October 23, 2022 • 37 mins
Monday 24th October 2022
Dietetics Digest
The views discussed on the podcast are the views of the guest alone and not of another organisation.
Is refeeding syndrome common? with Dr Kylie Matthews-Rensch APD
Dr Kylie Matthews-Rensch is an accredited practicing dietitian working at Royal Brisbane and Women's Hospital. Her research in refeeding syndrome has received national recognition and has impacted clinical practice guidelines across Queensland.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kylie Matthews (00:02):
refeeding syndrome really interested me
because as you mentioned before,there's not a great deal of
evidence, no one really knowswhat they're doing. It's all
it's very confusing. I sometimesI don't know where anyone's
pitch their numbers from I don'teven know where Australia has
picked their numbers from. We'vegot a conservative bunch of
clinicians. And then theguidelines aren't made up on
(00:25):
research. Most of them are basedon expert opinions. So if you've
got experts that are cautious,then of course, they're going to
recommend cautiousrecommendations. When I was a
student, the number of times Ihad to pay the doctor to tell
them that I thought a patientwas at risk of refeeding
syndrome was borderlineridiculous, like I can't believe
I used to harass the medics somuch, Dr. Kelly Matthews, she's
(00:49):
a dietitian. She's also aresearcher. And it all started
when she disagreed with theplacement supervisor so much
about if a patient had refeedingsyndrome and she decided to go
ahead and get a PhD in thetopic. Kelly is a dietitian
based in Queensland, Australia,who graduated from Griffith
University in 2014 and completedher PhD in refeeding syndrome in
(01:09):
2018. I don't know anyone whoknows more about refeeding
syndrome and Kaylee during thispodcast, we discuss her journey
and her thoughts as to whetherall dieticians should pursue
PhDs. This conversation islikely to challenge your current
practices around refeedingsyndrome and help you understand
more about this area. If you area dietitian who works with
patients who could be or are atrisk of refeeding syndrome. This
(01:32):
is a must listen podcast. Sowithout further ado, my name is
Aaron Boysen. This is thedietetics digest podcast. So
ensure you chew it thoroughly asthere's a lot to digest here.
Aaron Boysen (01:45):
Think you were first brought to my attention
from your presentation you didfor the dietitian network on
refeeding syndrome based uponwork you did in your masters and
PhD. I'm thrilled to have you onthe podcast today. I'd love to
get someone's background andunderstand why they originally
went into dietetics. Because Ithink that informs a lot about
their thought process and whothey become as a dietitian. So
(02:05):
what originally interested youinto becoming a dietitian, so I
never actually planned to be adietitian, I all through high
school, I thought I wanted to bea doctor. So I did my undergrad
in biomedical science. And Iactually flew down to Melbourne
to have my interview to get intomedicine. And on my flight home,
(02:25):
I decided I didn't want to doit. So I withdrew my
application. And for a couple ofyears, I bounced around ideas. I
did a year of psychology. Ithought about doing veterinary
science. And then all of asudden one day I woke up and
realised I love food. And I lovescience and why don't I put
(02:45):
those two together? So I went onand did my masters very next
year was dietetics, somethingyou were always exposed to did
you wake up that morning andthink I love food, I love
science and then have toresearch how you could use those
two interests. But it wasactually my friend Jenny from
high school, she was debatingher own career, and she was
(03:06):
tossing out all the differentAllied Health Professions. So
she was leaning towards socialwork. And then she's our
dietetics sounds really cool. Sodoes occupational therapy. And I
just think dietetics stuck in mybrain from that very random
conversation. So you went on todo your master's in dietetics.
And then you eventually you wenton to choose to do a PhD and
(03:28):
further research. Why did youchoose to do that pathway? Why
didn't you just go straight intowork and actually working with
people and food I never plannedto it's actually funny, I get a
yearly reminder on Facebook thatI posted that I would never do a
PhD when I was in the middle ofmy master's research.
Kylie Matthews (03:45):
I did my master's research because I
didn't like the other streamsthrough uni through the Master's
course, I think there was abusiness stream and there was a
community stream and I thought,Oh, no research would be really
nice. And then in our programme,we were offered a variety of
different topics. And someonesaid, you don't want to go with
Michelle Palmer unless you'regoing to really put in 100%. And
(04:05):
I was like I could totally putin 100% and refeeding syndrome
really interested me because asyou mentioned before, there's
not a great deal of evidence, noone really knows what they're
doing. So I thought it would bereally great to just go into
that and have a look.
Aaron Boysen (04:24):
Michelle was a hard worker. She was a hard
supervisor. And I can say thatbecause she went on to be my PhD
advisor and I love it a bit. Andshe knows I say this sort of
stuff. But she originally whileI was going through that
suggested that I would be goodfor a PhD candidate. And that
(04:44):
stuck with me and then it'sreally quite difficult to get
into the workforce here. Ialways knew I wanted to be a
hospital clinician. I think alot of students do. And then it
just seemed like a really goodoption and I could work one day
a week while I was doing my PhDat the hospital that Michelle
works at. So I got a nicebalance, having some clinical
(05:08):
work while doing my PhD.
Sounds like someone always betyou to do wondering that you
shouldn't go, Michelle, unlessyou're gonna work hard. And
you're just like, I can workright? I can do that. But you
telling me that you assume Idon't want to work hard. Against
this,
Kylie Matthews (05:22):
I see rid of my PhD actually ran my first full
marathon just to really shred myentire body. Just
Aaron Boysen (05:31):
and the PhD, what was the experience like doing a
PhD?
I think similar to most peoplethat go through a PhD the first
year, you work really hard. Andthen as soon as you get through
your candidate show you have alittle lull, my allow lasted a
while. So I would do work for afew hours every day, and then
really have to stop myself fromhaving an app and keep working.
(05:51):
And then you get to the lastyear of it, and you're like not,
I gotta punch it out. So Iactually started, I did it. The
opposite way to most peopleactually started working full
time in the last six months ofmy PhD. So I really had to work
extremely hard to get it overthe line and finish the writing
part of it. There were timeswhen it was hard to keep up the
motivation, I made sure that Iwent to conferences and that
(06:14):
sort of thing to really keepthat level of some motivation
going.
And for dietitians out there,working around the world and
things like that studentdieticians and younger
dietitians, so do you think ithelps you as a dietitian to have
the PhD background?
I think it is helpful if youlove research, and you want to
(06:38):
keep doing research. So my PhDhas opened a lot of doors for
me, I've been asked to presentinternationally, like at Aspen
last year, which was reallylovely. I've been able to act up
at work in the researchcoordinator roles and that sort
of thing. But I also work in adepartment that has a lot of
(06:59):
dieticians with PhDs. Andbecause we all want to do
research, we also really needthose people that just love to
do clinical work, becauseresearchers are always going to
want to do research, I love abit of a mix of clinical work
and research work. But I knownot all researchers are like
that. So I think it's importantto just focus on what you really
want to do. And don't just do aPhD because someone looks
(07:24):
impressive, because they've doneit.
I've actually really, to behonest, that's a really
interesting response. Because Ifeel like sometimes a lot of
people who from the PhDbackground are very encouraging.
And I don't know a little bitlike they, they really want
everyone to do PhDs and theythink it's for everybody,
however, but when I talk topeople on the ground, there's
loads of dieticians who areamazing clinicians, amazing for
(07:45):
patients really just fantasticpeople. But they really don't
enjoy the research side. And Ithink even some of them have
been pushed to do mastersbecause of pressures at work or
having a certain role. And thatbeing a requirement and just not
enjoying that side of the roleand actually just really
enjoying the patient work. Andthey sometimes feel a little bit
(08:08):
frustrated by the constantfeeling they need to do more
research, get morequalifications, and it feels a
bit. I don't know, it feels alittle bit uncomfortable for
themPhDs a long time. And if you're
not enjoying it, then life is soshort, is just look around with
COVID and everything. If you'renot doing something that you
aren't, there's no point I'vewatched people do their PhDs
that haven't really wanted to doit and they've come so close,
(08:30):
they've either dropped out orthey've come so close to
dropping out, they've had totake a lot of time off and then
really push themselves to finishit. And they're not going to do
research again after it's done.
Because they just it's taintednow. So I think it's Yeah, I
think it's important to reallythink about what you want out of
(08:52):
your career. Yeah, there's someamazing clinicians out there
that just don't want to borrowresearch and I have a lot of
respect for them that they'resticking to their guns and doing
what they love.
And they're fantastic in thatway. And I think, yeah, I think
we're gonna get betterclinicians and better dieticians
and happier dietitians if wejust let people work to their
(09:13):
skill set, instead of justmaking everyone fit in a in a
square hole. So what made you gointo refeeding syndrome? What
made you focus in on that areain particular dietetic practice,
so I remember when I was on myplacement for Masters, this was
after I'd done my researchproject, I was on my emplacement
and I was seeing a patient withmy supervisor, and I recommended
(09:38):
one sausages in a day to thispatient because she was
struggling to eat. I didn'tthink she was at risk of
refeeding syndrome. But mysupervisor did and I got a fair
amount of trouble forrecommending the surgeon daily.
And I found that reallyfrustrating because it's very
different now with Oralnutrition compared to when we
(10:01):
think of like the prisoners ofwar, who were suddenly given
something when they hadn't hadanything for a very long time.
Most people that come into ourhospitals here in Australia now,
they haven't been starved. Formonths or years, they've maybe
had two weeks of slightly poororal intake, and then someone's
realised and walk them tohospital if they haven't bought
(10:22):
themselves in. So I thought,because I was so frustrated, I
am a complainer, I will admitthat I complain to my fellow
students on placement. And er, Ijust realised refeeding syndrome
really needs a lot of researchdone in it. And I felt really
passionate that day, like I feltrange and
(10:44):
felt we did a PhD to prove herwrong.
Yeah, pretty much that andMichelle Obama loves it. And my
other primary advisor, she hatesit, I'm just really pushing them
with Sandra Capra. Because shenever wanted to look at
refeeding syndrome,it probably helped in the
development of the PhD and theresearch, if you have that sort
(11:05):
of back and forth betweendifferent individuals that are
there to support you.
Yeah, it was really wonderful,actually. Because I will admit,
when I started my PhD, I thoughtrefeeding syndrome was a lot
more common than I do now. So itwas nice to see that. Also,
because I am also stubborn, Iwill admit that I'm mentioning
(11:26):
all my faults to you todayaren't that changing my own mind
over that course was really niceas well. And I think having two
very different opinions in myadvisors was helpful for that
too.
Definitely. So just so we canget a little bit of a set the
scene, could you explain alittle bit about what is
(11:47):
refeeding syndrome? Or how wouldyou explain what refeeding
syndrome is.
So in simplest terms, I like tosay that refeeding syndrome
comes about because we have apatient that comes into
hospital, who is severelymalnourished, and their body is
in a state of catabolism. Whenwe start giving them nutrition,
(12:09):
any type of nutrition, oralenteral, or parenteral, the body
brief kicks back into what itshould be doing. And that means
because our body stores have ourelectrolytes our time and
everything is so low from beingseverely malnourished, those
levels plummet even further,because our bodies using them to
work through that food. So usingglucose in particular, which is
(12:31):
why people talk about monitoringhow much carbohydrate you're
giving these patients who are atrisk. So refeeding syndrome is I
like to always remind people,it's a combination of signs and
symptoms. It's not justhypophosphatemia, which a lot of
people will Bandy about. It'salso hypokalemia,
hypomagnesemia, FireMondeficiency and all the symptoms
(12:55):
that come along with that it canbe edoema, as well. And it
doesn't have to be all of thosetogether.
Is it easy to diagnose refeedingsyndrome? Would you be able to
see it on someone? Or do youjust make a sort of educated
guess based on the symptoms?
They're presenting with acollection of symptoms? You've
just started feeding after aperiod of starvation? Is that
how you deduce if it's refeedingsyndrome or not? Or is there
anything you can say for sure?
(13:18):
Is refeeding syndrome? Or is itjust really just an educated
guess a set of signs andsymptoms?
In my mind, it's an educatedguess there's no consensus on
definitions anywhere. When Italked to doctors in the
hospital, they just named thethree electrolytes and they say
if it's low, that's refeedingsyndrome. And I really do
disagree with that train ofthought, I think that sometimes
(13:42):
your electrolytes are going todrop. And because we'll never
get through ethics, you're nevergoing to know how if they'll
like drop and naturally liftback up as nutrition increases.
But I think it's a natural partof restarting nutrition, that
doesn't mean that you're goingto the full blown refeeding
syndrome. When I did my, I did acase study. For my PhD, I looked
(14:07):
back at the case histories ofpatients that have died in
Queensland with refeedingsyndrome listed on their death
certificate. And we only foundfive across 20 years. And when I
read through the case notes,there was only one of those
patients that I actually waslike, Oh my God, that person
actually did die with refeedingsyndrome. They had a lot of
(14:28):
other issues going on as well.
So it's hard to say whetherrefeeding syndrome with the
primary cause but yeah, that onewas really obvious to me,
whereas the others, I was justlike, I don't think this is it
at all. And I got reallyexcited. It sounds bad, but I
got really excited when I wasreading that case. Because like
that, that is what I've beenlooking for. And I don't see it
(14:49):
and I obviously feel reallyhorrible for that patient and
the patient's family that Iwould get excitement out of
reading that case but is so rarein a hospital system that has so
much support that can do dailybloods that can give
supplementation to patientseasily and that sort of thing.
(15:12):
What do you think about theterm? I've heard it described as
biochemical refeeding syndrome?
Is that even a thing? Or is thatjust made up being that I've
heard that term bandied aroundquite a bit for disturbances and
electrolytes and just calling itbiochemical refeeding? syndrome?
Yeah,yeah, I look, I don't mind the
term, I just find that mostpeople just hear the refeeding
syndrome part and just roll withit. So I'm always very cautious
(15:33):
of using too many times for one,one issue. So because, you know,
we've got refeeding,hypervelocity. Sorry, refeeding,
hyperphosphatemia, and thenwe've got refeeding syndrome and
biochemical refeeding syndrome.
And we've got general refeeding,like as in refeeding, our
patients, but some people whenthey see refeeding, they think
(15:55):
it's refeeding syndrome. And itjust gets very messy. I think.
So. But I do agree with thepremise of the biochemical
refeeding.
And, obviously, based on whatyou're saying, is very different
than a lot of the guidancearound the world. I'm quite
familiar with nice guidance, andwe've got other guidance for
different conditions such aseating disorders, where do you
(16:16):
think this this sort of cautioncomes from? Well, why are we so
cautious? In such a way we knowmalnutrition is probably way
more prevalent than refeedingsyndrome? Why are we so cautious
when we're refilling ourpatients? Where does that
caution come from? Do you think?
I think, for one, no one wantsto be the dietician that killed
(16:37):
someone with refeeding, becausethey let them go into refeeding
syndrome. The second is that alot of the cases, I think that
people will refer back to casesthat weren't managed well, and
they weren't managed well,because we didn't have the
research to show us what to do.
So there were the two cases inthe very early 80s, with the
(16:59):
parenteral nutrition andeveryone references those. But
the latest, the RCT that wasrecently published in November
shows us that no, we don't needto be that scared of parenteral
nutrition provided we are givingsupplementation and that sort of
thing. And when I talk aboutrefeeding syndrome, and I'm
explaining how bad it can be topeople that haven't heard of it
(17:21):
before, I always refer back tothe prisoners of war, because
they're actual, those wereactual cases, like when you're
reading the literature, you'relike, Oh, yes, that is legit.
That prisoner of war was in aconcentration camp for years,
and then they were let out andsomeone very kindly fed them.
And that was it. And I think asa profession as well, we are
(17:41):
cautious bunch, like, we'rebasically all type A, we like to
follow rules, we've got aconservative bunch of
clinicians, and then theguidelines aren't made up on
research. Most of them are basedon expert opinion. So if you've
got experts that are cautious,then of course, they're going to
recommend cautiousrecommendations.
(18:05):
Definitely, I remember I had astudent on placement with me,
and we're going through apatient and she was quite
concerned about this patient wasa risk of refeeding syndrome.
And our trust guidance werebased, similar to nice guidance,
just so everyone can get anexample that were going through
the guidelines. And she feltthat because the patient was at
risk of refeeding syndrome, shethought maybe I should be even
(18:26):
more cautious than Nice.
However, thanks to yourpresentation, I was able to
explain a little bit around kindof like the evidence and things
like that she was able tounderstand, maybe I shouldn't be
more cautious than Nice.
Yeah, long. Stories like thatmake me really sad for our
patients, because you know thatif they're underpaid, they're
generally in hospital for a lotlonger, and we're exacerbating
(18:48):
their malnutrition. So, alwaystrying to remind people of that,
like, you're probably doing moreharm than good. By sitting back
and panicking about that we cangenerally fix so if the
electrolytes start dropping, wecan give something
definitely. And that study yourreference previously, I will
have that study in the shownotes and it's a study it's a
(19:11):
randomised control trial,correct me if I'm wrong, a
randomised control trial,looking at parenteral nutrition,
high and low feeding. I'm notsure how they defined it. And
looking at markers for refeedingsyndrome. Yes, that's the one.
Yeah, so I'll share that in theshow notes. So that brings us on
to guidelines and the variationin guidelines around the world.
However, there's one variationthat sort of brings my attention
(19:31):
every single time and I'vealways wondered about it, is the
variation between nice andmarzipan. And they seem to move
around back and forth playingwith each other on two opposite
ends of the spectrum. They moveback and forth all the time. And
I know that I think they'reworking on another revision of
marzipan coming up in the summerthis year. They're probably
sitting around discussing at themoment they're probably wanting
(19:53):
to move in another direction ormove back and forth. Why is
this? Why is they're just payinga little bit of almost playing
like a game with each otheruntil the opposite ends of the
spectrum, why are they doingthis? From your assessment?
I wish I knew. So I sometimes Ijust I don't understand why
patients with eating disorderscan generally be fed higher
(20:13):
calories when they've probablybeen starving for longer than
the nice criteria, which islittle or no intake for five
days. Yeah, it still blows mymind, we can double the intake
for these patients that havebeen starving themselves for
potentially years. But we haveto be really cautious with our
88 year old who hasn't eatenproperly for five days. So who's
(20:36):
had a low BMI for her entirelife? And it's not because she
stabbed herself. It's justbecause she's a tiny little
lady. So yeah, it's frustrating.
And I get why clinicians willthen default to the more
conservative option. So if theysay this, these guidelines say
this, and these guidelines saythis, and the second set of
(20:56):
guidelines say something a bitmore conservative, they seem
safer. So why not default tofive calories per day to start
feeding? Yeah,I think probably also nice makes
it a little bit more confusingwith little to no intake, what
does that actually mean?
Or more expert opinion. It isfunny, though, because I read
(21:22):
them. And I think our AustralianNew Zealand guidelines are
quite, they're a bit moreassertive than both of marzipan
and nice. So we actually startfor our patients with medically
compromised eating sores, weactually start feeds it just
over 6000 kilojoules per day. Sono matter what their BMI is, and
(21:44):
that sort of thing, and thenadvanced up to 12,000
kilojoules. So yeah, there isvariation everywhere.
6000 kilojoules and calories isthat.
So that's a sorry, I can't I goback and forth. And it's very
confusing. So about 1500calories per day. 100. Yeah, and
(22:05):
then the new aspirinrecommendations that came out.
They also they're quite similarto nice and they're starting
rate. So they say start between10 and 20 calories per kilo. But
then they say you can advance upa bit faster as you can go up
33% towards go right every dayor two. It's all it's very
confusing. I sometimes I don'tknow where anyone's pitch their
(22:28):
numbers from I don't even knowwhere Australia has picked their
numbers from I just know that Ilike it, because it's a little
bit more assertive than some ofthe other countries. But yeah,
they're all they are alldifferent, which is
disappointing, because you'dlike to think that we can all
practice the same way.
Especially in Australia, Europe,UK, Australia. So did I say
(22:48):
America was the first time inAustralia? I can't remember.
Sorry. I remember. I was first adietitian and I was handing over
my plan to one of the doctors Imentioned refeeding syndrome and
Arendt mentioned aboutsupplementing time in and stuff
like that. And he says to me,refeeding syndrome doesn't
exist. Do you think that hasany? Where do you think that
comes from? I've heard it from afew other sort of doctors,
(23:10):
usually doctors, and usuallyprobably even more senior
doctors say it occasionally.
Where do you think that comesfrom? And is there we know
they're wrong? Obviously,because we're discussing
refeeding syndrome. And however,where do you think that probably
comes from? Do you think itcould come from a lot of
clinicians being overly cautiousand being warned about it about
100 times and never seeing itin better bias? I think for a
lot of these doctors have beenvery lucky that either their
(23:33):
dieticians have been on top ofit. And if the patients on feeds
have started quite slowly andbuilt up, or they're lucky if
the patient's on oral nutritionand just gradually started
eating more on their own withoutsometimes you do see patients
that go from zero to 100 whenthey're on oral nutrition, but I
do in my opinion, it's quiterare, not as rare as some of the
(23:55):
stuff we're talking about. But Ialso think there is an aspect of
the boy that cried wolf, when Iwas a student, the number of
times I had to pay the doctor totell them that I thought a
patient was at risk of refeedingsyndrome was borderline
ridiculous. Like, I can'tbelieve I used to harass the
medics so much. Whereas now Iwould barely page so generally,
(24:22):
we're actually very lucky in thehealth service that I'm in and
our doctors are very aware ofrefeeding syndrome. Our patients
that are have eating disordersor automatically started on
supplementation. And I thinkit's I think it's a good thing
that they're obviously I thinkit's a good thing that they're
very aware of it so I don't haveto page them but it's also come
(24:42):
with experience that noteveryone is at risk just because
they meet that nice criteriathat I've Yeah, I think it does
come with clinical practice. Itcomes from having good supervise
arises it comes with thinkingreally objectively about where
these where the criteria haveactually come from and what
(25:05):
supporting Yeah, I think for thepeople that say it's not real, I
always argue, tell me, how comethe prisoners of war dropped
dead? But there is also anaspect of, yes, we do, yell and
shout about it a lot, whichwould get on their nerves. And I
don't blame them to some degree.
(25:27):
Definitely. So you mentioned alittle bit around refeeding
syndrome was definitely commoncommon in prisoners of war when
they started eating, and it waswell done. It was documented and
it was seen, but we don't see itas much today in our modern
medical systems with themonitoring and the
supplementation and things likethat. What do you think makes
the biggest impact from thosetwo different settings? Is there
(25:49):
anything that makes the biggestimpact? Or what would you say
makes the biggest impact whentrying to manage refeeding
syndrome?
So primarily, biggest impact is,before we even get into the
hospital system, there's asupport most people like they
have family or they have friendschecking in on them, they have a
neighbour that's aware thatthere's that there could be
something wrong and that sort ofthing. So I find that don't see
(26:12):
that many patients come throughthe health care service that
have been neglected and staffedfor months and months on end,
which is what our prisons havewhat went through in the
hospital, I actually think itcomes down to the fact that we
can get blood results within acouple of hours. And we can give
some electrolyte supplementationvery quickly. I think that's
(26:36):
our, like our biggest tool inour toolbox like diamond
supplementation, multivitaminsupplementation is important.
But I really do think it'smonitoring what's actually
happening in this person's bodyand being able to fix it
quickly.
So that's the monitoring theelectrolytes and those sorts of
things actually made the biggestdifference over all the other
(26:59):
things. Yeah.
Yeah, we looked at in our healthservice, once I finished my PhD,
we changed our refeedingsyndrome guidelines quite
drastically. And it didn't makea difference if we fared really
fast. And I think that come it'sso it's not, I don't think it
comes down to what we're whatNutrition has provided. I think
(27:21):
it's all the other things thatcome into it. Yeah, I always
preach that. If you thinksomeone's at risk, make sure
there's daily blobs, likeminimum for four days, and most
of the guidelines, say 10 to 14,which I think is difficult in
clinical practice. Because, youknow, most of our patients,
unless they're quite sick,aren't staying in the healthcare
(27:42):
service for that. aren't stayingin hospital for that long
anymore. We're trying to reducelength of stay. So I think being
realistic about what you canmanage is important, too. So
yeah, I do think it's all thosemedical, like, we need our
medics to do blood tests. Yeah,definitely. Yeah. So
carbohydrate is one of thebiggest triggers of refeeding
syndrome, is there any benefitto manipulating macronutrient
(28:06):
composition. So for example,giving the patient a higher Fat
Feed instead of a highercarbohydrate feed. Yeah,
the research is quite limited init in this sort of field. For
me, I always say as long as it'sbalanced, so as long as you're
not giving a patient, straight,glucose drinks all day, every
day when they're at risk, thenyou shouldn't have a problem.
(28:29):
There is definitely discussionin the eating disorder
literature, that limitingcarbohydrate to 40% is
beneficial, especially when yourintro during enteral feeds. We
did our study a few years agoand carbohydrates 50%. And we
had no cases of refeedingsyndrome. So I think as long as
(28:51):
there's a little bit of commonsense there, like as long as
it's not 100% carbohydrate load,and there's a bit of other stuff
going on in there, then I thinkit's fine. And is there any
difference between parenteraland enteral nutrition? I think
my brain thinks that there'sless risk of say enteral
nutrition compared toparenteral.
When we when I did my systematicreview from my PhD, we actually
(29:14):
found that the patientsreceiving enteral nutrition were
getting most of the symptomsthat sent a lot of the papers
that we looked at because thedefinitions for refeeding
syndrome are all over the shop,some of them were counting
things like diarrhoea and thatsort of thing, which when you're
using enteral nutrition, I thinkis sometimes inevitable. So I do
(29:38):
take that with a grain of salt.
I think parenteral nutrition canbe more I want to say harsh or
are patients at risk ofrefeeding syndrome. So because
it's it's straight in ratherthan going through the digestive
system, but the literaturedoesn't support my thinking on
that. So I wouldn't take All ofwhat I just said with a grain of
(30:00):
salt. Yeah, unfortunately, Idon't think there's a clear cut
answer on that one hour. And I'msorry. So the literature is so
all over the shop too, becauseyou know, a lot of these studies
are done in ICU whereeverything's protocolized, which
is very different to being on ageneral ward
is very different than being ona general ward. So yeah,
definitely, there's aunderstanding the context of
where you work in stuff, but itmight be an area for research
(30:23):
that obviously, as we'rediscussing all these gaps, I
hope everyone's thinking there'san opportunity there, or there's
an opportunity there and justalways be looking for that
opportunity thing.
Yes, yeah, I always remindpeople that have a bit of a
competitive nature withresearch. There's always so many
topics. So if someone's nabbedsomething, there's always
something else, especially inrefeeding syndrome,
(30:45):
exactly. From Carly'sexperience, I dare a dietetic
student or a dietitian to doresearch in some of the areas
that we'll discuss today, I dareyou. And we'll see if they do
it, because I want to get morepeople doing doing research to
just prove people wrong and setthe record straight. I think
that's definitely a competitivenature. So I think a lot of the
(31:06):
information discussed here foreven when I was a new dietitian
will be quite sort of earthshattering. Or what do I do now?
How do I actually do this?
Should I just feed everyoneloads of calories? Am I just
purposely not feeding them? Howdoes this actually translate
into practice? So when we gointo managing Reif possible
refeeding syndrome and ourpatients, how does that actually
translate? What would you whatdo you think is a sensible way
(31:26):
to approach practice?
sensible ways, being sure ifyour medics, so being sure that
they will supplement what'sneeded, they will do blood
tests, there'll be all themonitoring that's recommended.
So I think that sets the systemup and allows the dietician to
(31:48):
be a bit more, I want to sayassertive or aggressive. When
because the research is so poor,the study that we've done on our
service is one of the moreassertive types that are out
there. And it's not withpatients with eating disorders,
it's just our patient that onthe general ward, and we start
at 50%. And if there's only mildor there's no electrolyte
(32:12):
decreases, we actually go togold within 24 hours. And we
didn't have any adverseoutcomes. With that, I will
highlight that this was a threemonth audit. And we I think it
was about, I want to say 90patients in the end, so it's not
huge. But we've had goodoutcomes from that. So I think
it's, I'm not saying go in anddo that exactly. Because that
(32:35):
would just be adding my own gotmy Kiley guidelines out there
with the 50,000 other guidelinesthat have different numbers and
recommendations. But findingsomething that you're
comfortable with. So when wewere updating the refeeding
syndrome guidelines for ourhealth service as a department,
we got together and we alltalked about what we all
(32:55):
individually do, because none ofus were following the
recommendations because we allfelt that was so conservative.
And then once we've been tolddid a poll on what everyone is
doing, really kicks that around,we looked at what the evidence
shows compared to what everyoneelse was doing. And that's how
we came up with that cut what wewere comfortable with as a
service providing to ourpatients. So you can't do it
(33:19):
alone. I don't think so. If yougo rogue, someone's gonna read
the chat entry and wonder whyyou're starting and doing
something so assertive comparedto the rest of the service. So I
think it's important to havethose discussions as a team.
Definitely, I think, yeah, ateam approach and then building
the guidelines together, andbasically what you all feel
comfortable with. And just sothere's uniformity. So when
(33:41):
you're actually going whendifferent dieticians cover, or
different dietitians coverdifferent services, there's not
confusion or there's not. Yeah,it just helps with continuity
and things like that, also, Ithink probably translate it is
this is a massive area forresearch a massive area of
development. And the only way wecan alarm has to say, improve
(34:02):
the guidelines. And the evidencebehind them is by create getting
more evidence getting more evenaudits or actual practice of
what dietitians are doing inpractice and how it impacts
patients. So that's obviously anarea where we can collect data
and and I know Allison from theUK is very bullish on this and
patients at risk of refeedingsyndrome. She's particularly
(34:23):
bullish, and she keeps onsaying, Let's collect evidence,
keep on collecting evidence, themore we have, the better and
obviously you might think Idon't have the capacity to do X
type of study or the dream studyor whatever. But I think with
everything, it's just collectingas much evidence as possible
becauseI love Allison, I've talked to
her about this before, like, Ireally want to do an RCT but in
(34:45):
our service here, it's just it'simpossible and she's always
turned around and said it's notimpossible. There's a study
published you can totally do it.
So like to tell people that likeDon't ever think it's impossible
because someone has just doneit. And it needs to be
replicated. And the poor thingshave so many problems with their
(35:08):
study as well, just with delaysand that sort of thing,
definitely need some more workout there as well.
Definitely, I'm so grateful thatyou obviously did your PhD in
this topic. And hopefully, it'sbeen really informative to those
who are dieticians and studentdieticians out there to really
understand a little bit moreabout refeeding syndrome. And I
think that's the push goingforward. I think, as we can see
(35:29):
from I mentioned the beginningof the pench handbook, from
quite prescriptive guidelines todisplaying the evidence and you
pick for yourself and lookingactually reading the studies.
And that was very muchencouraged when we went through
collating requirements, which isa story for another day, around
evidence and gaps in evidence.
But definitely the opening sortof accident. To be honest, a lot
(35:50):
of dietitians that I talked toat the time, were quite
frustrated with actually theywere like, how is this clear to
read? How do we tell people whatto do? This is going to be
really problematic for students.
And it's not prescriptive, andit's quite difficult to
understand. But I think movingmore towards that actually
understanding what's behind theguidelines, actually helps
(36:12):
people to be more informedpractitioners. I think it's so
important to understand what isactually behind certain
guidelines. And I think whatyour talk did originally, and
what some of this podcast hasdone is help inform me
personally, around what'sactually behind the refeeding
guidelines. So when I'mimplementing it, or actually
using the guidelines, Iunderstand the evidence and how
(36:35):
much evidence is behind it.
Thanks. Yeah, look, it was alearning curve for me too. I
remember reading our level Clevel D evidence. Okay. So that
means it's pretty rubbish. Butthen when you dig down deep into
it, you're like, Oh, okay.
There's really no studies. It'sit is expert opinions. Yeah, I
do think it's important. We dojournal club at work quite
regularly, and we rip apartguidelines all the time. It's
fun. Just rip them apart,looking at what's supporting
(36:57):
them. Yeah. And I highlyrecommend so.
I mean, yeah, it's a really goodpractice to do rip apart
guidelines and look at what'sactually behind them. I think
it's it just Yeah, it is reallyimportant. I think that's vital.
But thank you so much for comingon the podcast.
Kylie Matthews (37:13):
Thank you for having me on. It was fun.
refeeding syndrome really interested me
because as you mentioned before,there's not a great deal of
evidence, no one really knowswhat they're doing. It's all
it's very confusing. I sometimesI don't know where anyone's
pitch their numbers from I don'teven know where Australia has
picked their numbers from. We'vegot a conservative bunch of
clinicians. And then theguidelines aren't made up on
(00:25):
research. Most of them are basedon expert opinions. So if you've
got experts that are cautious,then of course, they're going to
recommend cautiousrecommendations. When I was a
student, the number of times Ihad to pay the doctor to tell
them that I thought a patientwas at risk of refeeding
syndrome was borderlineridiculous, like I can't believe
I used to harass the medics somuch, Dr. Kelly Matthews, she's
(00:49):
a dietitian. She's also aresearcher. And it all started
when she disagreed with theplacement supervisor so much
about if a patient had refeedingsyndrome and she decided to go
ahead and get a PhD in thetopic. Kelly is a dietitian
based in Queensland, Australia,who graduated from Griffith
University in 2014 and completedher PhD in refeeding syndrome in
(01:09):
2018. I don't know anyone whoknows more about refeeding
syndrome and Kaylee during thispodcast, we discuss her journey
and her thoughts as to whetherall dieticians should pursue
PhDs. This conversation islikely to challenge your current
practices around refeedingsyndrome and help you understand
more about this area. If you area dietitian who works with
patients who could be or are atrisk of refeeding syndrome. This
(01:32):
is a must listen podcast. Sowithout further ado, my name is
Aaron Boysen. This is thedietetics digest podcast. So
ensure you chew it thoroughly asthere's a lot to digest here.
Aaron Boysen (01:45):
Think you were first brought to my attention
from your presentation you didfor the dietitian network on
refeeding syndrome based uponwork you did in your masters and
PhD. I'm thrilled to have you onthe podcast today. I'd love to
get someone's background andunderstand why they originally
went into dietetics. Because Ithink that informs a lot about
their thought process and whothey become as a dietitian. So
(02:05):
what originally interested youinto becoming a dietitian, so I
never actually planned to be adietitian, I all through high
school, I thought I wanted to bea doctor. So I did my undergrad
in biomedical science. And Iactually flew down to Melbourne
to have my interview to get intomedicine. And on my flight home,
(02:25):
I decided I didn't want to doit. So I withdrew my
application. And for a couple ofyears, I bounced around ideas. I
did a year of psychology. Ithought about doing veterinary
science. And then all of asudden one day I woke up and
realised I love food. And I lovescience and why don't I put
(02:45):
those two together? So I went onand did my masters very next
year was dietetics, somethingyou were always exposed to did
you wake up that morning andthink I love food, I love
science and then have toresearch how you could use those
two interests. But it wasactually my friend Jenny from
high school, she was debatingher own career, and she was
(03:06):
tossing out all the differentAllied Health Professions. So
she was leaning towards socialwork. And then she's our
dietetics sounds really cool. Sodoes occupational therapy. And I
just think dietetics stuck in mybrain from that very random
conversation. So you went on todo your master's in dietetics.
And then you eventually you wenton to choose to do a PhD and
(03:28):
further research. Why did youchoose to do that pathway? Why
didn't you just go straight intowork and actually working with
people and food I never plannedto it's actually funny, I get a
yearly reminder on Facebook thatI posted that I would never do a
PhD when I was in the middle ofmy master's research.
Kylie Matthews (03:45):
I did my master's research because I
didn't like the other streamsthrough uni through the Master's
course, I think there was abusiness stream and there was a
community stream and I thought,Oh, no research would be really
nice. And then in our programme,we were offered a variety of
different topics. And someonesaid, you don't want to go with
Michelle Palmer unless you'regoing to really put in 100%. And
(04:05):
I was like I could totally putin 100% and refeeding syndrome
really interested me because asyou mentioned before, there's
not a great deal of evidence, noone really knows what they're
doing. So I thought it would bereally great to just go into
that and have a look.
Aaron Boysen (04:24):
Michelle was a hard worker. She was a hard
supervisor. And I can say thatbecause she went on to be my PhD
advisor and I love it a bit. Andshe knows I say this sort of
stuff. But she originally whileI was going through that
suggested that I would be goodfor a PhD candidate. And that
(04:44):
stuck with me and then it'sreally quite difficult to get
into the workforce here. Ialways knew I wanted to be a
hospital clinician. I think alot of students do. And then it
just seemed like a really goodoption and I could work one day
a week while I was doing my PhDat the hospital that Michelle
works at. So I got a nicebalance, having some clinical
(05:08):
work while doing my PhD.
Sounds like someone always betyou to do wondering that you
shouldn't go, Michelle, unlessyou're gonna work hard. And
you're just like, I can workright? I can do that. But you
telling me that you assume Idon't want to work hard. Against
this,
Kylie Matthews (05:22):
I see rid of my PhD actually ran my first full
marathon just to really shred myentire body. Just
Aaron Boysen (05:31):
and the PhD, what was the experience like doing a
PhD?
I think similar to most peoplethat go through a PhD the first
year, you work really hard. Andthen as soon as you get through
your candidate show you have alittle lull, my allow lasted a
while. So I would do work for afew hours every day, and then
really have to stop myself fromhaving an app and keep working.
(05:51):
And then you get to the lastyear of it, and you're like not,
I gotta punch it out. So Iactually started, I did it. The
opposite way to most peopleactually started working full
time in the last six months ofmy PhD. So I really had to work
extremely hard to get it overthe line and finish the writing
part of it. There were timeswhen it was hard to keep up the
motivation, I made sure that Iwent to conferences and that
(06:14):
sort of thing to really keepthat level of some motivation
going.
And for dietitians out there,working around the world and
things like that studentdieticians and younger
dietitians, so do you think ithelps you as a dietitian to have
the PhD background?
I think it is helpful if youlove research, and you want to
(06:38):
keep doing research. So my PhDhas opened a lot of doors for
me, I've been asked to presentinternationally, like at Aspen
last year, which was reallylovely. I've been able to act up
at work in the researchcoordinator roles and that sort
of thing. But I also work in adepartment that has a lot of
(06:59):
dieticians with PhDs. Andbecause we all want to do
research, we also really needthose people that just love to
do clinical work, becauseresearchers are always going to
want to do research, I love abit of a mix of clinical work
and research work. But I knownot all researchers are like
that. So I think it's importantto just focus on what you really
want to do. And don't just do aPhD because someone looks
(07:24):
impressive, because they've doneit.
I've actually really, to behonest, that's a really
interesting response. Because Ifeel like sometimes a lot of
people who from the PhDbackground are very encouraging.
And I don't know a little bitlike they, they really want
everyone to do PhDs and theythink it's for everybody,
however, but when I talk topeople on the ground, there's
loads of dieticians who areamazing clinicians, amazing for
(07:45):
patients really just fantasticpeople. But they really don't
enjoy the research side. And Ithink even some of them have
been pushed to do mastersbecause of pressures at work or
having a certain role. And thatbeing a requirement and just not
enjoying that side of the roleand actually just really
enjoying the patient work. Andthey sometimes feel a little bit
(08:08):
frustrated by the constantfeeling they need to do more
research, get morequalifications, and it feels a
bit. I don't know, it feels alittle bit uncomfortable for
themPhDs a long time. And if you're
not enjoying it, then life is soshort, is just look around with
COVID and everything. If you'renot doing something that you
aren't, there's no point I'vewatched people do their PhDs
that haven't really wanted to doit and they've come so close,
(08:30):
they've either dropped out orthey've come so close to
dropping out, they've had totake a lot of time off and then
really push themselves to finishit. And they're not going to do
research again after it's done.
Because they just it's taintednow. So I think it's Yeah, I
think it's important to reallythink about what you want out of
(08:52):
your career. Yeah, there's someamazing clinicians out there
that just don't want to borrowresearch and I have a lot of
respect for them that they'resticking to their guns and doing
what they love.
And they're fantastic in thatway. And I think, yeah, I think
we're gonna get betterclinicians and better dieticians
and happier dietitians if wejust let people work to their
(09:13):
skill set, instead of justmaking everyone fit in a in a
square hole. So what made you gointo refeeding syndrome? What
made you focus in on that areain particular dietetic practice,
so I remember when I was on myplacement for Masters, this was
after I'd done my researchproject, I was on my emplacement
and I was seeing a patient withmy supervisor, and I recommended
(09:38):
one sausages in a day to thispatient because she was
struggling to eat. I didn'tthink she was at risk of
refeeding syndrome. But mysupervisor did and I got a fair
amount of trouble forrecommending the surgeon daily.
And I found that reallyfrustrating because it's very
different now with Oralnutrition compared to when we
(10:01):
think of like the prisoners ofwar, who were suddenly given
something when they hadn't hadanything for a very long time.
Most people that come into ourhospitals here in Australia now,
they haven't been starved. Formonths or years, they've maybe
had two weeks of slightly poororal intake, and then someone's
realised and walk them tohospital if they haven't bought
(10:22):
themselves in. So I thought,because I was so frustrated, I
am a complainer, I will admitthat I complain to my fellow
students on placement. And er, Ijust realised refeeding syndrome
really needs a lot of researchdone in it. And I felt really
passionate that day, like I feltrange and
(10:44):
felt we did a PhD to prove herwrong.
Yeah, pretty much that andMichelle Obama loves it. And my
other primary advisor, she hatesit, I'm just really pushing them
with Sandra Capra. Because shenever wanted to look at
refeeding syndrome,it probably helped in the
development of the PhD and theresearch, if you have that sort
(11:05):
of back and forth betweendifferent individuals that are
there to support you.
Yeah, it was really wonderful,actually. Because I will admit,
when I started my PhD, I thoughtrefeeding syndrome was a lot
more common than I do now. So itwas nice to see that. Also,
because I am also stubborn, Iwill admit that I'm mentioning
(11:26):
all my faults to you todayaren't that changing my own mind
over that course was really niceas well. And I think having two
very different opinions in myadvisors was helpful for that
too.
Definitely. So just so we canget a little bit of a set the
scene, could you explain alittle bit about what is
(11:47):
refeeding syndrome? Or how wouldyou explain what refeeding
syndrome is.
So in simplest terms, I like tosay that refeeding syndrome
comes about because we have apatient that comes into
hospital, who is severelymalnourished, and their body is
in a state of catabolism. Whenwe start giving them nutrition,
(12:09):
any type of nutrition, oralenteral, or parenteral, the body
brief kicks back into what itshould be doing. And that means
because our body stores have ourelectrolytes our time and
everything is so low from beingseverely malnourished, those
levels plummet even further,because our bodies using them to
work through that food. So usingglucose in particular, which is
(12:31):
why people talk about monitoringhow much carbohydrate you're
giving these patients who are atrisk. So refeeding syndrome is I
like to always remind people,it's a combination of signs and
symptoms. It's not justhypophosphatemia, which a lot of
people will Bandy about. It'salso hypokalemia,
hypomagnesemia, FireMondeficiency and all the symptoms
(12:55):
that come along with that it canbe edoema, as well. And it
doesn't have to be all of thosetogether.
Is it easy to diagnose refeedingsyndrome? Would you be able to
see it on someone? Or do youjust make a sort of educated
guess based on the symptoms?
They're presenting with acollection of symptoms? You've
just started feeding after aperiod of starvation? Is that
how you deduce if it's refeedingsyndrome or not? Or is there
anything you can say for sure?
(13:18):
Is refeeding syndrome? Or is itjust really just an educated
guess a set of signs andsymptoms?
In my mind, it's an educatedguess there's no consensus on
definitions anywhere. When Italked to doctors in the
hospital, they just named thethree electrolytes and they say
if it's low, that's refeedingsyndrome. And I really do
disagree with that train ofthought, I think that sometimes
(13:42):
your electrolytes are going todrop. And because we'll never
get through ethics, you're nevergoing to know how if they'll
like drop and naturally liftback up as nutrition increases.
But I think it's a natural partof restarting nutrition, that
doesn't mean that you're goingto the full blown refeeding
syndrome. When I did my, I did acase study. For my PhD, I looked
(14:07):
back at the case histories ofpatients that have died in
Queensland with refeedingsyndrome listed on their death
certificate. And we only foundfive across 20 years. And when I
read through the case notes,there was only one of those
patients that I actually waslike, Oh my God, that person
actually did die with refeedingsyndrome. They had a lot of
(14:28):
other issues going on as well.
So it's hard to say whetherrefeeding syndrome with the
primary cause but yeah, that onewas really obvious to me,
whereas the others, I was justlike, I don't think this is it
at all. And I got reallyexcited. It sounds bad, but I
got really excited when I wasreading that case. Because like
that, that is what I've beenlooking for. And I don't see it
(14:49):
and I obviously feel reallyhorrible for that patient and
the patient's family that Iwould get excitement out of
reading that case but is so rarein a hospital system that has so
much support that can do dailybloods that can give
supplementation to patientseasily and that sort of thing.
(15:12):
What do you think about theterm? I've heard it described as
biochemical refeeding syndrome?
Is that even a thing? Or is thatjust made up being that I've
heard that term bandied aroundquite a bit for disturbances and
electrolytes and just calling itbiochemical refeeding? syndrome?
Yeah,yeah, I look, I don't mind the
term, I just find that mostpeople just hear the refeeding
syndrome part and just roll withit. So I'm always very cautious
(15:33):
of using too many times for one,one issue. So because, you know,
we've got refeeding,hypervelocity. Sorry, refeeding,
hyperphosphatemia, and thenwe've got refeeding syndrome and
biochemical refeeding syndrome.
And we've got general refeeding,like as in refeeding, our
patients, but some people whenthey see refeeding, they think
(15:55):
it's refeeding syndrome. And itjust gets very messy. I think.
So. But I do agree with thepremise of the biochemical
refeeding.
And, obviously, based on whatyou're saying, is very different
than a lot of the guidancearound the world. I'm quite
familiar with nice guidance, andwe've got other guidance for
different conditions such aseating disorders, where do you
(16:16):
think this this sort of cautioncomes from? Well, why are we so
cautious? In such a way we knowmalnutrition is probably way
more prevalent than refeedingsyndrome? Why are we so cautious
when we're refilling ourpatients? Where does that
caution come from? Do you think?
I think, for one, no one wantsto be the dietician that killed
(16:37):
someone with refeeding, becausethey let them go into refeeding
syndrome. The second is that alot of the cases, I think that
people will refer back to casesthat weren't managed well, and
they weren't managed well,because we didn't have the
research to show us what to do.
So there were the two cases inthe very early 80s, with the
(16:59):
parenteral nutrition andeveryone references those. But
the latest, the RCT that wasrecently published in November
shows us that no, we don't needto be that scared of parenteral
nutrition provided we are givingsupplementation and that sort of
thing. And when I talk aboutrefeeding syndrome, and I'm
explaining how bad it can be topeople that haven't heard of it
(17:21):
before, I always refer back tothe prisoners of war, because
they're actual, those wereactual cases, like when you're
reading the literature, you'relike, Oh, yes, that is legit.
That prisoner of war was in aconcentration camp for years,
and then they were let out andsomeone very kindly fed them.
And that was it. And I think asa profession as well, we are
(17:41):
cautious bunch, like, we'rebasically all type A, we like to
follow rules, we've got aconservative bunch of
clinicians, and then theguidelines aren't made up on
research. Most of them are basedon expert opinion. So if you've
got experts that are cautious,then of course, they're going to
recommend cautiousrecommendations.
(18:05):
Definitely, I remember I had astudent on placement with me,
and we're going through apatient and she was quite
concerned about this patient wasa risk of refeeding syndrome.
And our trust guidance werebased, similar to nice guidance,
just so everyone can get anexample that were going through
the guidelines. And she feltthat because the patient was at
risk of refeeding syndrome, shethought maybe I should be even
(18:26):
more cautious than Nice.
However, thanks to yourpresentation, I was able to
explain a little bit around kindof like the evidence and things
like that she was able tounderstand, maybe I shouldn't be
more cautious than Nice.
Yeah, long. Stories like thatmake me really sad for our
patients, because you know thatif they're underpaid, they're
generally in hospital for a lotlonger, and we're exacerbating
(18:48):
their malnutrition. So, alwaystrying to remind people of that,
like, you're probably doing moreharm than good. By sitting back
and panicking about that we cangenerally fix so if the
electrolytes start dropping, wecan give something
definitely. And that study yourreference previously, I will
have that study in the shownotes and it's a study it's a
(19:11):
randomised control trial,correct me if I'm wrong, a
randomised control trial,looking at parenteral nutrition,
high and low feeding. I'm notsure how they defined it. And
looking at markers for refeedingsyndrome. Yes, that's the one.
Yeah, so I'll share that in theshow notes. So that brings us on
to guidelines and the variationin guidelines around the world.
However, there's one variationthat sort of brings my attention
(19:31):
every single time and I'vealways wondered about it, is the
variation between nice andmarzipan. And they seem to move
around back and forth playingwith each other on two opposite
ends of the spectrum. They moveback and forth all the time. And
I know that I think they'reworking on another revision of
marzipan coming up in the summerthis year. They're probably
sitting around discussing at themoment they're probably wanting
(19:53):
to move in another direction ormove back and forth. Why is
this? Why is they're just payinga little bit of almost playing
like a game with each otheruntil the opposite ends of the
spectrum, why are they doingthis? From your assessment?
I wish I knew. So I sometimes Ijust I don't understand why
patients with eating disorderscan generally be fed higher
(20:13):
calories when they've probablybeen starving for longer than
the nice criteria, which islittle or no intake for five
days. Yeah, it still blows mymind, we can double the intake
for these patients that havebeen starving themselves for
potentially years. But we haveto be really cautious with our
88 year old who hasn't eatenproperly for five days. So who's
(20:36):
had a low BMI for her entirelife? And it's not because she
stabbed herself. It's justbecause she's a tiny little
lady. So yeah, it's frustrating.
And I get why clinicians willthen default to the more
conservative option. So if theysay this, these guidelines say
this, and these guidelines saythis, and the second set of
(20:56):
guidelines say something a bitmore conservative, they seem
safer. So why not default tofive calories per day to start
feeding? Yeah,I think probably also nice makes
it a little bit more confusingwith little to no intake, what
does that actually mean?
Or more expert opinion. It isfunny, though, because I read
(21:22):
them. And I think our AustralianNew Zealand guidelines are
quite, they're a bit moreassertive than both of marzipan
and nice. So we actually startfor our patients with medically
compromised eating sores, weactually start feeds it just
over 6000 kilojoules per day. Sono matter what their BMI is, and
(21:44):
that sort of thing, and thenadvanced up to 12,000
kilojoules. So yeah, there isvariation everywhere.
6000 kilojoules and calories isthat.
So that's a sorry, I can't I goback and forth. And it's very
confusing. So about 1500calories per day. 100. Yeah, and
(22:05):
then the new aspirinrecommendations that came out.
They also they're quite similarto nice and they're starting
rate. So they say start between10 and 20 calories per kilo. But
then they say you can advance upa bit faster as you can go up
33% towards go right every dayor two. It's all it's very
confusing. I sometimes I don'tknow where anyone's pitch their
(22:28):
numbers from I don't even knowwhere Australia has picked their
numbers from I just know that Ilike it, because it's a little
bit more assertive than some ofthe other countries. But yeah,
they're all they are alldifferent, which is
disappointing, because you'dlike to think that we can all
practice the same way.
Especially in Australia, Europe,UK, Australia. So did I say
(22:48):
America was the first time inAustralia? I can't remember.
Sorry. I remember. I was first adietitian and I was handing over
my plan to one of the doctors Imentioned refeeding syndrome and
Arendt mentioned aboutsupplementing time in and stuff
like that. And he says to me,refeeding syndrome doesn't
exist. Do you think that hasany? Where do you think that
comes from? I've heard it from afew other sort of doctors,
(23:10):
usually doctors, and usuallyprobably even more senior
doctors say it occasionally.
Where do you think that comesfrom? And is there we know
they're wrong? Obviously,because we're discussing
refeeding syndrome. And however,where do you think that probably
comes from? Do you think itcould come from a lot of
clinicians being overly cautiousand being warned about it about
100 times and never seeing itin better bias? I think for a
lot of these doctors have beenvery lucky that either their
(23:33):
dieticians have been on top ofit. And if the patients on feeds
have started quite slowly andbuilt up, or they're lucky if
the patient's on oral nutritionand just gradually started
eating more on their own withoutsometimes you do see patients
that go from zero to 100 whenthey're on oral nutrition, but I
do in my opinion, it's quiterare, not as rare as some of the
(23:55):
stuff we're talking about. But Ialso think there is an aspect of
the boy that cried wolf, when Iwas a student, the number of
times I had to pay the doctor totell them that I thought a
patient was at risk of refeedingsyndrome was borderline
ridiculous. Like, I can'tbelieve I used to harass the
medics so much. Whereas now Iwould barely page so generally,
(24:22):
we're actually very lucky in thehealth service that I'm in and
our doctors are very aware ofrefeeding syndrome. Our patients
that are have eating disordersor automatically started on
supplementation. And I thinkit's I think it's a good thing
that they're obviously I thinkit's a good thing that they're
very aware of it so I don't haveto page them but it's also come
(24:42):
with experience that noteveryone is at risk just because
they meet that nice criteriathat I've Yeah, I think it does
come with clinical practice. Itcomes from having good supervise
arises it comes with thinkingreally objectively about where
these where the criteria haveactually come from and what
(25:05):
supporting Yeah, I think for thepeople that say it's not real, I
always argue, tell me, how comethe prisoners of war dropped
dead? But there is also anaspect of, yes, we do, yell and
shout about it a lot, whichwould get on their nerves. And I
don't blame them to some degree.
(25:27):
Definitely. So you mentioned alittle bit around refeeding
syndrome was definitely commoncommon in prisoners of war when
they started eating, and it waswell done. It was documented and
it was seen, but we don't see itas much today in our modern
medical systems with themonitoring and the
supplementation and things likethat. What do you think makes
the biggest impact from thosetwo different settings? Is there
(25:49):
anything that makes the biggestimpact? Or what would you say
makes the biggest impact whentrying to manage refeeding
syndrome?
So primarily, biggest impact is,before we even get into the
hospital system, there's asupport most people like they
have family or they have friendschecking in on them, they have a
neighbour that's aware thatthere's that there could be
something wrong and that sort ofthing. So I find that don't see
(26:12):
that many patients come throughthe health care service that
have been neglected and staffedfor months and months on end,
which is what our prisons havewhat went through in the
hospital, I actually think itcomes down to the fact that we
can get blood results within acouple of hours. And we can give
some electrolyte supplementationvery quickly. I think that's
(26:36):
our, like our biggest tool inour toolbox like diamond
supplementation, multivitaminsupplementation is important.
But I really do think it'smonitoring what's actually
happening in this person's bodyand being able to fix it
quickly.
So that's the monitoring theelectrolytes and those sorts of
things actually made the biggestdifference over all the other
(26:59):
things. Yeah.
Yeah, we looked at in our healthservice, once I finished my PhD,
we changed our refeedingsyndrome guidelines quite
drastically. And it didn't makea difference if we fared really
fast. And I think that come it'sso it's not, I don't think it
comes down to what we're whatNutrition has provided. I think
(27:21):
it's all the other things thatcome into it. Yeah, I always
preach that. If you thinksomeone's at risk, make sure
there's daily blobs, likeminimum for four days, and most
of the guidelines, say 10 to 14,which I think is difficult in
clinical practice. Because, youknow, most of our patients,
unless they're quite sick,aren't staying in the healthcare
(27:42):
service for that. aren't stayingin hospital for that long
anymore. We're trying to reducelength of stay. So I think being
realistic about what you canmanage is important, too. So
yeah, I do think it's all thosemedical, like, we need our
medics to do blood tests. Yeah,definitely. Yeah. So
carbohydrate is one of thebiggest triggers of refeeding
syndrome, is there any benefitto manipulating macronutrient
(28:06):
composition. So for example,giving the patient a higher Fat
Feed instead of a highercarbohydrate feed. Yeah,
the research is quite limited init in this sort of field. For
me, I always say as long as it'sbalanced, so as long as you're
not giving a patient, straight,glucose drinks all day, every
day when they're at risk, thenyou shouldn't have a problem.
(28:29):
There is definitely discussionin the eating disorder
literature, that limitingcarbohydrate to 40% is
beneficial, especially when yourintro during enteral feeds. We
did our study a few years agoand carbohydrates 50%. And we
had no cases of refeedingsyndrome. So I think as long as
(28:51):
there's a little bit of commonsense there, like as long as
it's not 100% carbohydrate load,and there's a bit of other stuff
going on in there, then I thinkit's fine. And is there any
difference between parenteraland enteral nutrition? I think
my brain thinks that there'sless risk of say enteral
nutrition compared toparenteral.
When we when I did my systematicreview from my PhD, we actually
(29:14):
found that the patientsreceiving enteral nutrition were
getting most of the symptomsthat sent a lot of the papers
that we looked at because thedefinitions for refeeding
syndrome are all over the shop,some of them were counting
things like diarrhoea and thatsort of thing, which when you're
using enteral nutrition, I thinkis sometimes inevitable. So I do
(29:38):
take that with a grain of salt.
I think parenteral nutrition canbe more I want to say harsh or
are patients at risk ofrefeeding syndrome. So because
it's it's straight in ratherthan going through the digestive
system, but the literaturedoesn't support my thinking on
that. So I wouldn't take All ofwhat I just said with a grain of
(30:00):
salt. Yeah, unfortunately, Idon't think there's a clear cut
answer on that one hour. And I'msorry. So the literature is so
all over the shop too, becauseyou know, a lot of these studies
are done in ICU whereeverything's protocolized, which
is very different to being on ageneral ward
is very different than being ona general ward. So yeah,
definitely, there's aunderstanding the context of
where you work in stuff, but itmight be an area for research
(30:23):
that obviously, as we'rediscussing all these gaps, I
hope everyone's thinking there'san opportunity there, or there's
an opportunity there and justalways be looking for that
opportunity thing.
Yes, yeah, I always remindpeople that have a bit of a
competitive nature withresearch. There's always so many
topics. So if someone's nabbedsomething, there's always
something else, especially inrefeeding syndrome,
(30:45):
exactly. From Carly'sexperience, I dare a dietetic
student or a dietitian to doresearch in some of the areas
that we'll discuss today, I dareyou. And we'll see if they do
it, because I want to get morepeople doing doing research to
just prove people wrong and setthe record straight. I think
that's definitely a competitivenature. So I think a lot of the
(31:06):
information discussed here foreven when I was a new dietitian
will be quite sort of earthshattering. Or what do I do now?
How do I actually do this?
Should I just feed everyoneloads of calories? Am I just
purposely not feeding them? Howdoes this actually translate
into practice? So when we gointo managing Reif possible
refeeding syndrome and ourpatients, how does that actually
translate? What would you whatdo you think is a sensible way
(31:26):
to approach practice?
sensible ways, being sure ifyour medics, so being sure that
they will supplement what'sneeded, they will do blood
tests, there'll be all themonitoring that's recommended.
So I think that sets the systemup and allows the dietician to
(31:48):
be a bit more, I want to sayassertive or aggressive. When
because the research is so poor,the study that we've done on our
service is one of the moreassertive types that are out
there. And it's not withpatients with eating disorders,
it's just our patient that onthe general ward, and we start
at 50%. And if there's only mildor there's no electrolyte
(32:12):
decreases, we actually go togold within 24 hours. And we
didn't have any adverseoutcomes. With that, I will
highlight that this was a threemonth audit. And we I think it
was about, I want to say 90patients in the end, so it's not
huge. But we've had goodoutcomes from that. So I think
it's, I'm not saying go in anddo that exactly. Because that
(32:35):
would just be adding my own gotmy Kiley guidelines out there
with the 50,000 other guidelinesthat have different numbers and
recommendations. But findingsomething that you're
comfortable with. So when wewere updating the refeeding
syndrome guidelines for ourhealth service as a department,
we got together and we alltalked about what we all
(32:55):
individually do, because none ofus were following the
recommendations because we allfelt that was so conservative.
And then once we've been tolddid a poll on what everyone is
doing, really kicks that around,we looked at what the evidence
shows compared to what everyoneelse was doing. And that's how
we came up with that cut what wewere comfortable with as a
service providing to ourpatients. So you can't do it
(33:19):
alone. I don't think so. If yougo rogue, someone's gonna read
the chat entry and wonder whyyou're starting and doing
something so assertive comparedto the rest of the service. So I
think it's important to havethose discussions as a team.
Definitely, I think, yeah, ateam approach and then building
the guidelines together, andbasically what you all feel
comfortable with. And just sothere's uniformity. So when
(33:41):
you're actually going whendifferent dieticians cover, or
different dietitians coverdifferent services, there's not
confusion or there's not. Yeah,it just helps with continuity
and things like that, also, Ithink probably translate it is
this is a massive area forresearch a massive area of
development. And the only way wecan alarm has to say, improve
(34:02):
the guidelines. And the evidencebehind them is by create getting
more evidence getting more evenaudits or actual practice of
what dietitians are doing inpractice and how it impacts
patients. So that's obviously anarea where we can collect data
and and I know Allison from theUK is very bullish on this and
patients at risk of refeedingsyndrome. She's particularly
(34:23):
bullish, and she keeps onsaying, Let's collect evidence,
keep on collecting evidence, themore we have, the better and
obviously you might think Idon't have the capacity to do X
type of study or the dream studyor whatever. But I think with
everything, it's just collectingas much evidence as possible
becauseI love Allison, I've talked to
her about this before, like, Ireally want to do an RCT but in
(34:45):
our service here, it's just it'simpossible and she's always
turned around and said it's notimpossible. There's a study
published you can totally do it.
So like to tell people that likeDon't ever think it's impossible
because someone has just doneit. And it needs to be
replicated. And the poor thingshave so many problems with their
(35:08):
study as well, just with delaysand that sort of thing,
definitely need some more workout there as well.
Definitely, I'm so grateful thatyou obviously did your PhD in
this topic. And hopefully, it'sbeen really informative to those
who are dieticians and studentdieticians out there to really
understand a little bit moreabout refeeding syndrome. And I
think that's the push goingforward. I think, as we can see
(35:29):
from I mentioned the beginningof the pench handbook, from
quite prescriptive guidelines todisplaying the evidence and you
pick for yourself and lookingactually reading the studies.
And that was very muchencouraged when we went through
collating requirements, which isa story for another day, around
evidence and gaps in evidence.
But definitely the opening sortof accident. To be honest, a lot
(35:50):
of dietitians that I talked toat the time, were quite
frustrated with actually theywere like, how is this clear to
read? How do we tell people whatto do? This is going to be
really problematic for students.
And it's not prescriptive, andit's quite difficult to
understand. But I think movingmore towards that actually
understanding what's behind theguidelines, actually helps
(36:12):
people to be more informedpractitioners. I think it's so
important to understand what isactually behind certain
guidelines. And I think whatyour talk did originally, and
what some of this podcast hasdone is help inform me
personally, around what'sactually behind the refeeding
guidelines. So when I'mimplementing it, or actually
using the guidelines, Iunderstand the evidence and how
(36:35):
much evidence is behind it.
Thanks. Yeah, look, it was alearning curve for me too. I
remember reading our level Clevel D evidence. Okay. So that
means it's pretty rubbish. Butthen when you dig down deep into
it, you're like, Oh, okay.
There's really no studies. It'sit is expert opinions. Yeah, I
do think it's important. We dojournal club at work quite
regularly, and we rip apartguidelines all the time. It's
fun. Just rip them apart,looking at what's supporting
(36:57):
them. Yeah. And I highlyrecommend so.
I mean, yeah, it's a really goodpractice to do rip apart
guidelines and look at what'sactually behind them. I think
it's it just Yeah, it is reallyimportant. I think that's vital.
But thank you so much for comingon the podcast.
Kylie Matthews (37:13):
Thank you for having me on. It was fun.
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