Refeeding Syndrome — Cure Worse Than Condition

The commonality amongst all kinds of starvation, whether unavoidably imposed or intentional, is that a person cannot simply start eating normally again. This is due to the condition called refeeding syndrome, which is characterized, if the word can even be used for such a general purpose, by “a wide range of symptoms and a lack of clear diagnostic criteria.”

Consequently, although various recommendations have been made for the management of refeeding syndrome, they “remain controversial due to a lack of objective data and quantification standards.”

Who gets refeeding syndrome? Anyone who receives increased nutrition after a prolonged experience of starvation, and this includes a lot of people because there are plenty of “populations at high risk for malnutrition.” Whatever the cause of their malnutrition, they can’t just start randomly and heedlessly eating again. Immediately following World War II, this problem was dramatically apparent among certain populations…

[…] when individuals living during the famine unexpectedly became ill following nutritional reconstitution. In 1951, Schnitker et al reported that one-fifth of Japanese prisoners starved in prison camps died suddenly after nutritional and vitamin replenishment.

The lack of food in a concentration camp or POW camp is not the only possible cause of malnutrition. Even in peacetime, ordinary citizens may be in this kind of trouble for a number of reasons. In some cases, they may experience malnutrition because of inflammatory bowel disease and other conditions that impede the absorption of nutrients.

Poorly controlled diabetes is another possible cause, as well as cancer-related conditions; inadequate post-operative recovery; undergoing dialysis because of renal failure; chronic alcoholism; extreme weight loss from a starting point of morbid obesity; or suffering from an eating disorder.

Kids with problems

That last cause is where the topic intersects with childhood obesity, because teenagers trying to be thin can kill themselves by developing refeeding syndrome with its consequent “electrolyte and metabolic disturbances that manifest in cardiopulmonary, hematologic, and neurological dysfunction.” This is just a rough outline of what can happen when nutrition is replenished carelessly: Glucose levels, rise, followed by insulin levels…

[…] which then drive phosphorus and potassium intracellularly, causing a decrease in the amount of available extracellular potassium or hypokalemia… This increase in insulin and the effects on electrolyte migration (intracellular vs. extracellular) are compounded by nutritional electrolyte deficiencies.

The many and varied effects on the body of being fed after starvation include potentially fatal conditions with exotic names like torsades de pointes and Wernicke-Korsakoff encephalopathy. Because there is so much going on, treatment requires not just a doctor or a hospital bed, but an entire interprofessional team.

A WebMD article by multiple authors also asserts that “malnutrition has serious health consequences” and provides a list of ten of them, including paralysis and cardiac arrest, and also affirms that the cure for it, “refeeding syndrome is a life-threatening complication… without swift treatment, refeeding syndrome can result in death.” According to the article,

You will need to be admitted to the hospital, and doctors will prescribe a special formula of artificial nutrients to replenish your body. This process is called refeeding. You’ll get the artificial nutrients by mouth or through a tube.‌..

During refeeding, your metabolism can start to overproduce insulin, which triggers your body to synthesize protein and produce fat. The process can monopolize the electrolytes in your body. You don’t get sufficient electrolytes to your organs and this results in organ system problems.

A Cleveland Clinic website goes into more detail, naming phosphate deficiency (hypophosphatemia) which can manifest in a number of harmful ways. Or the person might experience a magnesium deficiency, which brings its own list of problems. Or a shortage of potassium or thiamine, adding such possibilities as delirium and amnesia.

Then, there are dehydration and blood sugar maladjustments. Ominously, one risk factor that could lead to refeeding syndrome is “recent loss of more than 10% of your body weight.” This fact might need special attention in light of the recent popularity of miracle weight-loss drugs.

The Cleveland Clinic notes,

Refeeding syndrome is a complication of treatment for malnourishment. This is already a stressful condition for your body to endure. It may seem counterintuitive, but too much cure too quickly can be harmful. Refeeding is a delicate and complex process. Ideally, it should be medically supervised. During medical refeeding, your healthcare team will monitor you closely. They’ll work to prevent refeeding syndrome and will be prepared to manage it if needed.

In other words, with refeeding syndrome, the cure can literally be worse than the condition. It can be so bad that medical personnel would much prefer to avoid and prevent it, and not have to reach the point of needing to treat it.

Your responses and feedback are welcome!

Source: “Refeeding Syndrome,” NIH.gov, 11/07/22
Source: “Refeeding Syndrome,” WebMD.com, 07/19/23
Source: “Refeeding Syndrome,” ClevelandClinic.org, undated
Image by Emilio Labrador/Attribution 2.0 Generic

Almost Half a Ton, Continued

Katie Peterson realized she needed help, but was trapped in the old catch-22 known as needing help too much. She had to lose 200 pounds before any medical institution would even consider her case; and was turned away by several facilities, which did not even want to make an appointment to talk it over until those 200 pounds were gone.

The general guidelines to qualify for bariatric surgery would frustrate a saint. As journalist Kati Blocker explained in a meticulously detailed piece for UCHealth.org,

You must have a BMI of 40 or more; or a BMI of 35 or more, plus a serious obesity-related health problem, such as type 2 diabetes, high blood pressure, or sleep apnea.

But at the same time, with all that going on, the patient must be deemed healthy enough to undergo surgery. Also, the doctors require the patient not to be a smoker — which Peterson was. The hopeful patient must have tried other weight-loss methods, like diet and exercise. There is a mandatory psychological exam.

Blocker writes,

Most importantly, you have to be committed to the long-term process of weight loss. By following the post-surgery recommendations, you give yourself the best possible chance to begin successfully.

In 2016, the family encountered both interpersonal and financial difficulties. Katie’s son got in some trouble serious enough to be arrested for. At this point, her lifelong habit of stress eating extended to consuming a bottle of pills all at once. She was hospitalized until a judge had pretty much no choice other than to let her go home, because no mental health facility would take her. She was still too big. Despite periodic talks with a therapist, she reverted to type:

I again stress ate. I was eating this whole time. From when I woke up to when I went to bed, I was eating something.

Although outside pressures eased a bit, Katie was up to 700 pounds and facing even more determined rejection from medical institutions. The math was simple. No 200-pound loss equals no surgery. Her depression did not lift, and the non-stop stress eating continued. But when her son graduated from high school, she felt inspired to look for help again and found an intriguing article online. After filling out a form, she was invited to meet with Dr. Robert Quaid of UCHealth.

The three-hour trip to Colorado involved being loaded into a minivan by half a dozen firefighters, and at Poudre Valley Hospital she weighed in at 890 pounds. This was the occasion of the quotation borrowed for our title:

I was flabbergasted. I couldn’t believe I’d let my life go that far where I was almost half a ton.

Dr. Quaid, the bariatric surgeon, made a treatment plan that would include attempted removal of the lap band, then a sleeve gastrectomy, to be followed around 18 months later by a single anastomosis duodenal switch, and then at some future point the removal of around 100 pounds of “excess tissue and skin.”

To help her attain mental and physical readiness, Peterson was paired up with nurse navigator Michelle Carpenter for ten months of preparatory life changes. In May of 2022, it finally happened. After the very complicated first surgery, she spend five days in the hospital before returning to Wyoming where therapy continued, along with virtual support group attendance and communication with Carpenter. The three-month follow-up visit was good, and by the six-month check-up Peterson had lost 242 pounds since surgery. She was down to 648.

Almost exactly one year ago, journalist Kati Blocker published another follow-up story about Katie Peterson, who had already lost 330 pounds at that point, a considerable improvement from her days of weighing “almost half a ton.” In the meantime, she had been cheered by messages from many strangers who reached out to encourage her and also to express how much she had encouraged them. These include a young man (almost 700 pounds) about whom Kati Blocker also wrote a very recent article.

Your responses and feedback are welcome!

Source: “900 pounds and hopeless:” Katie’s weight-loss story, UCHealth.org, 01/17/23
Source: “From 900 pounds to independence,” UCHealth.org, 11/07/23
Source: “Once nearly 700 pounds, this young man is on the road to better health,” UCHealth.org, 09/19/24
Image by Ian Britton/Attribution-NonCommercial 2.0 Generic

Almost Half a Ton

Is it exploitative to pass along the story of an extremely obese person? How could it be, if the subject voluntarily signs a contract and is appropriately compensated? On the other hand, there have been some TV programs, for instance, that did not really need to be made; some shows centering on obesity which the world could have happily gotten along without.

Before even thinking about spreading some types of news, this is what publishers, editors, and journalists would do well to pause and consider: Does the public really need to be told this story, and if so, why? Are we just going for cheap sensationalism here, or what?

In many cases, however, the motive is obviously sincere. For instance, not long ago journalist Kati Blocker wrote for UCHealth.org a very comprehensive biographical piece about one Katie Peterson, who at age 44 weighed nearly 900 pounds. Raised in a tiny midwestern town, Katie felt chronically stressed by negative emotions caused by traumatic life events. Despite having been adopted as a baby, she was aware of at least some of her genetic medical history, including proneness to obesity and heart disease.

Katie was a chubby baby and a heavy child. She was raised to believe that “it was something you were doing wrong. Obesity was your fault. It wasn’t hereditary. You ate too much.” She told Blocker,

I’ll be the first to say I have a food addiction. But at (a young) age, you don’t want to hear that. I started at age 12 seeing a therapist, my parents telling me there must be some tragic thing that happened for me to eat the way I ate.

In 2001, Katie married her first husband and gave birth to a son. She kept on gaining weight and was up to 646 pounds when she became pregnant again. For that high-risk delivery, she traveled to a neighboring state. A few years later, she traveled to yet another state for lap band surgery. She was able to lose 250 pounds in a year, but still could never get below 400.

Still, she felt pretty good, relative to how things had been. But life happened. There was a divorce, an attempt at college that failed, and another marriage. She met her biological father and began to build a relationship, but he died soon after. Other life reversals and family disasters followed, some of which caused her to feel guilt.

Following the classic tropes of eating the feelings or stuffing them deep inside, her consumption only increased. She says,

I dove into food like it wouldn’t be there anymore. I kept eating large amounts of things. It was horrible.

Blocker described Katie’s very circumscribed life, moving “with help from her then fiancé and her 17-year-old daughter” from the bed to the living room sofa, then back to bed at night. She wrote of her subject,

Like many people with a food addiction, eating made Peterson forget about life, so she’d have half of a pizza rather than a few slices. Chips and dip, cookies, candy — she didn’t care what it was.

Is it universally accepted that an addict just doesn’t care? Is it an immutable truism that a hooked person will ingest or inject anything, led on by even the faintest hope that it will put their head where they want it to be? Just throw any old substance in there, and hope for the best? Is this why so many die from fentanyl?

At any rate, the agony of existence was not purely mental. Carrying around all those pounds caused Peterson constant pain in the back, hips, and legs.

(To be continued…)

Your responses and feedback are welcome!

Source: “900 pounds and hopeless: Katie’s weight-loss story,” UCHealth.org, 01/17/23
Image by Pete Markham/Attribution-ShareAlike 2.0 Generic

How Are Weight Loss Medications Covered Globally?

We’ve been following the developments in the realm of GLP-1 agonists for a while now, including their potential to treat various conditions, risks, and availability. Let’s take a quick look at the recent headlines.

France is the latest European nation to decide against covering weight loss medications through its national insurance program. While the anti-obesity drug Wegovy is now available in the country, the French government is not offering enthusiastic support for it.

Novo Nordisk, the Danish pharmaceutical company that also manufactures the popular diabetes drug Ozempic, announced that Wegovy is now on sale in France for individuals struggling with obesity. According to a company representative, 10,000 people in France have already accessed the drug through an early access program.

Wegovy is expected to cost patients between €270 and €330 per month, but France’s national health insurance won’t cover the cost, meaning users will need to pay out-of-pocket. The drug is recommended only as a secondary option for those whose weight loss efforts through diet and exercise have failed.

Additionally, France’s drug safety agency mandates that initial prescriptions for Wegovy must come from an obesity specialist to prevent misuse, such as by individuals without weight-related health problems who may seek it for cosmetic purposes.

Elsewhere in Europe

Despite the widespread popularity of these anti-obesity drugs, which are predicted to generate global sales of $131 billion (€117.4 billion) by 2028, there have been shortages in the European Union since 2022. However, some experts, such as Dr. Jens-Christian Holm from Denmark’s University of Copenhagen, remain skeptical.

Dr. Holm said that the medications are “not the Holy Grail,” adding:

There are problems there. They cost a lot of money. There are side effects, and they are not working when you stop using them.

France is not alone in its cautious stance. For example, Germany’s national health system is prohibited by a 1980s law from covering drugs aimed at “lifestyle” conditions like obesity, smoking cessation, or hair loss. Therefore, while Wegovy has been available in Germany since 2023, only privately insured patients or those who pay out-of-pocket can access it, with the highest dose costing €302 per month.

In Denmark, where Novo Nordisk is based, the drug is also not typically covered. The Danish health authority has estimated that it would cost around 6 million Danish kroner (€805,000) to prevent a single cardiovascular event, a major factor in its decision not to cover the medication.

Meanwhile, in the United Kingdom, the health service recommends that Wegovy be used for a maximum of two years, refusing to fund longer-term use due to concerns about its cost-effectiveness. Given that many patients regain weight after stopping the medication, there is an ongoing debate among researchers, policymakers, and pharmaceutical companies about extending this usage period.

Wegovy is also available in other countries such as Norway, Spain, Switzerland, Italy, Iceland (where usage “increased by more than twenty-fold in five years,”) Australia, Brazil, Canada, Japan, the U.S., and the UAE, with further international launches planned.

Some nations are waiting to observe the effects of the drug before introducing it. For instance, while Wegovy is not yet available in the Netherlands, Dutch officials are already wary of the potential financial strain. Last year, Novo Nordisk requested that Wegovy be included in the Netherlands’ basic health insurance program. However, a government advisory panel expressed concerns in July about the drug’s long-term effects and the potential €1.3 billion annual cost, deeming it “socially irresponsible.”

These financial concerns might shift in the future, as Novo Nordisk has indicated that it could offer flexible pricing to encourage broader adoption of the drug. Additionally, new medications entering the market in the coming years could help reduce prices.

A Novo Nordisk spokesperson told Euronews Health that the company is continuously exploring ways to collaborate with healthcare systems to make its products more accessible, particularly for patients with significant unmet needs.

The U.S.: cost vs. benefits

Also in recent news, according to the U.S. Congressional Budget Office (CBO), the cost of paying for obesity drugs would be greater than the economic benefits. The CBO estimates that Medicare would spend $35 billion more on obesity drugs from 2026 to 2034, but the savings from improved health would be small.

Here are some details from the CBO’s analysis:

• The CBO estimates that the federal government would pay an average of $5,600 per user in 2026, and $4,300 per user by 2034.
• The CBO estimates that the savings from improved health would be less than $50 million in 2026, and increase to $1 billion in 2034.
• The CBO projects that expanded use of obesity drugs would improve beneficiaries’ health, mainly by reducing the incidence of obesity-related chronic diseases.
• The CBO continues to monitor trends in the use of obesity drugs, including their prices, effects on health, and coverage by insurance plans.

Your responses and feedback are welcome!

Source: “France won’t pay for weight loss drug Wegovy. What about other European countries?,” EuroNews Health, 11/10/24
Source: “Iceland Sees Sharp Rise in Use of Weight-Management Medications,” Iceland Review, 10/9/24
Source: “How Would Authorizing Medicare to Cover Anti-Obesity Medications Affect the Federal Budget?,” CBO.gov, October 2024
Image by Jakub Żerdzicki on Unsplash