The Effect of a Diet Based on Low Sodium and Slowly Absorbed Carbohydrates on the Incidence of Refeeding Syndrome in Patients With Head and Neck Cancer
The Effect of a Diet Based on Low Sodium and Slowly Absorbed Carbohydrates on the Incidence of Refeeding Syndrome in Patients With Head and Neck Cancer
The study is based on a master thesis which showed that 72% of patients with head and neck
 cancer admitted to a Danish hospital (Rigshospitalet, Copenhagen) developed refeeding
 syndrome after admission.

 Refeeding syndrome is characterized by a decrease in plasma phosphate levels, which develops
 after the reintroduction of an adequate food intake after a longer period of starvation or
 semi-starvation. This normally happens within 7 days after reintroduction of food.

 The aim of this study is to minimize the incidence of refeeding syndrome in this group of
 patients by reintroducing food slowly and by providing a diet low in sodium and high in
 slowly absorbed carbohydrates as a prevention diet (i.e. given before a potential decrease in
 plasma phosphate levels appear). Both patients that eat normally, patients with eating tubes
 and patients with central vein catheters are included in the study, but the data will be
 evaluated both together and separately.
A large weight loss as a result of a longer period (>30 days) of starvation or
 semi-starvation will result in a metabolic adaptation to the decreased food intake. To
 prevent the degradation of muscle mass into gluco- and ketogenic amino acids to be used for
 energy production, a shift from gluconeogenesis to lipolysis occurs. Lipids therefore become
 the primary energy fuel, and the body adapts to use ketone bodies instead of glucose. The
 reduction in glucose metabolism results in a decreased need for amino acids for use in
 gluconeogenesis. This means that less amino acids are needed for gluconeogenesis and
 therefore important muscle mass is preserved. At the same time as the lipid stores are
 degraded, an intracellular depletion of phosphate, potassium and magnesium occurs. The serum
 levels of these electrolytes stay within the normal range as long as the body is in the
 adaptive starvation state. A too quick reintroduction of food to the body will result in a
 major glucose-induced increase in insulin secretion that will stimulate the transport of
 glucose, phosphate, potassium and magnesium from plasma into the cells. Because the
 extracellular blood volume is much smaller than the intracellular, an influx of these
 electrolytes to the intracellular space will result in a quick and large decrease in the
 plasma levels. Likewise, an influx of glucose means that it again can enter the glucolysis,
 and the need for phosphate and the co-factor thiamine, for the production of ATP, will
 increase. The increased production of adenosine triphosphate (ATP) will activate membrane
 pumps and reestablish the membrane potential. This means that sodium will be transported from
 the large intracellular space to the small extracellular, with subsequent fluid retention and
 edema formation.

 Therefore a slowly introduced diet low in sodium and high in slowly absorbed carbohydrates
 might prevent the development of refeeding syndrome.
Inclusion Criteria:

 -  authoritative

 -  written consent

 -  suspected of or diagnosed with head and neck cancer

 -  Increased risk of Refeeding syndrome, defined by one of the below:

 -  A-score of 1 in the Nutritional Risk Screening 2002 (NRS 2002)

 -  high levels of alcohol consumption (men>168g alcohol/week corresponding to
 approximately 14 units, women>84g alcohol/week corresponding to approximately 7 units)

 -  anamnesis with prior radiation therapy

 -  Head and neck pain that require pain management or inhibits food intake

 -  the presence of problems with eating that are so serious that the food intake is
 inhibited

 Exclusion Criteria:

 -  minor or declared incapable of managing own affairs

 -  patients that are incapable of understanding and communicating in Danish

 -  patients with dementia

 -  if the patient is not diagnosed with head and neck cancer