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Refeeding Syndrome

The research on breaking a fast is based mostly on studies focused on refeeding syndrome. This syndrome was first observed in severely malnourished individuals who suddenly ate (refeed) a significant amount of food. Such malnourishment is not directly comparable with shorter fasts but no research is done specifically on breaking a short-term fast. It should be noted here that short fasts up to 24 hours have minimal potential to bring symptoms of refeeding syndrome. However, you won’t make a mistake with following the rules stated here even for shorter fast. You just don’t need to worry too much about it as less than 24h fasts won’t have such a drastic effect on your metabolism and gut.

As published in a comprehensive review on refeeding published in Gastroenterology Research and Practice, the problem of refeeding is described as abnormal shifts of electrolytes and fluid. Our body has to maintain stable levels of electrolytes in our blood. To do so it “sucks” electrolytes outside of cells. Therefore, serum levels of electrolytes can be relatively stable but the total body levels decrease as electrolytes are taken out of cells.

The problem comes at the moment when we ingest food and insulin levels rise. Insulin allows our cells to absorb glucose by triggering a signalling cascade which results in glucose transporters (GLUT4) being translocated onto the cellular membrane. Besides glucose, insulin also stimulates the influx of electrolytes inside the cell. As mentioned, the intracellular stores are depleted as they compensated for reduced blood levels. This creates a large concentration gradient between blood and intracellular space. Once the cells are stimulated by insulin, electrolytes rapidly move out of blood as they follow laws of osmolarity, moving from places with a higher concentration (blood) into spaces with lower concentration (cell).

The most affected electrolytes drained out the bloodstream are magnesium, phosphate and potassium. The rapid movement of these can compromise the cell membrane potential. This potential – a difference between outer and inner cellular membrane – is crucial for the transmission of nerve signals. Respiratory insufficiency or arrhythmia can be consequences of these deficiencies, in extreme cases (not common in healthy fasting individuals) seizure can be induced by impaired nerve signalling. Further, low serum levels of these ions can lead to nausea, vomiting or lethargy.

References

https://onlinelibrary.wiley.com/doi/abs/10.1177/014860719001400190?casa_token=Em1taODHxIoAAAAA:-fHKhQNQAwRSCRAK9UGOWQDWuHrjiFvj2tK1xy6HSWFdv8hhORL3dxOQEfA8wBFZcoAO-CdkFIP23g
https://pubmed.ncbi.nlm.nih.gov/29448987/
https://www.hindawi.com/journals/grp/2011/410971/
https://www.nature.com/articles/1602854
https://clinicalnutritionespen.com/article/S1751-4991(09)00062-6/pdf
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/566807?casa_token=TxB3z6PFypMAAAAA:bzkvynaqzLt7HTeWfB9eANAOP80LN97XrLj6_iC8MUVwMk2KqWURBLCz6iBQRWmr-0FIWUnh
https://www.sciencedirect.com/science/article/pii/B9780123756688100063
https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/fractional-magnesium-absorption-is-significantly-lower-in-human-subjects-from-a-meal-served-with-an-oxalaterich-vegetable-spinach-as-compared-with-a-meal-served-with-kale-a-vegetable-with-a-low-oxalate-content/D44B642494EA1D2F55852C8D92A9F602
https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/fractional-magnesium-absorption-is-significantly-lower-in-human-subjects-from-a-meal-served-with-an-oxalaterich-vegetable-spinach-as-compared-with-a-meal-served-with-kale-a-vegetable-with-a-low-oxalate-content/D44B642494EA1D2F55852C8D92A9F602
https://pubmed.ncbi.nlm.nih.gov/14985216/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6835310/
https://pubmed.ncbi.nlm.nih.gov/15826055/