted to an HDU/ICU if possible for tailored replacement.

    Inhumanity to Man

    But let us return to refeeding's place in history. The reports of the freed prisoners dropping dead at the bite of a Hershey's bar is a myth that circulated for many a year (plausible, I appreciate—Americans, what is that chocolate?), but these sudden deaths were rare, their numbers exaggerated. The deaths, commensurate with the pathophysiology of refeeding syndrome, occurred over days. It was tragedy layered upon tragedy.

    If nothing else, this history and its connection to the modern presentation of refeeding syndrome should be another opportunity for us never to forget man's inhumanity to man. And it is as good an opportunity as ever to revisit the gift that was Primo Levi, who survived Auschwitz and was able to write about it in a way nobody else has throughout history.

    In his book If This Is A Man, he shines the light on one of humanity's darkest hours. I cannot implore you enough to read it. A chemist, Mr. Levi also wrote autobiographically about the periodic table, circling back to the wonders of the elements, phosphorus, in particular. If I may end by quoting Mr. Levi:

    You who live safe

    In your warm houses,

    You who find warm food

    And friendly faces when you return home.

    Consider if this is a man

    Who works in mud,

    Who knows no peace,

    Who fights for a crust of bread,

    Who dies by a yes or no.

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    Dr. Johnstonis a board-certified emergency physician, thus the same as you but with a weird accent. She works in a trauma center situated down the unfashionable end of Perth, Western Australia. She is the author of the novel Dustfall, available on her website, She also contributes regularly to the blog, Life in the Fast Lane, Follow her on Twitter @Eleytherius, and read her past columns at

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