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Starvation and Refeeding Syndrome

Starvation and Refeeding Syndrome. Ashley Skibsted Concordia College, MN. Objectives. Explain the pathophysiology of starvation/ refeeding syndrome and their effects on the body Identify factors contributing to the signs and symptoms of starvation/ refeeding syndrome

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Starvation and Refeeding Syndrome

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  1. Starvation and Refeeding Syndrome Ashley Skibsted Concordia College, MN

  2. Objectives • Explain the pathophysiology of starvation/refeeding syndrome and their effects on the body • Identify factors contributing to the signs and symptoms of starvation/refeeding syndrome • Describe the medical nutrition therapy for starvation/refeeding syndrome

  3. Starvation & Refeeding Syndrome (RFS) Statistics • Hunger is the single gravest threat to the world's public health1 • Malnutrition is the biggest contributor to child mortality, present in ½ of all cases1 • Currently affects more than one billion people • 1 in 6 people on the planet1 • In 2007, 923 million people worldwide were reported as being undernourished1 • The prevalence of RFS in severely malnourished/starving patients who are being refed is 48%2 • 34% of all ICU patients • 9.5% of patients hospitalized for malnutrition from GI fistulae • 25% of cancer patients Food and Agriculture Organization. Economic and Social Development Department. “The State of Food Insecurity in the World, 2008 : High food prices and food security - threats and opportunities”. Food and Agriculture Organization of the United Nations, 2008, p. 2. Boateng, A., Sriram, K., Meguid, M., & Crook, M. (2010). Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition, 26(2), 156-167.

  4. -1 person dies every second as a result of hunger1 4000 every hour 100 000 each day 36 million each year 58 % of all deaths -On average, 1 child dies every 5 seconds as a result of hunger2 700 every hour 16,000 each day 6 million each year 60% of all child deaths 1. United Nations Information Service. “Independent Expert On Effects Of Structural Adjustment, Special Reporter On Right To Food Present Reports: Commission Continues General Debate On Economic, Social And Cultural Rights”. United Nations March 29, 2004, p. 6. “Around 36 million people died from hunger directly or indirectly every year.”. 2. Food and Agriculture Organization Staff. “The State of Food Insecurity in the World, 2002: Food Insecurity : when People Live with Hunger and Fear Starvation”. Food and Agriculture Organization of the United Nations, 2002, p. 6. “6 million children under the age of five, die each year as a result of hunger.” http://www.fao.org/hunger/en/

  5. Starvation Studies • People released from concentration camps after WWII • Oral feeding resulted in fatal diarrhea, heart failure, and neurological complications (coma, convulsions) • Keys Study: effects of starvation and refeeding of healthy volunteers • mean weight loss 23% after starvation

  6. Keys’ Study • 36 young men between ages 20 and 33 served as volunteer subjects • Study began: November 1944 • Control data was obtained for 3 months in which subjects were provided 3,492 calories/day • 6 months of starvation followed (Feb.-July 1945) on a 1,570 calorie diet • Simulated the food available in western and central Europe under conditions of severe food shortages during WWII • 3 months controlled rehabilitation (ending in October 1945) http://www.stop-trans-fat.com/images/KeysAncel.jpg Franklin, J., Schiele, B., Brozek, J., & Keys, A. (1948). OBSERVATIONS ON HUMAN BEHAVIOR IN EXPERIMENTAL SEMISTARVATION AND REHABILITATION. Journal of Clinical Psychology, 4(1), 28-45. Retrieved from Academic Search Premier database.

  7. Keys’ Study: Physical Changes • Size and weight of subjects dramatically changed • 24% body weight lost • Face and body showed marked emaciation • Wasting of muscle and subcutaneous adipose tissues • Clothes/shoes too large • Edema in knees, ankles, and face • Nails grew more slowly • Hair fell out in large amounts • Shaving was done infrequently • Cuts bled less than normal and healed slower than normal • Physical ability to laugh, sneeze, and blush was reduced/absent • Muscle cramps/soreness • Pigmentation, thinning, and roughening of the skin • Extremities “went to sleep” • Tolerance to heat was greatly increased • Tolerance to cold was decreased • Vertigo, giddiness, and momentary blackouts when rising from lying or sitting positions • Polyuria and nocturnia Franklin, J., Schiele, B., Brozek, J., & Keys, A. (1948). OBSERVATIONS ON HUMAN BEHAVIOR IN EXPERIMENTAL SEMISTARVATION AND REHABILITATION. Journal of Clinical Psychology, 4(1), 28-45. Retrieved from Academic Search Premier database.

  8. Physical Changes cont. • Inability to focus, eye aches, and “spots” before their eyes • Increase in auditory acuity • Decrease in pulse rate and basal metabolism • Physical exertion made subjects tired • Overall energy expenditure maintained on a “high” level by scheduled physical activity • Walking to the mess hall, walking 20 miles/week • Fatigue, weakness, and hunger complaints • Moved slowly and cautiously • Climbed stairs one at a time • Coordination was affected • Tripped over curbstones and bumped into objects • Described increasing weakness, loss of ambition, narrowing of interests, depression, irritability, and loss of sexual desire http://curezone.com/upload/Members/new03/86_minn.jpg Franklin, J., Schiele, B., Brozek, J., & Keys, A. (1948). OBSERVATIONS ON HUMAN BEHAVIOR IN EXPERIMENTAL SEMISTARVATION AND REHABILITATION. Journal of Clinical Psychology, 4(1), 28-45. Retrieved from Academic Search Premier database.

  9. http://gunpowder.quaker.org/StarvationStudysummary.html

  10. Keys’ Study: Rehabilitation Phase • Purpose: measure the efficiency of several levels of refeeding in order to secure the most efficient, practical, and economic regimen for dietary rehab. • Little change in composition of diet, just amount • 2,448 calories during 1st 6 weeks • 3,257 calories 7-10th weeks • 3,518 calories 10-12th weeks • Recovery process slow; 20-50% of weight loss was gained back by end of the study • Edema increased in some men • New complaints: flatus, belching, distension, and stomach ache http://www.sph.umn.edu/epi/images/exam_retro.jpg Franklin, J., Schiele, B., Brozek, J., & Keys, A. (1948). OBSERVATIONS ON HUMAN BEHAVIOR IN EXPERIMENTAL SEMISTARVATION AND REHABILITATION. Journal of Clinical Psychology, 4(1), 28-45. Retrieved from Academic Search Premier database.

  11. Basics of Starvation • 2-3 hours after a meal, nutrients aren’t available for energy • Body shifts from relying on glucose to fat and glycogen • Glycogen stores depleted, body begins breakdown of protein from muscles • Ketosis • Death within ~3 weeks. Marshall, P., Howe, E., Feldman, Elesha. (Eds.). (2007). Nutrition Therapy and Pathophysiology: Belmont: Thomson Books/Cole. Rolfes, S., Whitney, E. (2008). Understanding Nutrition (11th ed.). Bemont: Thomson Wadsworth.

  12. From “Stuffed” To Starving: Physiology of Starvation • Body is supplied with glucose via food intake • Brain, RBC’s, and working muscles use up glucose • 2-3 hours: Nutrients no longer available for energy Rolfes, S., Whitney, E. (2008). Understanding Nutrition (11th ed.). Bemont: Thomson Wadsworth.

  13. Physiology of Starvation cont. • Several hours later: glucose used up • Blood glucose goes down, signaling lipolysis • Fat from cells broken down to acetyl coA for energy • Amino acids released from muscle • Yield pyruvate • Few days: protein provides 90% needed glucose, glycerol 10% • Acetyl CoA combines to make ketones • ~10 days: Ketone production increases until it’s meeting needs • As keto acids increase, blood pH drops • Ketosis- induces loss of appetite Rolfes, S., Whitney, E. (2008). Understanding Nutrition (11th ed.). Bemont: Thomson Wadsworth.

  14. Physiology of Starvation cont. • If food consumed: body shifts out of ketosis • Hormones of fasting decrease metabolism • Decreased energy output • Fat/lean tissue conserved • Lean organ tissues shrink & do less metabolic work Rolfes, S., Whitney, E. (2008). Understanding Nutrition (11th ed.). Bemont: Thomson Wadsworth. http://www.reallynatural.com/pictures/15_woman-eating-apple.jpg

  15. Signs & Symptoms of Starvation • Wasting • Decreased heart rate • Decreased respiratory rate • Decreased metabolism • Decreased body temperature • Impaired vision • Organ failure • Decreased Resistance to disease • Depression • Anxiety • Food-related dreams Rolfes, S., Whitney, E. (2008). Understanding Nutrition (11th ed.). Bemont: Thomson Wadsworth.

  16. Morbid Obesity with Profound Weight Loss http://watchmojo.com/blogs/images/darts_andy_fordham.jpg

  17. Homeless Adult http://www.weareca.org/index.php/en/era/WWI-1940s/okies.html

  18. Fasting Religious Person http://www.seekeronline.org/images/fasting.jpg

  19. Teenager With Anorexia Nervosa http://tashacleary.files.wordpress.com/2010/04/normal_00031778.jpg

  20. Malnourished Hospital Patient http://popcornlungclaim.com/images/old_man_hospital_bed.jpg

  21. Starving Child https://jspivey.wikispaces.com/Immigration+GC http://www.weightwatchers.com.my/home2/documents/starving_children.jpg

  22. Clinical Indicators of Starvation Clinical/History: • Height • Weight • BMI • Recent weight • Weight changes • Usual weight • Desirable BMI • Diet Hx • Poor appetite • BP • Edema • Muscle Wasting • Tricep Skin Fold • Mid Arm Muscle Circumference • Mid Arm Circumference Lab Work: • C-Reactive Protein • Albumin, Transthyretin • May be altered • Chol, TG • Decreased • Serum Fe • AlkPhos • Decreased • Glucose • Hgb + Hct • Urine Acetone Escott-Stump, S. (2007). Nutrition Related-Diagnostic Care (6th ed.). Belmont: Lippincott Williams & Wilkins.

  23. Medical Nutrition Therapy (MNT) for Starvation • Calculate the pt.’s goal weight and correct weight loss • Provide adequate micronutrients and macronutrients • Monitor fluid administration carefully • Avoid hazardous refeeding (hypophosphatemia, hypomagnesemia, hypokalemia, etc.) • Prevent sepsis, overfeeding, hyperglycemia, heart failure, or other organ failure by refeeding slowly • Correct complications (dehydration, electrolyte imbalances, infections, vitamin-mineral deficiencies, and other biochemical changes) • Allow normal growth of brain and prevent permanent IQ deficits in children • Provide Enteral/Parenteral feeding if needed and appropriate Escott-Stump, S. (2007). Nutrition Related-Diagnostic Care (6th ed.). Belmont: Lippincott Williams & Wilkins.

  24. MNT cont. Mild Protein-Calorie Malnutrition (PCM): • Provide sufficient calories and protein, gradually increasing to meet needs • Provide adequate CHO and caloric intake to spare protein and correct weight loss Severe PCM: • Start with i.v. glucose • Gradually add lactose-treated milk and soft, easily tolerated solids • Provide high-biologic value proteins with sufficient calories adequate to use nitrogen effectively • Avoid overfeeding • use 20-25kcal/kg, progressing gradually to 35-40kcal/kg • Add vitamin/mineral supplement (including thiamin!!) • Provide enteral feeding if needed • Start with continuous vs. intermittent/bolus feedings at a slow rate until serum electrolyte levels are stable Escott-Stump, S. (2007). Nutrition Related-Diagnostic Care (6th ed.). Belmont: Lippincott Williams & Wilkins.

  25. Basics of Refeeding Syndrome • Starvation • Reintroduction to CHO • Body shifts from ketones to CHO as energy source • Mineral balance is altered • Symptoms appear • Death

  26. Complications: Refeeding Syndrome (RFS) • Metabolic alterations that may occur during nutritional repletion of starved patients • Hypophosphatemia • Hypokalemia • Hypomagnesemia • Trace-element deficiency • Vitamin Deficiency

  27. Physiology of RFS • Hypophosphatemia: • Reintroduction to CHO • Insulin secretion increases • Glucose taken up rapidly into cells, taking phosphorus with it • Hypokalemia: • Reintroduction to CHO • Insulin secretion increases • Cellular uptake of K • Hyperglycemia • Reintroduction to CHO rapidly • Body doesn’t have time, energy, or metabolic activity to catabolize CHO as quickly, resulting in hyperglycemia Boateng, A., Sriram, K., Meguid, M., & Crook, M. (2010). Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition, 26(2), 156-167.

  28. Physiology of RFS cont. • Hypomagnesemia • Cellular uptake of magnesium after feeding • Trace Element Deficiency • Results from increased enzymatic activity (DNA/RNA metabolism and oxidative/reductive processes) • Zinc & selenium • Vitamin Deficiency • Rapid depletion after onset of refeeding due to their role in biochemical functions • Thiamin: • Already depleted stores are driven to a “nadir” • Wernicke’s Encephalopathy • Lactic Acidosis Boateng, A., Sriram, K., Meguid, M., & Crook, M. (2010). Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition, 26(2), 156-167.

  29. Boateng, A., Sriram, K., Meguid, M., & Crook, M. (2010). Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition, 26(2), 156-167. doi:10.1016/j.nut.2009.11.017.

  30. Pathogenesis of RFS Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R., Shenkin, A., Allison, S., et al. (2008). Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. European Journal of Clinical Nutrition, 62(6), 687-694. doi:10.1038/sj.ejcn.1602854.

  31. Effects of RFS • Hypophosphatemia: hemolysis, anemia, susceptibility to infections, inadequate oxygen delivery to tissues, generalized ischemia, diminished cellular growth/regulation, multiple organ failure (=death) • Hypomagnesemia: tremors, muscle twitching, cardiac arrhythmias and paralysis • Hypokalemia: cardiac abnormalities • Hyperglycemia: hyperosmosis, coma • Thiamin Deficiency: Wernicke’s Encephalopathy, lactic acidosis Boateng, A., Sriram, K., Meguid, M., & Crook, M. (2010). Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition, 26(2), 156-167. doi:10.1016/j.nut.2009.11.017.

  32. Clinical Indicators Clinical/History • Height • Weight • BMI • Desirable BMI • % Usual Weight • Hx of weight changes • Diet Hx • Edema • Tachycardia • Temperature • Rhabdomyolysis • Respiratory insufficiency Lab Work • Alkphos (low) • Mg++ (low) • K+ (low) • Glucose • Na+ • Chol, TG • Serum Fe • RBC dysfunction • Ca++ • BUN, Cr • pCO2 • pC2 Escott-Stump, S. (2007). Nutrition Related-Diagnostic Care (6th ed.). Belmont: Lippincott Williams & Wilkins.

  33. Medical Nutrition Therapy for Refeeding Syndrome • Gradually correct starvation • Advance calories while monitoring cardiac and respiratory side effects • Monitor organ function, fluid balance, and serum electrolytes daily during first week • Monitor for neurological, hematological, and metabolic complications Escott-Stump, S. (2007). Nutrition Related-Diagnostic Care (6th ed.). Belmont: Lippincott Williams & Wilkins.

  34. MNT cont. • Cautiously initiate feeding • 20 kcal/kg for the 1st 3 days, progressing slowly to 25 kcal/kg • Start protein slowly and increase gradually to protect and restore lean body mass • Restrict CHO intake at first to 150-200 g/d to prevent rapid insulin surge • CHO in TPN should be initiated at 2 mg/kg/min • Fat calories should make up the difference Escott-Stump, S. (2007). Nutrition Related-Diagnostic Care (6th ed.). Belmont: Lippincott Williams & Wilkins.

  35. MNT cont. • Maintain fluid balance • adjust when edema exists • fluids must be administered in moderation • Adjust for sodium and potassium intakes depending on lab values until normal • Na levels should be corrected to no more than 12 mM/L within 24 hours • Reach target goals for K = 3.5-5.0 mEq/L • Attn: anorexia nervosa pts. (K depleted by underlying condition) Escott-Stump, S. (2007). Nutrition Related-Diagnostic Care (6th ed.). Belmont: Lippincott Williams & Wilkins.

  36. MNT cont. • Supplement with Thiamin and other vitamins and minerals as needed. • Excesses are not required • provide Thiamin before/along with glucose administration • high doses up to 300 mg Escott-Stump, S. (2007). Nutrition Related-Diagnostic Care (6th ed.). Belmont: Lippincott Williams & Wilkins.

  37. MNT cont. • Correct vitamin/mineral deficiencies • P: Maintenance of serum P levels in normal range = 3.0-4.5 mg/dL • May resolve most of the symptoms • Milk supplementation in children who can handle oral intake • Mg: maintain normal levels =1.8-3.0 mg/dL • Must be supplemented if plasma levels <0.5 mg/dL due to cardiac arrhythmias, abdominal discomfort, neuromuscular abnormalities Escott-Stump, S. (2007). Nutrition Related-Diagnostic Care (6th ed.). Belmont: Lippincott Williams & Wilkins. Boateng, A., Sriram, K., Meguid, M., & Crook, M. (2010). Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition, 26(2), 156-167.

  38. Case Reports Chronic Alcoholism • 62YOM drank 750mL of wine daily for past 8 years • Went in for femoral surgery and 2nd post-op day, had thiamin deficiency and hypomagnesemia • Given 200mg/day thiamine supplements (300mg/day for next 3 days) and magnesium supplements 20mmol/day through i.v. • Hypotension resolved after 3h • 12h later, his neurological symptoms improved http://fycs.ifas.ufl.edu/news/images/alcohol.jpg Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R., Shenkin, A., Allison, S., et al. (2008). Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. European Journal of Clinical Nutrition, 62(6), 687-694.

  39. Case Reports cont. Hunger Striker • 27YO went on a hunger strike over 4mo • Refused all nourishment apart from coffee/tea. • Became weaker, more inactive, and apathetic while in hospital. • Treated with enteral/parenteral nutrition 1600kcal/day. • 3 days later, gained 5kg due to Na/fluid retention and developed RFS. • Pt. given 200 mg Thiamin, potassium phosphate, magnesium sulphate • After 3 days electrolytes/mineral concentrations were normal. http://mindorocybermovement.files.wordpress.com /2009/11/rome-hunger-strike.jpg Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R., Shenkin, A., Allison, S., et al. (2008). Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. European Journal of Clinical Nutrition, 62(6), 687-694.

  40. Case Reports cont. Kuwaiti Child • 13 month boy presented with acute severe malnutrition in the form of marasmic kwashiorkor • Admitted to hospital with Hx of watery diarrhea for past 2 weeks, decreased oral intake and lethargy • Miserable, mildly dehydrated, edematous, dry dark scaly skin rash and pitting edema • Weight was below 3rd percentile, BMI was 13.2kg/m2 • Abdomen distended with ascites • Started on i.v. fluids (0.45 saline + 5% dextrose); total caloric intake started at 70kcal/kg/day • Watery diarrhea continued with persistence of dehydration • Blood sugar increased within 2 days; hypophosphatemia, hypocalcemia, hypomagnesemia present • Increased to 100kcal/kg/day through following 7 days • High dose thiamin (200mg) given from day 4. • Condition improved. http://www.babyboybabygirlpictures.com/baby-picture-baby-boy-OurAngelishome-IvanoMak-photo.jpg Al Sharkawy, I., Ramadan, D., & El-Tantawy, A. (2010). ‘Refeeding Syndrome’ in a Kuwaiti Child: Clinical Diagnosis and Management. Medical Principles & Practice, 19(3), 240-243.

  41. Case Reports cont. Post-bariatric surgery for obesity • 30YOW had gastric bypass surgery for severe obesity (BMI 60.9 kg/m2) • Lost 35 kg in first 4mo • Felt unwell with vomiting after food and unable to ingest anything more than sips of liquid • Serum concentrations of phosphate and potassium were normal; folate, iron were low. • Began nasogastric feeding @ 1000kcal/day • 10h later, pulse rose and blood pressure fell, developed hypokalemia, hypophosphatemia, and lactic acidosis • Given thiamin i.v. 300 mg/day and enteral feed 1500kcal/day • Within 4h thiamin i.v., her heart failure improved and acidosis resolved. http://www.mandarinconsulting.com/acidrefluxblog /wp-content/uploads/2009/08/obesity_surgery1.jpg Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R., Shenkin, A., Allison, S., et al. (2008). Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. European Journal of Clinical Nutrition, 62(6), 687-694.

  42. Case Reports cont. Extreme Vegetarian • 54YOM became a vegetarian, eating only apples. • Next 3 years: lost ½ his body weight (BMI 13.8kg/m2) • K, Fe, B12, and albumin were all low • Started 1250ml/day of parenteral nutrition • 48h later, dependent edema, ascites, dyspnoea, and sinus tachycardia; serum K and Mg+ fell=RFS • Corrected by i.v. supplements http://www.buddhachannel.tv/portail/local/cache-vignettes/L300xH284/vegetarian-IQ-19cd8.jpg Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R., Shenkin, A., Allison, S., et al. (2008). Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. European Journal of Clinical Nutrition, 62(6), 687-694.

  43. Controversy • Is nutrition morally obligatory or optional? • Intentional killing? • Some acts are wrong or right independent of their consequences • Maintains life, but cannot restore unconsciousness • ADA Position: Individuals have the right to request or refuse nutrition/hydration as MNT (2008). Position of the American Dietetic Association: Ethical and Legal Issues in Nutrition, Hydration, and Feeding. Journal of the American Dietetic Association, 108(5), 873-882.

  44. RD’s Role • RD’s Role: • make recommendations on providing, withdrawing, or withholding nutrition in individual cases • serve as active members of institutional ethics committees • promotes the rights of the individual pt. • helps the health care team implement appropriate therapy • Consider: cultural, social, psychological, religious/spiritual needs (2008). Position of the American Dietetic Association: Ethical and Legal Issues in Nutrition, Hydration, and Feeding. Journal of the American Dietetic Association, 108(5), 873-882.

  45. Reimbursement Issues • Who pays for the underdeveloped countries that don’t have access or money for food? • Who pays for extended hospital stay due to refeeding syndrome? • Waste of money to treat patients who voluntarily starve themselves? • i.e. hunger striker

  46. Summary • Starvation is severe reduction in vitamin, mineral, and energy intake and the most extreme form of malnutrition • Refeeding Syndrome is the condition of metabolic disturbances, such as fluid and electrolyte imbalances, due to food intake after a prolonged period of starvation • When treating starvation/RFS, refeed slowly to prevent hypophosphatemia, hypomagnesimia, & hypokalemia. High doses of thiamin may be necessary before/during refeeding • Prevention: educate health professionals on the severity of RFS, educate the public about a proper diet to prevent severe starvation (in anorexia nervosa, hunger strikes, etc.)

  47. Feed A Starving Child • www.worldvision.org • Become a sponsor and provide a child with clean water, nutritious food, education, and health care

  48. Resources • Al Sharkawy, I., Ramadan, D., & El-Tantawy, A. (2010). ‘Refeeding Syndrome’ in a Kuwaiti Child: Clinical Diagnosis and Management. Medical Principles & Practice, 19(3), 240-243. • Boateng, A., Sriram, K., Meguid, M., & Crook, M. (2010). Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition, 26(2), 156-167. • Escott-Stump, S. (2007). Nutrition Related-Diagnostic Care (6th ed.). Belmont: Lippincott Williams & Wilkins. • Food and Agriculture Organization. Economic and Social Development Department. “The State of Food Insecurity in the World, 2008 : High food prices and food security - threats and opportunities”. Food and Agriculture Organization of the United Nations, 2008, p. 2. “FAO’s most recent estimates put the number of hungry people at 923 million in 2007, an increase of more than 80 million since the 1990–92 base period.”. • Franklin, J., Schiele, B., Brozek, J., & Keys, A. (1948). OBSERVATIONS ON HUMAN BEHAVIOR IN EXPERIMENTAL SEMISTARVATION AND REHABILITATION. Journal of Clinical Psychology, 4(1), 28-45. Retrieved from Academic Search Premier database. • Marshall, P., Howe, E., Feldman, Elesha. (Eds.). (2007). Nutrition Therapy and Pathophysiology: Belmont: Thomson Books/Cole. • Rolfes, S., Whitney, E. (2008). Understanding Nutrition (11th ed.). Bemont: Thomson Wadsworth. • Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R., Shenkin, A., Allison, S., et al. (2008). Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. European Journal of Clinical Nutrition, 62(6), 687-694.

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