Refeeding syndrome is primarily known to the Israeli public in the context of survivors of the ghettos and camps from World War II. Under dire circumstances, the term has re-emerged in the headlines in connection with the return of the hostages, who now must also contend with the dangers involved in consuming food after prolonged starvation.

Refeeding syndrome was first described in the previous century in prisoners who were released after World War II. Observations detailed that prisoners of war who suffered from extreme hunger and malnutrition, and in the first days following their release, developed heart and nervous system complications, such as cardiac arrhythmias, cardiac arrest, seizures, and coma. At the time, the cause of these complications among the released prisoners was unclear, and only after years was it understood that they resulted from unrestricted refeeding after a prolonged period of starvation, thereby leading to the development of refeeding syndrome [1, 2].

Under normal conditions, carbohydrates from food are the primary source of energy in our bodies. In the early stages of starvation, during the first one to two days, several significant changes occur, as is the case with a voluntary fast such as the Yom Kippur fast. Normally, the liver and muscles contain an available energy reserve in the form of glycogen—a polysaccharide. At the onset of starvation or fasting, the liver and muscles break down glycogen into the monosaccharide glucose, which is the most readily available and common carbohydrate in the body’s energy production processes.

During this period, the body reduces the production of insulin—a hormone that promotes tissue construction and is vital in regulating blood glucose levels—and increases the levels of glucagon, a hormone that raises blood glucose by breaking down glycogen stores and promotes the breakdown of fat tissue.

After about three days, when the body has exhausted its glycogen reserves, another source of energy is required to meet the body’s needs, particularly for organs or tissues such as the brain, kidneys, and red blood cells, which require a great deal of glucose. At this stage, the body breaks down fat tissue and muscle proteins, in a process called gluconeogenesis, and uses them as a source of energy. As a result of this breakdown, the body’s fat and muscle mass decrease, and simultaneously, the levels of other essential nutrients—such as the minerals phosphorus, potassium, and magnesium—also decline.

At the end of starvation, when a person begins to receive food again, the body resumes secreting insulin, which promotes the rapid uptake of sugars into cells along with phosphorus, potassium, and magnesium. The rapid entry of these minerals into the cells causes a sharp drop in their blood levels, a process that has dangerous—and sometimes fatal—potential.

Low levels of phosphorus, potassium, and magnesium in the blood, together with a decline in essential vitamin levels, are responsible for the life-threatening manifestations of refeeding syndrome, such as vomiting, confusion, cardiac arrhythmias, respiratory failure, seizures, and ultimately death.

To prevent the syndrome, refeeding must be restarted by initially administering small, measured amounts of food and gradually increasing them. This ensures that insulin is secreted moderately and the sharp drop in mineral concentrations is avoided, until gradually the body adapts to the new state in which there is no food restriction. The Ministry of Health has announced that in the initial phase of the hostages' return, they will receive a gradual diet such as crackers, apple sauce, water, and tea [3]. Over time, each individual’s variety and amount of food is adjusted slowly and carefully, based on comprehensive tests and assessments of their medical team.

This is one small challenge among many in a long list of hardships and obstacles awaiting the hostages as they return and embark on their physical and mental rehabilitation. Photos of the released hostages clearly show and unmistakably illustrate the horrific conditions in which the hostages are held. These conditions constitute a clear death threat and underscore the importance of their release for the sake of their health.

Sources:

1. Refeeding – A Literature Review
2. A previous article by Little, Big Science on refeeding syndrome
3. A post by the Ministry of Health regarding the nutrition of the captives